Antimicrobial Resistance Pattern of Pseudomonas aeruginosa Isolates from Tertiary Care Hospitals in Kathmandu.

Background Antimicrobial resistance, caused by Pseudomonas aeruginosa (P. aeruginosa), poses a global health threat, limiting treatment options and increasing morbidity and mortality rates due to its intrinsic and multidrug resistance. Objective To determine the antimicrobial resistance patterns of P. aeruginosa isolates from patients visiting or admitted to tertiary care hospitals in Kathmandu. Method A cross-sectional study was conducted at Bir Hospital and Tribhuvan University Teaching Hospital (TUTH) from December 2021 to December 2022. Isolates were identified and tested for antibiotic susceptibility following standard microbiological guidelines. Result The antimicrobial resistance of 200 P. aeruginosa isolates increased from low to high levels, as per the recommended anti-pseudomonal antibiotics by the Clinical and Laboratory Standards Institute (CLSI), from 0% to 94%. piperacillin/tazobactam exhibited significantly lower resistance at 18(9%) and while considerably higher resistance was observed with ceftazidime at 188(94%) compared to different antibiotics, followed by amikacin 34(17%), imipenem 58(29%), ciprofloxacin 42(21%), aztreonam 51(25.5%), and fosfomycin 44(22%). No resistance was observed to colistin and polymyxin B. P. aeruginosa resistant to carbapenem was accounted for 33.5% of the total, and multidrug resistance categories included multidrug resistance (MDR) at 39.0%, extensively drug resistance (XDR) at 13.5%, and P. aeruginosa difficult-to-treat (DTR PA) at 4.6%. Conclusion Most of the isolates were resistant to anti-pseudomonal antibiotics; however, colistin, polymyxin B, amikacin, doripenem, piperacillin/tazobactam, and fosfomycin were effective against MDR P. aeruginosa. Regular surveillance measures are essential to manage antimicrobial resistance.

Real Time Trans-Rectal Elastography of Prostate Correlation with Histopathology in a Suspected Case of Prostate Cancer.

Background Early detection of prostate cancer, the second most common cancer in men worldwide, is the key for its successful treatment. Commonly used clinical criteria and imaging tools for detection of prostate cancer are less sensitive. Objective This study was aimed to find role of real time transrectal elastography of prostate for detection of prostate cancer. Method Study was conducted in 66 patients with clinical suspicion of prostate cancer, who were sent for ultrasound guided prostate biopsy. Transrectal ultrasound with real time elastography was performed in all the patients prior to the biopsy and looked for hard areas within the prostate. Then six-core tru-cut biopsy were taken in six zones of prostate, including the hard areas detected in the elastography. The histopathology report were correlated with the elastography findings. Result Median prostate specific antigen of the patients was 11.5 ng/ml with interquartile range of 8 to 23.5 ng/ml. Digital rectal examination showed hard nodular findings in 35 patients. Transrectal ultrasound showed 81 hypoechoic lesions in 31 patients. Elastography showed 127 hard areas in 31 patients. Histopathology showed 90 positive biopsy cores in 23 patients. Cancer detection rate of elastography was 82.6%. At 95% confidence interval, patients with elastography detected hard lesions had 19.4 times more likelihood to have prostate cancer. Sensitivity of elastography was high as compared to digital rectal examination and transrectal ultrasound alone. Conclusion Transrectal elastography had high sensitivity over clinical tools and transrectal ultrasonography for detection of prostate cancer.

Perceived sources of stress amongst dental students: A multicountry study.

AIMS: The aim of this study was to explore the perceived sources of stress reported by dental students from fourteen different countries. METHODS: A total of 3568 dental students were recruited from 14 different dental schools. The dental environmental stress (DES) questionnaire was used including 7 domains. Responses to the DES were scored in 4-point Likert scale. Comparison between students was performed according to the study variables. The top 5 stress-provoking questions were identified amongst dental schools. Data were analysed using SPSS software program. Mann-Whitney and Kruskal-Wallis tests were used as appropriate. Logistic regression analysis was also conducted to determine the effect of the studied variables on the stress domains. The level of statistical significance was set at <.05. RESULTS: Internal consistency of the scale was excellent (0.927). Female students formed the majority of the total student population. The percentage of married students was 4.8%. Numbers of students in pre-clinical and clinical stages were close together. The most stress-provoking domain was "workload" with a score of 2.05 ± 0.56. Female students scored higher stress than male students did in most of the domains. Significant differences were found between participating countries in all stress-provoking domains. Dental students from Egypt scored the highest level of stress whilst dental students from Jordan scored the lowest level of stress. CONCLUSION: The self-reported stress in the dental environment is still high and the stressors seem to be comparable amongst the participating countries. Effective management programmes are needed to minimise dental environment stress.

Characterization of Leaf Rust and Stripe Rust Resistance in Spring Wheat 'Chilero'.

Since 1984, the 'Chilero' spring wheat line developed by CIMMYT has proven to be highly resistant to leaf rust and stripe rust. Amid efforts to understand the basis of resistance of this line, a recombinant inbred line (RIL) population derived from a cross between Avocet and Chilero was studied. The parents and RILs were characterized in field trials for leaf rust and stripe rust in three locations in Mexico between 2012 and 2015 and genotyped with DArT-array, DArT-GBS, and SSR markers. A total of 6,168 polymorphic markers were used to construct genetic linkage maps. Inclusive composite interval mapping detected four colocated resistance loci to both rust diseases and two stripe rust resistant loci in the Avocet × Chilero population. Among these, the quantitative trait locus (QTL) on chromosome 1BL was identified as a pleotropic adult plant resistance gene Lr46/Yr29, whereas QLr.cim-5DS/QYr.cim-5DS was a newly discovered colocated resistance locus to both rust diseases in Chilero. Additionally, one new stripe rust resistance locus on chromosome 7BL was mapped in the current population. Avocet also contributed two minor colocated resistance QTLs situated on chromosomes 1DL and 4BS. The flanking SNP markers can be converted to breeder friendly Kompetitive Allele Specific PCR (KASP) markers for wheat breeding programs.

Outcome of Endoscopic Variceal Band Ligation.

INTRODUCTION: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices. METHODS: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved. RESULTS: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL. CONCLUSIONS: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices with very few complications.

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal.

INTRODUCTION: Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients. METHODS: A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t - test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and P value of <0.05 was considered as significant. RESULTS: Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (P <0.001) while older patients mostly presented with per rectal bleeding (P< 0.008). CONCLUSIONS: In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.

Identification and Mapping of Adult Plant Resistance Loci to Leaf Rust and Stripe Rust in Common Wheat Cultivar Kundan.

Leaf rust (LR) and stripe rust (YR) are important diseases of wheat worldwide. We used 148 recombinant inbred lines (RIL) from the cross of Avocet × Kundan for determining and mapping the genetic basis of adult plant resistance (APR) loci. The population was phenotyped LR and YR for three seasons in field trials conducted in Mexico and genotyped with the diversity arrays technology sequencing (DArT-Seq) and simple sequence repeat markers. The final genetic map was constructed using 2,937 polymorphic markers with an average distance of 1.29 centimorgans between markers. Inclusive composite interval mapping identified two co-located APR quantitative trait loci (QTL) for LR and YR, two LR QTL, and three YR QTL. The co-located resistance QTL on chromosome 1BL corresponded to the pleiotropic APR gene Lr46/Yr29. QLr.cim-2BL, QYr.cim-2AL, and QYr.cim-5AS could be identified as new resistance loci in this population. Lr46/Yr29 contributed 49.5 to 65.1 and 49.2 to 66.1% of LR and YR variations, respectively. The additive interaction between detected QTL showed that LR severities for RIL combining four QTL ranged between 5.3 and 25.8%, whereas the lowest YR severities were for RIL carrying QTL on chromosomes 1BL + 2AL + 6AL. The high-density DArT-Seq markers across chromosomes can be used in fine mapping of the targeted loci and development SNP markers.

Genetic Analysis of Resistance to Leaf Rust and Yellow Rust in Spring Wheat Cultivar Kenya Kongoni.

The Kenyan wheat (Triticum aestivum L.) 'Kenya Kongoni' exhibits high levels of adult plant resistance (APR) to leaf rust (LR) and yellow rust (YR). We determined the genomic regions associated with LR and YR resistance in a population of 148 recombinant inbred lines generated from a cross between 'Avocet-YrA' and Kenya Kongoni. Field experiments to characterize APR to LR and YR were conducted in four and two Mexican or Uruguayan environments, respectively. A linkage map was constructed with 438 diversity arrays technology and 16 simple-sequence repeat markers by JoinMap 4.1 software. Genetic analyses showed that resistance to both rusts was determined by four to five APR genes, including Lr46/Yr29 and Sr2/Lr27/Yr30. Quantitative trait loci (QTL) analysis indicated that pleiotropic APR loci QYLr.cim-1BL corresponding to Lr46/Yr29 and QYLr.cim-7BL that is a putative novel QTL accounted for 5 to 57% and 12 to 35% of the phenotypic variation for resistance to LR and YR, respectively. These loci, in combination with another three LR QTL and two YR QTL, respectively, conferred high levels of resistance to both LR and YR in wheat under Mexican and Uruguayan environments. Among other detected QTL, QLr.cim-1DS, QLr.cim-2BL, and QYLr.icm-7BL may be new loci for APR to both rusts in common wheat.

Strengthening Free Healthcare in Rural Nepal.

Nepal, a mountainous country in South East Asia, still lags in increasing access to healthcare and reducing health inequity. Possible Non Government Organization based in Achham, Nepal, which is a sister organization of Possible International Non Government Organization based in New York, USA recognized the increasing health needs in the far western rural hilly parts of Nepal, where extreme poverty and illiteracy was creating a vulnerable picture especially in Achham. Possible (previously named Nyaya Health) started to operate Bayalpata Hospital in 2009 after completing more than one year of free health services in Sanfe-Bagar, Achham, in partnership with the Nepalese Ministry of Health and Population. It supports the idea that free health service has its own challenges but a public-private partnership can thrive while promote equity in health services.

Genetic Analysis of Adult Plant Resistance to Yellow Rust and Leaf Rust in Common Spring Wheat Quaiu 3.

Identifying and utilizing rust resistance genes in wheat has been hampered by the continuous and rapid emergence of new pathogen races. A major focus of many wheat breeding programs is achieving durable adult plant resistance (APR) to yellow (stripe) rust (YR) and leaf (brown) rust (LR), caused by Puccinia striiformis and P. triticina, respectively. This study aimed to determine the genetic basis of resistance to YR and LR in the common spring wheat 'Quaiu 3'. To that end, we evaluated 198 F5 recombinant inbred lines (RILs), derived from a cross of susceptible 'Avocet-YrA' with Quaiu 3, for APR to LR and YR in artificially inoculated field trials conducted in Mexico during the 2009 and 2010 growing seasons. High narrow-sense heritability (h2) estimates, ranging between 0.91 and 0.95, were obtained for both LR and YR disease severities for both years. The quantitative and qualitative approaches used to estimate gene numbers showed that, in addition to known resistance genes, there are at least two to three APR genes associated with LR and YR resistance in the RIL population. The moderately effective race-specific resistance gene Lr42 and the pleiotropic slow-rusting APR gene Lr46/Yr29 were found to interact with additional unidentified APR genes. The unidentified APR genes should be of particular interest for further characterization through molecular mapping, and for utilization by wheat breeding programs.

Universal health coverage in a regional Nepali hospital: who is exempted from payment?

This study assessed the characteristics of beneficiaries of a government-led policy of exemption for payment being provided in a regional hospital in Nepal. In January and February 2012, 9547 patients sought services at the out-patient clinic, the majority (83%) of whom were from the same district although this was a referral hospital for 15 districts. Only 10.8% received exemption from payment; 66% of the individuals aged >60 years and eligible for exemption were missed. These shortcomings highlight intrinsic weaknesses in the current implementing mechanisms for payment exemption, which may not be providing financial protection. This hampers efforts towards achieving universal health coverage.

Cette étude a évalué les caractéristiques des bénéficiaires d'une politique d'exemption de paiement menée par le Gouvernement du Népal dans un hôpital régional. Pendant les mois de janvier et février 2012, 9547 patients ont bénéficié des services de la polyclinique externe ; la majorité d'entre eux (83%) provenaient du même district en dépit du fait que l'hôpital régional servait d'hôpital de référence pour 15 districts. Seuls 10,8% des patients ont bénéficié de l'exception de paiement. Celle-ci n'a pas été attribuée à 66% des individus âgés de >60 ans et éligibles pour cette exemption. Ces déficiences témoignent de la faiblesse intrinsèque des mécanismes actuels de mise en œuvre de l'exemption de payement, ce qui pourrait entraîner l'absence d'apport d'une protection financière et entraver les efforts visant à réaliser la couverture universelle de santé.

En el presente estudio se evaluaron las características de los beneficiarios de una política gubernamental de exoneración del pago en un hospital regional de Nepal. Entre enero y febrero del 2012, 9547 pacientes recurrieron a los servicios de un dispensario clínico; la mayoría de las personas (83%) provenía de un mismo distrito, aunque el hospital de referencia atiende a la población de 15 distritos. Solo 10,8% se beneficiaron de la exención de pago; 66% de las personas > 60 años que cumplían con los requisitos de adjudicación no recibieron la ayuda. Estas fallas indican debilidades intrínsecas en los mecanismos vigentes de aplicación de la medida de exoneración de pago, con lo cual tal vez no se ofrece la protección económica adecuada y se obstaculizan las iniciativas encaminadas a lograr la cobertura universal de salud.

Depression among undergraduate medical students.

BACKGROUND: Psychological stress is common in medical school and associated with depression. Medical education is grooming in Nepal, but only few studies are done concerning mental health of medical students. OBJECTIVE: To assess the prevalence of depression among medical students at different levels of education and find about their stressors. METHODS: A cross sectional, questionnaire-based survey was carried out among the undergraduate medical students of B.P.Koirala Institute of Health Sciences, Nepal. 50 students each from Bachelor of Medicine and Bachelor of Surgery (MBBS) first and third year were enrolled in the study conducted between November 2008 to January 2009. The depression levels were assessed using Zung depression scale. Students were asked to complete the questionnaire and then the depression levels calculated .The stress inducing factors during their course of medical education were also assessed. RESULTS: The overall prevalence of depression among the students was 29.78 percent. The prevalence of depression in first and third year was 36.74and 22.22 percent respectively. The prevalence of depression was 32.43 percent among female students versus 28.07 percent in male students. Both first and third year students gave high ratings to academic stress and hectic lifestyle as the main stress inducing factors. CONCLUSION: The prevalence of depression is seen especially in the first year medical students. So, attempts should be made to alleviate the stressors right from the time they join medical school. Since academic stress proved to be one of the major factors, measures to make the academic curriculum more student-friendly are suggested.

Pattern of breast cancer in a tertiary care center.

INTRODUCTION: Breast Cancer is the second commonest cause of cancer death in women. Almost all women survive breast cancer if it is detected before it starts to spread. The aim of the study is to analyze the demographical profile, stage of presentation, histological type, and treatment modalities of breast cancer in a tertiary care setting. METHODS: Total 1141 cases of breast cancer had been followed retrospectively from 1999 to 2006 A.D. in a tertiary care center and their patterns were analyzed. RESULTS: The mean age of presentation of breast cancer was 47.30 +/- 11.57 years in female and 59.03 +/- 14.63 in male, 31 (2.1%) cases of breast cancer were male. There were 123 (10.78%) stage I, 281 (24.62%) stage II, 466 (40.84%) stage III, and 271 (23.75%) stage IV patients. Infiltrating ductal carcinoma was the commonest variety 610 (53.5%). Chemotherapy was the mainstay for treatment of breast cancer 341 (29.9%) followed by surgery 287 (25.2%). CONCLUSIONS: Breast cancer trend is rising with more in late and advanced stages, mostly due to lack of awareness. Infiltrating ductal carcinoma is the commonest variety. Chemotherapy is the most commonly used modality of treatment. Male breast cancer present late and is not so uncommon.

Electrocardiograph and chest X-ray in prediction of left ventricular systolic dysfunction.

INTRODUCTION: Echocardiography is the definitive diagnostic tool for left ventricular systolic dysfunction. But it's expensive and requires trained manpower and thus might not be available in the primary care set up. ECG and Chest X ray, the more basic investigations, may help diagnose LVSD or at least streamline those who absolutely require echocardiography in primary care setup. METHODS: ECG, Chest X ray and Echocardiography along with clinical assessment were performed on 35 patients with some form of complaints related to heart. The inferences on systolic function obtained from ECG, Chest X ray were compared with Echocardiography findings. RESULTS: Out of 35 participants, 25 had left ventricular ejection fraction less than 45%, 28 had abnormal ECG, 30 had cardiomegaly in chest X-ray. A set of pre-selected ECG abnormalities had a sensitivity of 100% (83.4-100), specificity of 70% (35.4-91.9) and a positive predictive value of 89.3% (70.6-97.2) in diagnosing LVSD. Likewise, the figures were 92% (72.5-98.6), 30% (8.1-64.6) and 76.7% (57.3-89.4) respectively for a cardio-thoracic ratio of more than 0.5 in chest X-ray. CONCLUSIONS: Although, ECG and Chest X ray could not replace Echocardiography, they could very well give an idea of the systolic function of an individual and suggest the need or no need for an echo-study in primary care setup.

A scenario of cervical carcinoma in a cancer hospital.

INTRODUCTION: Cervical carcinoma is an important women's health problem throughout the world. There are very few published data on this disease in Nepal. We wanted to study the pattern of cervical carcinoma based on hospital data. METHODS: A 10 years retrospective study of scenario of cervical carcinoma was conducted. The data have been analyzed according to age, occurrence of other cancers, histological type, religion, risk factors and district wise. RESULTS: The number of cervical carcinoma showed a rising pattern over the 10 year period. The median age of the patients was 45 years and maximum frequency (33%) of cases were found in the age group 40 to 49 years. Squamous cell carcinoma comprised 40% of cases, Adenocarcinoma 4% and 1.1% cases were of mixed variety. 92% of cases were Hindu by religion. 43% of patients were smoker in our study, 5% had positive family history. Chitwan with 7.35% had the maximum number of cases followed by Rupandehi with 6.40% and Nawalparasi with 5.41%. CONCLUSIONS: The cancer pattern revealed by the present study provides valuable leads to cervical cancer epidemiology in Nepal. Routine cytological screening of the population for cervical cancer is highly necessary for its early detection and treatment.

Effect of acute hepatitis E infection in patients with liver cirrhosis.

INTRODUCTION: Hepatitis E virus is a major cause of enterically transmitted hepatitis. Mortality is very high if it is associated with pregnancy, especially during third trimester. This study was carried out to find out the effects of acute HEV hepatitis on Chronic Liver Disease patients of different etiologies. METHODS: The consecutive patients of liver cirrhosis with definite evidence of recent HEV infection were enrolled in this study. Acute hepatitis was diagnosed by presence of prodromal symptoms and anti-HEV IgM antibody in their serum. The outcomes after superinfection with HEV hepatitis were determined by changes in Child Pugh score, recovery of liver function test, hospital stay and mortality. RESULTS: After exclusion 25 were studied. The etiology of cirrhosis in patients was: alcohol 13, autoimmune hepatitis 3, hepatitis B 2, Budd Chiari syndrome 2, alcohol plus hepatitis B 1, hepatitis C 1, cardiac cirrhosis 1, Wilson's disease 1 and cryptogenic 1. All patients with no recent decompensation showed signs of decompensation during admission. Seven (28%) patients died. The cause of death was either upper gastrointestinal bleeding or hepatorenal syndrome. Remaining patients had prolonged hospital stay with deterioration of Child-Pugh's score. CONCLUSIONS: Superinfection of HEV in cirrhotic patient causes rapid decompensation. The morbidity and mortality is higher compared to those non-infected patients. Development of hepatorenal syndrome and upper GI bleeding was commonest cause of death.

Solitary rectal ulcer syndrome: uncommon cause of rectal bleeding in children.

Rectal polyp and hemorrhoids are common causes of bleeding per rectum in pediatric age group. However, there are some other causes which should be considered in differential diagnosis. We have acquainted a case of rectal bleeding due to solitary rectal ulcer in a child of 10 year. Colonoscopic examination was required for diagnosis as proctoscopic examination and digital rectal examination missed the diagnosis, probably due to poor co-operation by the patient and rare nature of the disease. Although well recognized in the adult population, the pediatric experience with this condition is limited.

Selecting suitable sites for animal waste application using a raster GIS.

Rapid growth of intensive animal industries in southeast Queensland, Australia, has led to large volumes of animal waste production, which possess serious environmental problems in the Murray Darling Basin (MDB). This study presents a method of selecting sites for the safe application of animal waste as fertiliser to agricultural land. A site suitability map for the Westbrook subcatchment within the MDB was created using a geographic information system (GIS)-based weighted linear combination (WLC) model. The factors affecting the suitability of a site for animal waste application were selected, and digital data sets derived from up to 1:50,000 scale maps were acquired. After initial preprocessing, digital data sets were clipped to the size of the delineated subcatchment boundary producing input factors. These input factors were weighted using the analytical hierarchy process (AHP) that employed an objectives-oriented comparison (OOC) technique to formulate the pairwise comparison matrix. The OOC technique, which is capable of deriving factor weight independently, formulated the weight derivation process by making it more logical and systematic. The factor attributes were classified into multiple classes and weighted using the AHP. The effects of the number of input factors and factor weighting on the areal extent and the degree of site suitability were examined. Due to the presence of large nonagricultural and residential areas in the subcatchment, only 16% of the area was found suitable for animal waste application. The areal extent resulting from this site suitability assessment was found to be dependent on the areal constraints imposed on each input factor, while the degree of suitability was principally a function of the weight distribution between the factors.