Maternal and fetal characteristics and causes of stillbirth in a tertiary care hospital of Nepal: secondary analysis of registry-based surveillance data.

OBJECTIVES: Stillbirth is one of the vital indicators of quality care. This study aimed to determine maternal-fetal characteristics and causes of stillbirth in Nepal. DESIGN: Secondary analysis of single-centred registry-based surveillance data. SETTING: The study was conducted at the Department of Obstetrics and Gynecology, Chitwan Medical College Teaching Hospital, a tertiary care hospital located in Bharatpur, Nepal. PARTICIPANTS: All deliveries of intrauterine fetal death, at or beyond 22 weeks' period of gestation and/or birth weight of 500 g or more, conducted between 16 July 2017 and 15 July 2019 were included in the study. MAIN OUTCOME MEASURES: The primary outcome measure of this study was stillbirth, and the secondary outcome measures were maternal and fetal characteristics and cause of stillbirth. RESULTS: Out of 5282 institutional deliveries conducted over 2 years, 79 (1.5%) were stillbirths, which gives the stillbirth rate of 15 per 1000 births. Of them, the majority (75; 94.9%) were vaginal delivery and only four (5.1%) were caesarean section (p<0.0001). The proportion of the macerated type of stillbirth was more than that of the fresh type (58.2% vs 41.8%; p=0.13). Only half of the mothers who experienced stillbirth had received antenatal care. While the cause of fetal death was unknown in one-third of cases (31.6%; 25/79), among likely causes, the most common was maternal hypertension (29.1%), followed by intrauterine infection (8.9%) and fetal malpresentation (7.6%). Four out of 79 stillbirths (5%) had a birth defect. CONCLUSION: High rate of stillbirths in Nepal could be due to the lack of quality antenatal care. The country's health systems should be strengthened so that pregnancy-related risks such as maternal hypertension and infections are identified early on. Upgrading mothers' hygiene and health awareness is equally crucial in reducing fetal deaths in low-resource settings.

A Study of Metabolic Parameters in Patients with Gout: A Single Center Study from Nepal.

BACKGROUND AND AIMS: To study the prevalence of deranged metabolic parameters in patients with gout. METHODS: This was a prospective, cross-sectional observational study conducted at a tertiary level rheumatology center in Nepal. Patients over 18 years and diagnosed as gout using the ACR/EULAR 2015 classification criteria were included in the study. Known cases of chronic kidney disease, liver disease and heart diseases were excluded. Baseline demographic data along with records of weight, waist circumference, lipid profile, glucose profile, blood pressure measurement, serum uric acid level and inflammatory markers were taken. Diagnosis of metabolic syndrome (MS) was made according to the National Cholesterol Education Program criteria. Approval was obtained from the ethical review board of the National Center for Rheumatic Diseases. RESULTS: A total of 523 patients with gout were enrolled in the study, out of which 97.0% were male. The mean age at diagnosis was 49.1±12.8 years. Most of the patients were overweight with a mean BMI of 27.0±3.6 kg/m2. About 8.1% had preexisting diabetes mellitus, 24.6% had hypertension, 5.1% had hypothyroidism and 45.1% had dyslipidemia. Patients fulfilling 2 out of 5 criteria of MS were 60.6% whereas 30.6% fulfilled 3 out of 5 criteria. CONCLUSION: Gout was commonly observed in middle-aged men. The prevalence of metabolic syndrome and its components was high in patients with gout. Management of gout should also include screening and management of the metabolic syndrome.

Clinico-demographic Profile of Undifferentiated Inflammatory Arthritis Patients.

BACKGROUND: Undifferentiated inflammatory arthritis is a group of inflammatory joint diseases that do not fulfil the classification criteria for any other rheumatic or connective tissue disorders. This study aims to describe the clinical, demographic and serological features of undifferentiated inflammatory arthritis cases presenting at a tertiary level rheumatology centre from Nepal. METHODS: A descriptive cross-sectional study conducted at National Centre for Rheumatic Diseases, Kathmandu, Nepal which represents a midterm analysis of the undifferentiated inflammatory arthritis registry maintained at the centre. Patients more than 18 years of age, who consented for the study having least one swollen or tender joint were enrolled. Ethical approval was obtained from Nepal Health Research Council. RESULTS: A total of 1120 patients were enrolled in the study out of which 941 (84%) were females. The mean age at diagnosis was 46.0±12.8 years and most of them were in overweight range (mean BMI: 27.0±5.8) with 818 (73%) patients having BMI more than 24.0. Patients mostly had low disease activity at presentation (DAS 28 score of 2.5±0.8). Other markers of inflammation and patient reported outcome measures (health assessment questionnaire, patient global assessment and visual analogue scale) were also in the moderate range. Seropositivity for anti-citrullinated peptides and anti-nuclear antibodies was seen in 5 (0.45%) and 43 (3.8%) patients respectively. Majority of patients were non-smokers (77%). Inflammatory arthritis on musculoskeletal ultrasonography was seen in 638 (57%). CONCLUSIONS: Undifferentiated inflammatory arthritis was more common in overweight females. Serological markers and smoking status are not common features in these patients.

Translation, validation and cross-cultural adaptation of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language.

OBJECTIVE: To translate, cross-culturally adapt and test the psychometric properties of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language (Nepali FIQR). METHODS: The translation was performed following the methodological standards described by Beaton. Comprehensibility testing of the preliminary version was done in 40 fibromyalgia patients, and a pre-final version was prepared after making changes in the original version to maintain the equivalence with the target version. Psychometric testing was done in another group of 130 fibromyalgia patients to test for content validity and reliability. Construct validity was tested with visual analog score (VAS) for pain and Short Form (SF)-36. RESULTS: Nepali FIQR was comprehensible to 92.5% patients. The internal consistency was also acceptable with Cronbach's alpha of 0.900, 0.714 and 0.863 for function, overall and symptoms domain, respectively. Construct validity was also acceptable with a moderate correlation between Nepali FIQR and VAS and SF-36. Test-retest reliability of the total Nepali FIQR and of each item were acceptable with intraclass correlation coefficient (ICC) of >0.7 in all items except for question 1 of function domain (ICC: 0.65). CONCLUSIONS: Nepali FIQR is a comprehensible, reliable and valid tool for evaluation of the functional status of Nepalese patients with fibromyalgia and should be implemented in routine clinical care and research settings.

A Simplified Understanding of the Black Swan: Anti-phospholipid Antibody Syndrome.

Anti-phospholipid Antibody Syndrome or Hugh's syndrome is a heterogeneous disorder, first fully described in 1980s. The syndrome is caused by the presence of specific antibodies against phospholipid binding plasma proteins in the serum of the patient, with or without underlying autoimmune diseases, that causes prolongation of tests of coagulation. High index of clinical suspicion is required for diagnosis of Anti-phospholipid Antibody Syndrome. Stroke or myocardial infarction in young, unprovoked recurrent deep vein thrombosis and recurrent pregnancy loss are typical scenarios where Anti-Phospholipid Antibody Syndrome should be suspected. Presence of non-criteria manifestations like livedo reticularis, skin ulcers, nephropathy, valvular heart disease and thrombocytopenia adds to diagnostic clue for presence of Anti-Phospholipid Antibody Syndrome. Treatment of Anti-Phospholipid Antibody Syndrome has preventive and therapeutic aspects that usually focus on thrombotic and obstetric manifestations of the disease. Therapeutic anti-coagulation with heparin followed by warfarin is required for patients presenting with acute thrombosis. Those with venous thrombosis are given moderate intensity warfarin International Normalized Ratio, 2-3), whereas those with arterial thrombosis or recurrent venous thrombosis even on warfarin are treated with high intensity warfarin (International Normalized Ratio, 3-4). Similarly, anticoagulation with heparin is advised in patients with obstetric Anti-Phospholipid Antibody Syndrome throughout pregnancy and up to six weeks postpartum. Treatment recommendations are still not clear for asymptomatic Anti-Phospholipid Antibody Syndrome positive patients and in those with non-criteria manifestations of the disease. Steroids, intravenous immunoglobulin and immunosuppressant are reported to be effective in severe cases of catastrophic antiphospholid syndrome characterized by rapid small vessel thrombotic involvement of multiple organ systems. Studies are evaluating the efficacy of direct thrombin inhibitors in the management of refractory cases. Keywords: anticoagulants; anti-phospholipid syndrome; obstetric APS; thrombotic APS.

Translation, cross-cultural adaptation and validation of Nepali version of Health Assessment Questionnaire-Disability Index in rheumatoid arthritis patients from Nepal.

OBJECTIVE: To translate, cross-culturally adapt and validate the Health Assessment Questionnaire-Disability Index (HAQ-DI) in Nepali language (Nepali HAQ). METHODS: Translation was done fulfilling the methodological standards described by Beaton. Comprehensibility testing of the preliminary version was done in 50 rheumatoid arthritis (RA) patients, and a prefinal version was prepared after making changes in the original version to maintain the equivalence with the target version. Psychometric testing was done in another group of 127 rheumatoid patients to test for content validity and reliability. Construct validity was tested with visual analog score (VAS) and numeric rating scales (NRS) for pain and stiffness. RESULTS: Nepali HAQ was comprehensible in >95% of patients. Reliability testing showed an intraclass coefficient for overall Nepali HAQ of 0.76, ranging from 0.71 to 0.95. The internal consistency was acceptable with a Cronbach's alpha of .92. Construct validity was also acceptable with a moderate correlation between Nepali HAQ and VAS and NRS. CONCLUSIONS: Nepali HAQ is a comprehensible, reliable and valid tool for evaluation of the functional status of Nepalese patients with RA and should be implemented in clinical care and research settings.

Efficacy of high dose vitamin D supplementation in improving serum 25-hydroxyvitamin D among laboratory personnel working at the Nepal National Center for Rheumatic Diseases.

Vitamin D deficiency is a highly prevalent condition worldwide. However, few studies have been conducted to examine the vitamin D status of laboratory personnel and the correlation between vitamin D deficiency and working conditions. The aim of the present study was to assess changes in serum 25-hydroxyvitamin D [25(OH)D] concentration with a weekly dose of oral cholecalciferol (60,000 IU) for two months. The prospective, open-label, interventional study was conducted from January 2016 to March 2016 at the National Centre for Rheumatic Diseases, Kathmandu, Nepal. The serum level of 25(OH)D in 19 healthy laboratory volunteers was measured at baseline and following the 2-month regimen with cholecalciferol supplement at 60,000 IU (1,500 µg)/week in oral tablet form. At baseline the mean serum 25(OH)D level was 10.31±7.78 ng/ml, which was increased following completion of the course of oral cholecalciferol to 59.78±14.74 ng/ml. This difference in the mean serum level of 25(OH)D compared with baseline was significant to P<0.001. These results indicate that vitamin D deficiency is prevalent among laboratory workers, and that high dose vitamin D3 (60,000 IU cholecalciferol) in tablet form may be effective in achieving sufficient serum 25(OH)D among laboratory personnel who tend to have lower baseline serum 25(OH)D. In conclusion, vitamin D deficiency may be common among laboratory workers, and guidelines should be formulated to implement vitamin D supplementation among laboratory personnel, as well as indoor workers, in Nepal.

HYPEREMESIS GRAVIDARUM IN A TERTIARY CARE CENTRE IN EASTERN NEPAL: A PROSPECTIVE OBSERVATIONAL STUDY.

BACKGROUND: Hyperemesis gravidarum (HG) is the most severe form of nausea and vomiting of pregnancy which can have potentially dangerous complications if untreated. Its treatment is basically supportive as the condition itself is self-limiting. The aim of our study was to evaluate maternal characteristics in patients with HG including risk factors and treatment outcome with respect to improvement in Pregnancy Unique Quantification of Emesis (PUQE) scores, number of doses of antiemetics used, weight gain during treatment and duration of intravenous fluid therapy METHODS: A cross-sectional study where all women admitted to B.P. Koirala Institute of Health Sciences with a diagnosis of HG during a period of one year were studied for different maternal characteristics. The severity of disease was quantified using Modified PUQE score and the various treatment outcomes considered. RESULTS: The admission for hyperemesis gravidarum (n=81, including 13 readmissions) was 10.64% of total early pregnancy admissions (n = 735).The condition was more common in nulliparous patients (56%) at a mean period of gestation of 8.93 ± 2.33 wks. Most patients suffered from moderate to severe disease at presentation, mean PUQE scores being 12.29 ± 1.59. The median number of doses of intravenous antiemetics used was three (IQR 3-6), median weight gain was one kg (IQR 0-1 kg), median duration of intravenous fluid therapy was 24 hrs (IQR 24-48 hrs) and mean length of hospital stay was 3.2 ± 1.48 days. CONCLUSIONS: Hyperemesis is one of the common causes of hospitalization in early pregnancy. Treatment has favourable outcome with early recovery.