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This paper will provide an overview of the philosophical premises, the generation of research questions, data collection and analysis process, potential ethical issues, and quality of inference of living theory action research methodology. Based on the ontological value that everyone has knowledge within themselves, living theory action research considers knowledge to be the creation from evaluation and reflection as part of actions to improve educational practices. This paper suggests a way to move ahead with living theory action research by shedding light on the significance of multimedia use and the role of educational influence in its methodology to communicate the meanings of expression of embodied values and for the validation process. This paper aims to help emerging educational action researchers understand living theory action research as an innovative methodology to address the gap between values and practical implementation for action researchers.

IntroductionThe World Health Organization stated self-medication involves the use of medicinal products by the consumer to treat self-recognized disorders or symptoms without prescribed by a physician. Self-medication is a worldwide public health issue and is more common in developing countries. Analgesics and cough syrups were Nepals most commonly used classes of drugs, which could be easily available over the counter. Methods:A pre-experimental one-group pretest and post-test design was used to assess the effectiveness of the Structural Teaching Program (STP) on self-medication knowledge and its adverse effects. A nonprobability purposive sampling techniquewas used. The study included 120 middle-aged adults residing in Lalitpur, Nepal. A structured knowledge questionnaire were developed, translated into the local language, and distributed to respondents. Descriptive and inferential statistics were used to analyze the data. Results:The mean pre-test knowledge score was 32.9% (SD 16.9%), the mean post-test knowledge score was 83.1% (9.5%), and the enhancement mean knowledge was 50.2% (SD 10.7%). When a pairedt-test was done, the obtained value of 36.34 was found to be significant at 0.05. There was a significant relationship between respondents pretest knowledge levels of self-medication and its adverse effects and socio-demographic variables such as age, religion, education, family income, occupation, and type of family, number of children, previous knowledge and source of information. Conclusion: The respondentshad inadequate knowledge about self-medication and its adverse effects. The mean pre-test and post-test knowledge scores of respondents differed significantly. As a result, the study found that STP was effective.

Objectives: This study aimed to identify the multi-trajectories of 3-D health of older adults in China and to explore whether the childhood predictors are associated with 3-D health trajectory. Methods: Data came from five waves of the China Health and Retirement Longitudinal Study (CHARLS, 2011 to 2018). A multi-trajectory modeling approach was carried out to jointly estimate the trajectories of 3-D health. A multinomial regression model was used to investigate the relationship between childhood predictors and the joint trajectories. Results: We identified three typical joint 3-D health trajectories. Female, childhood health, maternal and paternal educations, childhood friendships, family and neighborhood predictors could all affect disability trajectories of older adults directly or indirectly through adults variables. Discussion: The 3-D health trajectories showed increasing trends, thus the government should perform more interventions toward the childhood predictors for better health of older adults.

With technological innovations happening at workplaces, 21st century organizations demand competencies in thinking creatively and critically. These two skills will potentially help prospective employees become confident individuals, concerned citizens, self-directed learners, and active professionals. In this context, it becomes imperative to overhaul the lecture-based and banking model of the traditional pedagogical approach in order to impart such skills among undergraduate and graduate students. To address this issue, a lab-based teaching-learning method focused on problem-solving and design thinking was introduced at OAMK Labs in Finland. This study assesses the efficacy of lab-based learning in enhancing creativity and critical thinking among students from engineering, management, and science backgrounds of Kathmandu University, Nepal. The study was conducted in a workshop setting using a randomized control trial (RCT) where participants were divided into control and treatment groups. Participants in treatment group took part in a design thinking workshop that applied lab-based learning pedagogy, while those in the control group were given some reading material on improving creativity and critical thinking. Standard tests on both critical and creative thinking in a pre- and post-stages were administered to both groups. Data was analyzed using standard Difference-in-Differences technique. The results showed that while the level of critical thinking improved significantly, among the learners in treatment group alone, the creativity level in the post-stage increased significantly among learners in both groups. Results validated the efficacy of lab-based teaching-learning in addressing the need for critical and creative thinking skills among learners. Keywords: critical thinking, creativity, lab based learning, innovation, higher education, Difference-in-Differences

Significance Nearly half of all pregnancies in the United States are unintended due to millions of women avoiding available hormonal contraceptive methods as a result of real and/or perceived side effects associated with the use of exogenous hormones. Topical vaginal delivery of antisperm monoclonal antibodies that could agglutinate sperm into clusters too large to penetrate mucus and prevent sperm from reaching the egg represents a potentially safe and potent mechanism for nonhormonal contraception. We report here the engineering of a vaginal film loaded with hexavalent (i.e., 6 Fab) antisperm IgG, made using GMP manufacturing processes, that possesses significantly superior agglutination potency than the parent IgG, enabling potent on-demand nonhormonal contraception via effectively agglutinating all human sperm within minutes., Nonhormonal products for on-demand contraception are a global health technology gap; this unmet need motivated us to pursue the use of sperm-binding monoclonal antibodies to enable effective on-demand contraception. Here, using the cGMP-compliant Nicotiana-expression system, we produced an ultrapotent sperm-binding IgG antibody possessing 6 Fab arms per molecule that bind a well-established contraceptive antigen target, CD52g. We term this hexavalent antibody “Fab-IgG-Fab” (FIF). The Nicotiana-produced FIF had at least 10-fold greater sperm-agglutination potency and kinetics than the parent IgG, while preserving Fc-mediated trapping of individual spermatozoa in mucus. We formulated the Nicotiana-produced FIF into a polyvinyl alcohol–based water-soluble contraceptive film and evaluated its potency in reducing progressively motile sperm in the sheep vagina. Two minutes after vaginal instillation of human semen, no progressively motile sperm were recovered from the vaginas of sheep receiving FIF Film. Our work supports the potential of multivalent contraceptive antibodies to provide safe, effective, on-demand nonhormonal contraception.

Many women risk unintended pregnancy because of medical contraindications or dissatisfaction with contraceptive methods, including real and perceived side effects associated with the use of exogenous hormones. We pursued direct vaginal delivery of sperm-binding monoclonal antibodies (mAbs) that can limit progressive sperm motility in the female reproductive tract as a strategy for effective nonhormonal contraception. Here, motivated by the greater agglutination potencies of polyvalent immunoglobulins but the bioprocessing ease and stability of immunoglobulin G (IgG), we engineered a panel of sperm-binding IgGs with 6 to 10 antigen-binding fragments (Fabs), isolated from a healthy immune-infertile woman against a unique surface antigen universally present on human sperm. These highly multivalent IgGs (HM-IgGs) were at least 10- to 16-fold more potent and faster at agglutinating sperm than the parent IgG while preserving the crystallizable fragment (Fc) of IgG that mediates trapping of individual spermatozoa in mucus. The increased potencies translated into effective (>99.9%) reduction of progressively motile sperm in the sheep vagina using as little as 33 μg of the 10-Fab HM-IgG. HM-IgGs were produced at comparable yields and had identical thermal stability to the parent IgG, with greater homogeneity. HM-IgGs represent not only promising biologics for nonhormonal contraception but also a promising platform for engineering potent multivalent mAbs for other biomedical applications.

Background: The prevalence of antimicrobial resistance (AMR) among Gram-negative bacteria is alarmingly high. Reintroduction of colistin as last resort treatment in the infections caused by drug-resistant Gram-negative bacteria has led to the emergence and spread of colistin resistance. This study was designed to determine the prevalence of drug-resistance among beta-lactamase-producing strains of Escherichia coli and K. pneumoniae, isolated from the clinical specimens received at a tertiary care centre of Kathmandu, Nepal during the period of March to August, 2019.Methods: A total of 3216 different clinical samples were processed in the Microbiology laboratory of Kathmandu Model Hospital. Gram-negative isolates (E. coli and K. pneumoniae) were processed for antimicrobial susceptibility test (AST) by using modified Kirby-Bauer disc diffusion method. Drug-resistant isolates were further screened for extended-spectrum beta-lactamase (ESBL), metallo-beta-lactamase (MBL), carbapenemase and Klebsiella pneumoniae carbapenemase (KPC) production tests. All the suspected enzyme producers were processed for phenotypic confirmatory tests. Colistin resistance was determined by minimum inhibitory concentration (MIC) using agar dilution method. Colistin resistant strains were further screened for plasmid-mediated mcr-1 gene using conventional polymerase chain reaction (PCR).Results: Among the total samples processed, 16.4% (529/3216) samples had bacterial growth. A total of 583 bacterial isolates were recovered from 529 clinical samples. Among the total isolates, 78.0% (455/583) isolates were Gram-negative bacteria. The most predominant isolate among Gram-negatives was E. coli (66.4%; 302/455). In AST, colistin, polymyxin B and tigecycline were the most effective antibiotics. The overall prevalence of multidrug-resistance (MDR) among both of the isolates was 58.0% (199/343). In the ESBL testing, 41.1% (n=141) isolates were confirmed as ESBL-producers. The prevalence of ESBL-producing E. coli was 43% (130/302) whereas that of K. pneumoniae was 26.8 % (11/41). Similarly, 12.5 % (43/343) of the total isolates, 10.9% (33/302) of E. coli and 24.3% of (10/41) K. pneumoniae were resistant to carbapenem. Among 43 carbapenem resistant isolates, 30.2% (13/43) and 60.5% (26/43) were KPC and MBL-producers respectively and 33.3% (11/33) and 20% (2/10) of the isolates of E. coli and K. pneumoniae were KPC-producers respectively. Similarly, 63.6 % (21/33) and 50% (5/10) of the E. coli and K. pneumoniae were MBL-producers, respectively. In MIC assay, 2.2 % (4/179) of E. coli and 10% (2/20) of K. pneumoniae isolates were confirmed as colistin resistant (MIC ≥4 µg/ml). Overall, the prevalence of colistin resistance was 3.1% (6/199) and acquisition of mcr-1 was 16.6% (3/18) among the tested isolates.Conclusion: High prevalence of drug-resistance in our study is indicative of a deteriorating situation of AMR. Moreover, significant prevalence of resistant enzymes in our study reinforces their roles in the emergence of drug resistance. Resistance to last resort drug (colistin) and the isolation of mcr-1 indicate further urgency in infection management. Therefore, extensive surveillance, formulation and implementation of effective policies, augmentation of diagnostic facilities and incorporation of antibiotic stewardship programs can be some remedies to cope with this global crisis.

Non-hormonal products for on-demand contraception are a global health technology gap, motivating us to pursue the use of sperm-binding monoclonal antibodies as a strategy to enable safe, effective, desirable, on-demand contraception. Here, using cGMP-compliant Nicotiana-expression system, we produce an ultra-potent sperm-binding IgG antibody possessing 6 Fab arms per molecule that bind a well-established contraceptive antigen target, CD52g. We term this hexavalent antibody “Fab-IgG-Fab” (FIF) to reflect its molecular orientation. The Nicotiana-produced FIF exhibits at least 10-fold greater sperm agglutination potency and kinetics than the parent IgG, while preserving Fc-mediated trapping of individual spermatozoa in mucus. We formulate the Nicotiana-produced FIF into a polyvinyl alcohol-based water-soluble contraceptive film, and evaluate its potency in reducing progressively motile sperm in the sheep vagina. Two minutes after vaginal instillation of human semen, no progressively motile sperm are recovered from the vaginas of sheep receiving FIF-Film. In contrast, high numbers of progressively motile sperm are recovered from sheep receiving a placebo film control. Our work supports the potential of highly multivalent contraceptive antibodies to provide safe, effective, on-demand non-hormonal contraception.

Summary Previous studies have focused on the determinants of basic public health services utilization, such as socioeconomic status and mobility characteristics, rather than on health literacy. Thus, this study aimed to estimate the effect of health literacy on the utilization of basic public health services among Chinese migrants. Based on the 2016 China Migrants Dynamic Survey data (N = 2335), this study used propensity score matching approach to estimate the effect of health literacy on the utilization of basic public health services, including the establishment of health records and receipt of health education, and to explore heterogeneity in this effect based on educational attainment and urban–rural status. The findings show that high levels of health literacy increased the probability of establishing health records and receiving more health education. Also, high levels of health literacy had a positive effect on the utilization of basic public health services among Chinese migrants, especially those with less education or living in urban areas. Policy makers should more carefully consider the actual situation and needs of migrants who are living in urban areas or have less education, constructing more targeted service programs.

Background Stakeholder engagement is important from the management point of view to capture knowledge, increase ownership, reduce conflict, encourage partnership, as well as to develop an ethical perspective that facilitates inclusive decision making and promotes equity. However, there is dearth of literature in the process of stakeholder engagement. The purpose of this paper is to describe the process of increasing stakeholder engagement and highlight the lessons learnt on stakeholder engagement while designing, implementing, and monitoring a study on diabetes and hypertension prevention in workplace settings in Nepal. Methodology We identified the stakeholders based on the 7P framework: Patients and public (clients), providers, payers, policy makers, product makers, principal investigators, and purchasers. The identified stakeholders were engaged in prioritization of the research questions, planning data collection, designing, implementing, and monitoring the intervention. Stakeholders were engaged through focus group discussions, in-depth interviews, participatory workshops, individual consultation, information sessions and representation in study team and implementation committees. Results The views of the stakeholders were synthesized in each step of the research process, from designing to interpreting the results. Stakeholder engagement helped to shape the methods and plan, and process for participant’s recruitment and data collection. In addition, it enhanced adherence to intervention, mutual learning, and smooth intervention adoption. The major challenges were the time-consuming nature of the process, language barriers, and the differences in health and food beliefs between researchers and stakeholders. Conclusion It was possible to engage and benefit from stakeholder’s engagement on the design, implementation and monitoring of a workplace-based hypertension and diabetes management research program in Nepal.

This study investigated the association between social integration and utilization of essential public health services among internal migrants. Data were from the 2017 China Migrants Dynamic Survey. Social integration was measured through four dimensions: economic integration, structural integration, sociocultural adaptation, and self-identity. Multilevel logistic regressions were used taking into account heterogeneity in the level of regional development. The utilization of health records and health education was less than 40% and varied widely across regions. Social integration was related to a higher likelihood of utilization of health records and health education. Moreover, sociocultural adaptation had a stronger effect on the utilization of health records in developed regions than in developing regions, and structural integration was strongly and positively related to the utilization of health education in developed regions. Hence, it appears that the relationship of some dimensions of social integration and utilization of essential public health services is moderated by the level of economic development. Promoting structural integration and sociocultural adaptation could strongly improve utilization of essential public health services in developed regions.

Multivalent antibodies such as sIgA can crosslink motile entities such as sperm and bacteria, creating agglomerates that are too large to permeate the dense mucin matrix in mucus, a process commonly referred to as immune exclusion. Unfortunately, sIgA remains challenging to produce in large quantities, and easily aggregates, which prevented their use in clinical applications. To develop sIgA-like tetravalent antibodies that are stable and can be easily produced in large quantities, we designed two IgGs possessing 4 identical Fab domains, with the Fabs arranged either in serial or in the diametrically opposite orientation. As a proof-of-concept, we engineered these tetravalent IgG constructs to bind a ubiquitous sperm antigen using a Fab previously isolated from an immune infertile woman. Both constructs possess at least 4-fold greater agglutination potency and induced much more rapid sperm agglutination than the parent IgG, while exhibiting comparable production yields and identical thermostability as the parent IgG. These tetravalent IgGs offer promise for non-hormonal contraception and underscores the multimerization of IgG as a promising strategy to enhance antibody effector functions based on immune exclusion.

Background: Since 2012, China has come into a new period of health development. This paper comprehensively described China’s health development and explored associated influencing factors during the last 6 years (2012-2017).Methods: Data for this study came from statistics yearbook and analysis unit were provincial regions. Comprehensive evaluation (principal component analysis and entropy weight method) was employed to calculate the comprehensive health index to evaluate the health. Then linear growth model was applied to explore factors that influenced the development.Results: Results showed that, since 2012, China’s health had a sustainable growth but inequities among provincial regions were still existing and becoming larger. For influencing factors, time was always a significant positive predictor ( ) and it was affected by geographical distributions ( ) and distance to Beijing ( ), which indicated that regions in central or far from Beijing had a lower growth. Among socioeconomics variables, urbanization level was the final factor ( ) that promoted China’s health development and caused development inequalities. Besides, health level was also influenced by the distance to Beijing ( ), regions near to Beijing had a higher health level.Conclusion: Time effect was the results of policy, during 2012 to 2017, China’s sustainable health development was brought by the policy effect and growth of urbanization level.Thus, it is crucial for one country to introduce suitable health policies and narrow the urban-rural gaps to improve its health. Distance to Beijing represented the potential political influence on health of one country’s capital due to the policy execution level which means that supervisions need to be strengthened for regions far from the capital. Besides, supports and supervisions also need to be enhanced in central regions. They were one of the reasons that caused development inequalities.

Millions of women avoid using available contraceptives and risk unintended pregnancies every year, due to perceived and/or real side-effects associated with the use of exogenous hormones. Naturally occurring anti-sperm antibodies can prevent fertilization in immune infertile women by limiting sperm permeation through mucus, particularly multivalent antibodies such as sIgA that offers robust agglutination potencies. Unfortunately, sIgA remains challenging to produce in large quantities and easily aggregates. Here, we designed two tetravalent anti-sperm IgGs with a Fab domain previously isolated from an immune infertile woman. Both constructs possess at least 4-fold greater agglutination potency and induced much more rapid sperm agglutination than the parent IgG while exhibiting comparable production yields and identical thermostability as the parent IgG. These tetravalent IgGs offer promise for non-hormonal contraception and underscore the multimerization of IgG as a promising strategy to improve existing mAb therapeutics.

Many women risk unintended pregnancy due to dissatisfaction with available hormonal contraceptive methods. This led us to pursue topical sperm-binding monoclonal antibodies as a strategy for safe, non-hormonal contraception. Motivated by the greater agglutination potencies of polymeric immunoglobulins such as IgM and the exceptional bioprocessing ease in manufacturing IgG, we engineered IgGs possessing 6-10 Fabs against a unique surface antigen universally present on human sperm. These highly multivalent IgGs (HM-IgGs) are at least 10- to 16-fold more potent and faster than the parent IgG at agglutinating sperm, while preserving Fc-mediated trapping of individual spermatozoa in mucus. The increased potencies translate to effective (>99.9%) reduction of progressively motile sperm in the sheep vagina using 33 micrograms of the 10 Fab HM-IgG. HM-IgGs produce at comparable yields and possess identical thermal stability to the parent IgG, with greater homogeneity. HM-IgGs represent not only promising biologics for non-hormonal contraception but also a promising platform for generating potent agglutinating mAb for diverse medical applications.

Childhood overweight and obesity have shown an increase in recent birth cohorts. China has undergone rapid socioeconomic transitions accompanied by lifestyle changes that have profoundly affected the physical growth of children. Less empirical research has considered the role of community context on the cohort effects of children's body mass index (BMI) z-score trajectories. We used the mixed effect models for repeated measurements with restricted cubic spline to predict the BMI z-score trajectories in children aged 1-17 years, influenced by different birth cohorts and community context using data from the China Health and Nutrition Survey from 1991 to 2011, and stratified by sex. Results indicated that the mean of BMI z-scores of children aged 1-17 years have increased in the 2000s cohort. Community context contributed to significant differences in BMI z-score increase with age from middle childhood, and this trend of community inequalities divergences in middle childhood in recent birth cohorts. Therefore, to promote equitable growth for all children in China, policy interventions focusing on the community context may have far-reaching effects on the health of children and adolescents.

The main aims of this study were to study the patterns of mutations in rpoB, katG, and inhA genes in Mycobacterium tuberculosis strains isolated from patients from Nepal and to evaluate the performance of genotype MTBDRplus assay, taking conventional drug susceptibility testing as gold standard for diagnosis of MDR-TB. A total of 69 Mycobacterium tuberculosis strains isolated from 73 smear positive sputum samples from patients suspected of suffering from multidrug-resistant tuberculosis were used in our study. The drug susceptibility pattern of Mycobacterium tuberculosis isolated from these sputum specimens was determined by using genotype MTBDRplus assay taking conventional drug susceptibility testing as reference. The sensitivity and specificity of the genotype MTBDRplus assay for the detection of MDR-TB were found to be 88.7% and 100%, respectively. 88.7% of the rifampicin resistant isolates had mutations in rpoB gene. Similarly, 79.7% and 9.4% of isoniazid resistant isolates had mutations in katG and inhA genes, respectively. Genotype MTBDRplus assay was found to be very rapid and highly sensitive and specific method for diagnosis of MDR-TB and will be very helpful for early diagnosis of MDR-TB in high tuberculosis burden countries.

Not Available.Janaki Medical College Journal of Medical Sciences (2016) Vol. 4 (2): 50-52

BACKGROUND\ud There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital.\ud \ud METHODS\ud Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication.\ud \ud RESULTS\ud Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years.\ud \ud CONCLUSIONS\ud Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis.

Nuclear magnetic resonance (NMR)-based metabolomics profile comparisons of embryogenic and non-embryogenic calli of sugarcane were performed using principal component analysis (PCA) to determine a possible relationship between certain metabolites and somatic embryogenesis. Mahalanobis distance (DM) analysis showed significant metabolic profile differences between the embryogenic and non-embryogenic callus groups. Significantly different spectral buckets and their corresponding metabolites have been identified using volcano- and loading-plot analyses, where glucose, fructose, sucrose, and alanine were observed at higher concentrations and asparagine, glutamine, lysine, 2-hydroxyisobutyrate, and choline were observed at lower concentrations in embryogenic calli than in non-embryogenic calli. The results of this research indicate possible roles of different sugars, amino acids, and aliphatic compounds during sugarcane somatic embryogenesis.

Studies on returns to research have been established in different countries to justify research funding and allocation of research priorities. However in Nepal, there are no scientific studies carried out recently on return to research investment in major crops and commodities, despite priority given in agricultural sector. This paper has summarized the research investment with respect to major cereals viz; rice, maize, and wheat and income generated by the impact of improved varieties of these crops in Nepal. Internal rate of return for major cereal crops (rice, maize, and wheat) was estimated using time series data of 1995 to 2005. The findings revealed that there is a negative annual growth rate (-0.59%) of NARC budget during 1998-2004. There was a food deficit during mid nineties, however, in the late nineties while despite tremendous curtailing of budget for research, a surplus of food grain was observed. Although the situation of positive food grain balance is not the result of current year's efforts on research it could be the impacts of years of efforts that were in a continuous pace in the past for agriculture R&D coupled with the impacts of extension related activities in the country. Food surplus is mainly contributed by the efforts of massive release of improved varieties of crops by NARC during late nineties. The internal rate of return (IRR) of these cereals for a decade (1995-2004) was in the range of 84-105%, which is around Rs 235673 millions of income generation while investment for their research was Rs 559 millions (0.24% of their revenue). This indicates that there is gross under funding on research for major crops, despite their significant contribution in national economy, food security, and livelihood improvement in Nepal. Finally paper suggests for increased investment in agricultural research for meeting increasing needs of food, income, and employment of growing population as well as enhancing and sustaining future agricultural R&D in the country.Nepal Agric. Res. J. Vol. 8, 2007, pp. 103-112DOI: http://dx.doi.org/10.3126/narj.v8i0.11602

Background and Objectives: Multidrug-resistant (MDR) Mycobacterium tuberculosis strains are serious threats to the control of tuberculosis and comprise an increasing public health problem. Rapid detection of such strains is quite critical in timely management of such issues. The study was performed with an objective to compare Genotype MTBDRplus reverse hybridization probe assay (Hain Lifescince, GmBH, Nehern, Germany) with culture based proportion method for rapidly identifying MDR-TB strains from suspected multi drug resistant cases, referred to GENETUP Kathmandu, Nepal. Methodology: A commercially available new Genotype MTBDRplus assay was evaluated for its ability to detect mutations in Mycobacterial isolates conferring resistance to rifampicin (RMP) and isoniazid (INH). A total of 64 MDR isolates (i.e., at least resistant to RMP and INH), 5 fully susceptible strains and 1 RMP sensitive strains by conventional proportion method were analyzed using Genotype MTBDRplus assay. MTBDRplus assay is designed to detect the mutations in the hot spot region of rpoB gene, katG and regulatory region of inhA gene. Results: The MTBDRplus assay detected 59 of 61 RMP resistant strains (96.72%) with mutations on 81-bp hot spot region of rpoB gene and 60 of 63 INH resistant strains (95.23%) with mutation in codon 315 katG and regulatory region of inhA. The sensitivity and specificity for the detection of RMP resistance were 96.72% and 100% respectively. While, value of the same two variables for INH resistance were 95.23% and 100%, respectively. Conclusions: The new Genotype MTBDRplus assay represents a rapid, reliable, upgraded tool with high sensitivity and specificity for the detection of INH and RMP resistance strains that can readily be included in a routine laboratory work for the early diagnosis and control of MDR-TB. DOI: http://dx.doi.org/10.3126/jmcjms.v1i1.7884 Janaki Medical College Journal of Medical Sciences (2013) Vol. 1 (1):30-37

Background Multidrug resistant tuberculosis (MDR-TB) is a serious public health problem in Nepal. It is a major obstacle for the control of the tuberculosis. The main objectives of this study were to determine the prevalence of the multidrug resistant pulmonary tuberculosis and to evaluate the drug susceptibility patterns of Mycobacterium tuberculosis isolated from previously treated and newly diagnosed cases of pulmonary tuberculosis. Methods A cross-sectional study was conducted from March 2013 to August 2013 at German-Nepal tuberculosis project (GENETUP) laboratory, Kathmandu, Nepal. For this the sputum samples from total of 153 (49 new and 104 previously treated) suspected pulmonary tuberculosis patients were used. The diagnosis of the tuberculosis was performed by using fluorescent microscopy and culture, while the drug susceptibility testing of Mycobacterium tuberculosis was performed by proportion method. Lowenstein-Jensen (L-J) medium was used for the culture of Mycobacterium tuberculosis and the colonies grown were identified on the basis of the colony morphology, pigment production and biochemical characteristics. Results The prevalence of MDR-TB among all the cases of culture positive pulmonary tuberculosis was 15.6 %. The rate of MDR-TB among previously treated culture positive tuberculosis patients was 19.4 % and that among newly diagnosed culture positive pulmonary tuberculosis cases was 7.1 %. The highest rate of resistance of Mycobacterium tuberculosis, was toward streptomycin (24.4 %) followed by isoniazid (23 %), rifampicin (17.8 %) and ethambutol (15.6 %). Among the total of MDR-TB cases among previously treated patients, highest percentage of the cases were relapse (61.1 %) followed by chronic (16.7 %). Conclusions The high prevalence of DR/MDR-TB in our study reflects poor implementation of tuberculosis control program. On the basis of the drug susceptibility patterns of M. tuberculosis we found in our study, we recommend to include ethambutol instead of streptomycin in the multidrug therapy for the treatment of tuberculosis patients in Nepal. Further, due to high rate of MDR-TB among previously treated patients, we do not recommend to use first line drugs for the treatment of pulmonary tuberculosis among previously treated patients.

Xpert MTB/RIF assay is regarded as a great achievement of modern medicine for the rapid diagnosis of multidrug-resistant tuberculosis (MDR-TB). The main purpose of this study was to determine the performance of Xpert MTB/RIF assay compared to conventional drug susceptibility testing (DST) method for the diagnosis of MDR-TB. A comparative cross sectional study was carried out at German-Nepal Tuberculosis Project, Kathmandu, Nepal, from April 2014 to September 2014. A total of 88 culture positive clinical samples (83 pulmonary and 5 extra-pulmonary) received during the study period were analyzed for detection of multidrug-resistant tuberculosis by both GeneXpert MTB/RIF assay and conventional DST method. McNemar chi square test was used to compare the performance of Xpert with that of DST method. A p-value of less than 0.05 was considered as statistically significant. Of total 88 culture positive samples, one was reported as invalid while 2 were found to contain nontuberculous Mycobacteria (NTM). Among remaining 85 Mycobacterium tuberculosis culture positive samples, 69 were found to be MDR-TB positive by both methods. The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of GeneXpert MTB/RIF assay were found to be 98.6%, 100%, 100% and 93.8% respectively. Statistically, there was no significant difference between the diagnostic performance of Xpert and conventional DST method for detection of MDR-TB. GeneXpert MTB/RIF assay was found to be highly sensitive, specific and comparable to gold standard conventional DST method for the diagnosis of MDR-TB.

BACKGROUND: Antitubercular drugs cause derangement of hepatic function revealed by clinical examination and abnormal liver function test results. Potential hepatotoxicity of some of the first-line antitubercular agents remains a problem, especially during the initial period of treatment. OBJECTIVE: To determine the incidence of antitubercular drug—induced hepatotoxicity in a Nepalese urban population and assess the risk factors. METHOD: Fifty patients diagnosed with active tuberculosis infection with normal pretreatment liver function were monitored clinically as well as biochemically in a prospective cohort analysis. RESULTS: Antitubercular drugs were found to be associated with derangement of hepatic function, resulting in elevation of liver enzymes to a variable extent (t = −4.550, p < 0.01 for aspartate aminotransferase [AST]; t = −5.467, p < 0.01 for alanine aminotransferase [ALT] at 95% CI). Thirty-eight percent of patients had 2 times and 30% had >3 times elevation of ALT. Similarly, 40% and 29% of patients showed 2 and >3 times elevation of the AST level, respectively. Four patients (8%) developed drug-induced hepatotoxicity. Jaundice was the presenting symptom in all patients. The time interval for onset of hepatotoxicity after initiation of therapy was 12–60 days (median 28). Antitubercular drug—induced hepatotoxicity was found more often in younger patients (6% vs 2%; p = 0.368, OR 2.75). Female gender was also a higher risk (p = 0.219, OR 4.2). Most patients who had developed hepatitis were diagnosed per sputum-smear positive reactions. Nutritional status, assessed by body mass index and serum albumin level, was the next predisposing factor. CONCLUSIONS: A finding of an 8% incidence of hepatotoxicity is considerably high. Risk factors of hepatotoxicity included female gender, disease extent, and poor nutritional status. Timely detection and temporary withdrawal of the offending agent can completely cure antitubercular drug—induced hepatotoxicity.

Rapid line probe assay (LPA) can be a practical and rapid alternative to the slow conventional phenotypic drug susceptibility testing (DST) for detection of drug resistant tuberculosis (TB). The purpose of this study is to determine the diagnostic accuracy of Genotype MTBDRplus, LPA for TB, and compare its performance with conventional DST. A total of 54 culture samples were analyzed for DST using both conventional proportion method and MTBDRplus, where conventional DST identified 43 isolates (79.6%) as drug resistant. Among these 43 drug resistant isolates, 30 isolates (69.7%) were found to be multidrug resistant (MDR). Of all observed mutations using MTBDRplus, codon 531 of rpoB gene and codon 315 of katG gene were found to have highest mutational frequency for RIF resistance (64.7%) and INH resistance (96.8%), respectively. In the present study, MTBDRplus assay was shown to have excellent specificity (100%) for both RIF and INH resistance while sensitivity of the assay was little lower with value of 89.4% for RIF resistance and 91.4% for INH resistance. Therefore, the assay can be a rapid, reliable, and promising molecular test for early detection of MDR-TB in Nepal.

Most first-line anti-tuberculosis drugs have less in vitro activity against atypical mycobacteria. Loop-mediated isothermal amplification (LAMP) was used for the rapid diagnosis of mycobacterial species. The sensitivity of LAMP was 96.1% (49/51) in smear-positive and culture-positive sputum samples and 85.0% (17/20) in smear-negative and culture-positive samples. Of the 77 total LAMP-positive samples, 75 (97.4%) were identified as Mycobacterium tuberculosis and 2 (2.6%) as M. intracellulare. One of the M. intracellulare-infected cases was identified in a patient with suspected mycobacteriosis and another was found in a follow-up patient.

Setting: Within the national tuberculosis control programme in Nepal, cure rates of only 30%–40% were achieved using standard chemotherapy. High cure rates are particularly difficult to achieve in the Kathmandu valley, because of the mobility of the population and the large numbers of private practitioners. Short-course chemotherapy (SCC) was not used in tuberculosis (TB) control programmes in Nepal before 1991. Therefore we started our pilot programme with a fully supervised, intermittent SCC regimen. In addition we established a mycobacteriological laboratory for routine culture and susceptibility tests. Objective: The main objective was to demonstrate the high effectiveness of a three-times weekly SCC regimen and the feasibility of directly observed treatment (DOT). Design: In our new out-patient department we put all active TB patients under SCC. The duration of therapy was 9 months or longer, depending upon bacteriological and radiological needs. The results were well recorded and evaluated by central supervision. Outcome of treatment was recorded at 24–48 months. Results: From January 1990 to December 1993, 771 pulmonary TB patients (618 new cases and 153 old cases) commenced treatment. Of these, 645 (84%) were cured or completed treatment, 84 (11%) defaulted, 15 (2%) died, 15 (2%) were treatment failures and 12 (3.0%) relapsed. Conclusion: Directly observed intermittent SCC is highly cost-effective. The results of our service programme showed that it is possible to introduce such a regimen in an urban area of Nepal.

Background Tuberculosis (TB) is a major public health problem in Nepal. Strain variation in Mycobacterium tuberculosis may influence the outcome of TB infection and disease. To date, the phylogenetic diversity of M. tuberculosis in Nepal is unknown. Methods and Findings We analyzed 261 M. tuberculosis isolates recovered from pulmonary TB patients recruited between August 2009 and August 2010 in Nepal. M. tuberculosis lineages were determined by single nucleotide polymorphisms (SNP) typing and spoligotyping. Drug resistance was determined by sequencing the hot spot regions of the relevant target genes. Overall, 164 (62.8%) TB patients were new, and 97 (37.2%) were previously treated. Any drug resistance was detected in 50 (19.2%) isolates, and 16 (6.1%) were multidrug-resistant. The most frequent M. tuberculosis lineage was Lineage 3 (CAS/Delhi) with 106 isolates (40.6%), followed by Lineage 2 (East-Asian lineage, includes Beijing genotype) with 84 isolates (32.2%), Lineage 4 (Euro-American lineage) with 41 (15.7%) isolates, and Lineage 1 (Indo-Oceanic lineage) with 30 isolates (11.5%). Based on spoligotyping, we found 45 different spoligotyping patterns that were previously described. The Beijing (83 isolates, 31.8%) and CAS spoligotype (52, 19.9%) were the dominant spoligotypes. A total of 36 (13.8%) isolates could not be assigned to any known spoligotyping pattern. Lineage 2 was associated with female sex (adjusted odds ratio [aOR] 2.58, 95% confidence interval [95% CI] 1.42–4.67, p = 0.002), and any drug resistance (aOR 2.79; 95% CI 1.43–5.45; p = 0.002). We found no evidence for an association of Lineage 2 with age or BCG vaccination status. Conclusions We found a large genetic diversity of M. tuberculosis in Nepal with representation of all four major lineages. Lineages 3 and 2 were dominating. Lineage 2 was associated with clinical characteristics. This study fills an important gap on the map of the M. tuberculosis genetic diversity in the Asian region.