The impact of social determinants on health outcomes in a region in the North of England: a structural equation modelling analysis.

OBJECTIVES: The aim of this study was to identify the impact of social determinants of health on physical and mental health outcomes in a UK population. STUDY DESIGN: Structural equation modelling was used to hypothesise a model of relationships between health determinants and outcomes within a region in the North of England using large-scale population survey data (6208 responses). METHODS: We analysed responses from a population survey to assess the influence of a deprivation-based index at the environmental level, education and income on a behaviour index (smoking, alcohol consumption, physical activity, and dietary habits) and the influence of all these factors on self-reported physical health and the influence of the behaviour index and income on mental wellbeing. RESULTS: The proposed model was well supported by the data. Goodness-of-fit statistics, most notably a low value of the root mean square error of approximation (RMSEA), supported the validity of the proposed relationships (RMSEA = 0.054). The model revealed all examined paths to be statistically significant. Income and education were influential in determining an individual's behaviour index score, which, with income was the most important predictor of both the correlated outcomes of physical health and mental wellbeing (P < 0.001 in all cases). CONCLUSIONS: Findings challenge the traditional view of singular causal pathways, emphasising that interventions should consider the underlying influencing socio-economic conditions, which would influence behaviour and therefore physical and mental wellbeing. The extent to which the model is supported by the data, and the statistical significance of individual relationships accentuates the imperative for comprehensive public health strategies that integrate multiple socio-economic factors.

Teenage Pregnancy and Associated Risk Factors and Outcome in Nepal From 2000-2020: A Systematic Review and Meta-Analysis.

Background Teenage pregnancy is considered a high-risk pregnancy in terms of reproductive outcome and the subsequent financial constraint. Objective To assess the prevalence of teenage pregnancy, associated risk factors, and outcomes in the context of Nepal. Method We searched electronic databases to search relevant articles published from January 2000 till October 2020 using the keywords with appropriate Boolean operators. All the data were extracted into a standardized form designed in Excel. We conducted a statistical analysis using Comprehensive Meta-Analysis Software (CMA) version 3. Data pooled for proportion with 95% confidence interval (CI). A Forest plot was used to visualize the degree of variation between studies. Result Fourteen studies were included in the analysis after the rigorous screening of 4425 studies. Prevalence of teenage pregnancy was 13.2% (Proportion, 0.132; CI, 0.077- 0.215). Among teenage pregnancies, 11.8% were already multigravida (Proportion, 0.118; CI, 0.029-0.374). Among teen pregnancies, 18.6% were illiterate; among the literate, only 25.9% were of education above grade 10,31.9% were unaware of contraceptive methods, and only 3.2% reported using any contraception methods. 75.4% of teenage pregnancies had a vaginal delivery with or without episiotomy, 6.5% by instrumental deliveries, and 21.5% by cesarean section. Preterm delivery was 12.0%, and post-term delivery was 8.2%. Abortion was reported in 11.1% of teenage pregnancies. Major tears were reported in 52.9%, obstructed labor was in 4%, and pre-labor rupture of the membrane was in 7.0% of teenage pregnancies. The low birth weight of newborns was 19.4%. Stillbirth and neonatal deaths were 1.7% and 1.4%, respectively. Conclusion The prevalence of teenage pregnancy in Nepal was 13.2%. The majority of them did not use any form of contraceptives; and had low education. Several maternal and neonatal complications were reported among teenage pregnancies.

Systematic evaluation of magnetic sensitivities of anisotropic magnetoresistive sensors at liquid helium temperature for superconducting cavities.

Trapped magnetic flux in bulk superconductors reduces the quality factor Q in superconducting radio-frequency (SRF) cavities. However, the mechanisms underlying flux trapping and radio-frequency loss are not well understood. Detailed observation of the magnetic distributions is important for understanding such phenomena. Magnetic field mapping is useful for observing the magnetic field distribution around SRF cavities. Measuring the change in the magnetic field around the cavity elucidates the flux trapping behavior. Anisotropic magnetoresistive (AMR) sensors are inexpensive and small devices that can detect magnetic flux density. The magnetic sensitivities of AMR sensors need to be evaluated at liquid helium temperature for the magnetic field mapping of SRF cavities. In this study, a test stand was constructed to calibrate the magnetic sensitivities of AMR sensors in liquid helium, and 110 AMR sensors were tested using this stand. The magnetic sensitivities were evaluated systematically. A solenoid coil was used to control the uniform external magnetic field and to measure the magnetic sensitivity at low temperatures. All AMR sensors exhibited suitable sensitivities to the magnetic field around the SRF cavity. The variation in these sensitivities in all AMR sensors was ∼1%. The AMR sensors were found to have sufficient sensitivity for mapping the magnetic field around the exterior surface of the SRF cavity.

Cutaneous Leishmaniasis in Natives of Central Region of Nepal.

We report two cases of cutaneous leishmaniasis in natives of central region of Nepal. The first patient in our series, an adult female, presented with a small nodule on the philtrum of upper lip and the second case, a male child, presented with two crusted plaques on forehead. The final diagnosis was based on histopathological findings; however, species characterization was not possible because of its unavailability in the country. These patients responded well to the treatment with Miltefosine (First case) and Fluconazole (second case). Moreover, these cases sparks a question about the origin of diseases in this region and calls for further research in future to find out the cause and prevalence of this disease in Nepal. This case report also emphasizes to consider cutaneous leishmaniasis as differential diagnosis for granulomatous presentations in our context.

Nasal Carriage Rate of Methicillin Resistant Staphylococcus aureus among Health Care Workers at a Tertiary Care Hospital in Kathmandu, Nepal.

BACKGROUND: Methicillin-resistant Staphylococcus aureus is one of the most common causes of nosocomial infections. Due to its multidrug resistant nature; infections due to Methicillin-resistant Staphylococcus aureus are often very difficult to treat. Colonized health care workers are the important sources of Methicillin-resistant Staphylococcus aureus. The objectives of this study were to determine the nasal carriage rate of Methicillin-resistant Staphylococcus aureus among health care workers at Kathmandu Medical College and Teaching Hospital, Nepal and to assess their antimicrobial susceptibility patterns. METHODS: A cross sectional study was conducted among 252 health care workers from July to November 2013. Mannitol salt agar was used to culture the nasal swabs. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion technique following Clinical and Laboratory Standards Institute guidelines. Methicillin-resistant Staphylococcus aureus strains were confirmed by using cefoxitin disc and by determining the minimum inhibitory concentration of oxacillin by agar dilution method. RESULTS: Of 252 healthcare workers, 46(18.3%) were positive for Staphylococcus aureus among which 19(41.3%) were Methicillin-resistant Staphylococcus aureus carriers. Overall rate of nasal carriage of Methicillin-resistant Staphylococcus aureus was 7.5% (19/252).The higher percentages of lab personnel were nasal carriers of S. aureus (31.6%) and Methicillin-resistant Staphylococcus aureus (10.5%).The percentages of nasal carriage of S. aureus (35.7%) and Methicillin-resistant Staphylococcus aureus (14.3%) were highest in the health care workers from post operative department. Higher percentage of Methicillin-resistant Staphylococcus aureus were susceptible toward amikacin (100%) and vancomycin (100%) followed by cotrimoxazole (84.2%). CONCLUSIONS: High rates of nasal carriage of S. aureus and Methicillin-resistant Staphylococcus aureus were observed among the healthcare workers, which indicate the need of strict infection control measures to be followed to control the nosocomial infections.

Paediatric Stroke: A Rare Presentation of Iron Deficiency Anemia in a Four Year Old Child.

Paediatric stroke is an uncommon syndrome with even lesser annual incidence rates of arterial ischemic stroke in infants and children. In children the diagnosis of stroke is frequently delayed or missed. This is due to subtle and nonspecific clinical presentations, a complicated differential diagnosis and a lack of awareness by physicians and also delay in the seeking of medical attention as in our case. We report you a rare case of a four year old child from remote Nepal who presented to our Out Patient Department after a long gap of around four months after the sudden onset of loss of consciousness and decreased movement of right limbs who after detailed history examination and lab investigations and imaging revealed ischemic stroke due to iron deficiency anemia.

Pompe Disease: Cyanosed Hypotonic Infant with Normal Respiratory Rate.

Infantile hypotonia or floppy infant is a diagnostic challenge when it presents with other presenting complaints such as fever, cough or diarrhea. Many times the hypotonia goes unnoticed when other symptom covers the hypotonia and child continues to receive the treatment for other symptoms. We report a rare case from Nepal of infantile Pompe disease who presented with the history of fever and cough in the recent earthquake disaster camp at remote part of Sindhupalchowk, Nepal. He was being treated as a case of pneumonia. Pompe disease can be diagnosed clinically by taking detailed history and correlating the clinical findings during the presentation with other symptoms. In our case the normal respiratory rate, reduced Spo2 and presence of crackles dominated the hypotonia and was mistreated as pneumonia. High index of suspicion is necessary in diagnosing Pompe disease.

Prescribing for older people discharged from the acute sector to residential aged-care facilities.

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk-benefit ratio.

Safety profile and patient satisfaction of the routine use of propofol in gastrointestinal endoscopy.

BACKGROUD: Routine use of sedation in upper gastrointestinal endoscopy is uncommon in Nepal. There is no study on use of propofol sedation in routine endoscopy examination in Nepal. This study was conducted in order to assess the patient satisfaction and safety profile in patient undergoing routine upper GI endoscopic examination on outpatients. OBJECTIVE: To study safety profile and patient satisfaction of use of propofol in patients undergoing upper GI endoscopy. METHOD: A prospective, observational study was conducted in the endoscopy unit of Dhulikhel hospital, Kathmandu University Hospital from July 2011 to 2012 July. Patients who were referred to upper GI endoscopy were offered to sedation under propofol. Informed consent was taken after explaining side effects, advantages and risk-benefit to the clients. The propofol was administered by the endoscopy nurse under guidance and supervision of the endoscopy performing physician. Data were collected and analyzed using SPSS version 16.0 with 0.05 level of significance. RESULT: Total of 203 patients included in the study. Among 203 patients, 21.2% were males and 78.8% were females; 83.7% were of less than of 60 years age and 16.3% above 60 years of age. The mean total dose of propofol required was 136.08 ± 48.82 mg. Total of 29.1 % of cases required O2 administration during the procedure time due to transient drop in O2 saturation. Total of 4.4% of cases required fluid administration due to transient fall in blood pressure. Total of 68.0% of cases were completely sedated; 28.6% had minor restless and 3.4% showed agitation during induction period of propofol sedation. Total of 99.5% of patients reported pleasant experience while 0.5% reported unpleasant. Among 203 respondents, 98.5% responded they would prefer to do the procedure under propofol sedation in the future; 1.5% responded they did not want sedations in the future. CONCLUSION: Upper GI endoscopy can safely be performed under propofol sedation administered by registered trained nurse under the supervision of endoscopist.

Frailty: a key indicator to minimize inappropriate medication in older people.

Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.

The burden of dengue infection in some vulnerable regions of Nepal.

Dengue is an emerging mosquito borne disease of public health importance in Nepal. A descriptive cross sectional study was carried out to estimate sero-prevalence and distribution pattern of dengue in certain vulnerable regions of Nepal from June to September 2009. A total of 460 venous blood samples were collected from individuals experiencing a febrile illness clinically consistent with dengue infection visiting nearby hospitals of Kanchanpur, Kailali, Banke, Dang and Chitwan districts. The sero-prevalence of dengue virus specific IgM was determined by enzyme linked immunosorbent assay (ELISA) kit. The anti-dengue IgM positivity was found to be 12.17%. The higher frequency of positive cases (16.4%) were from age group 20-40 years followed by < 20 years age group with 9.7% and 5.3% from > 40 years age group. The association between dengue infection and age is found to be statistically significant (p < 0.05). The male:female ratio was determined as 1.3:1 in IgM positive population. Among sampling areas, Kanchanpur showed highest prevalence of dengue infection (15.5%) followed by Chitwan (11.7%), Kailai (11.1%), Banke (10.7%) and Dang (8.3%). Similarly, 94.6% of the positive cases were indigeneous and had no history of travel to other countries. Dengue is firmly established in terai region with increasing trends of infection and expansion into newer areas raising a public health threat. Regular epidemiological studies are suggested which could further reveal the contributing factors associated with dengue virus infection and help in formulating strategies in reducing the transmission rate and control of the infection.

Etiology and antimicrobial susceptibility pattern of bacterial pathogens from urinary tract infection.

Urinary tract infection (UTI) is the most common infection in both community and hospital patients. In majority of the cases, empirical antimicrobial treatment is practiced before the laboratory results of urine culture. Thus, antibiotic resistance may increase in urinary bacterial pathogens due to improper use of drugs. This study was designed to find out the etiological agents of UTI and their prevalence, and to determine the antimicrobial susceptibility pattern of the bacterial pathogens isolated from urine culture. This study was conducted in Kathmandu Model Hospital, Kathmandu, Nepal from April to October, 2009. Midstream Urine samples from 1323 patients suspected of UTI were analyzed by microscopy, and conventional semi-quantitative culture technique for the significant growth. Antimicrobial susceptibility test was performed for the isolates by Modified Kirby-Bauer disk diffusion method. Data were analyzed using SPSS software window version 16. The overall prevalence of UTI was found to be 18.89%. The most frequent causative organisms isolated were Escherichia coli (82.30%), Enterococcus faecalis (5.60%), Citrobacter freundii (3.60%), Enterobacter aerogenes (2.40%), Coagulase Negative Staphylococci (2.40%), Pseudomonas aeruginosa (1.20%), Proteus mirabilis (0.8%), Klebsiella pneumoniae (0.4%), and Staphylococcus aureus (0.4%). Nitrofurantoin and Amoxycillin were found to be the most effective antibiotic against gram negative and gram positive isolates respectively. E. coli was found to be the most common etiological agent of UTI and Nitrofurantoin was the most effective drug among the isolates.

Evaluation of non-HDL-c and total cholesterol: HDL-c ratio as cumulative marker of cardiovascular risk in diabetes mellitus.

BACKGROUND: Cardiovascular disease (CVD), is the primary cause of morbidity and mortality in patients with diabetes and have approximately--two to four times higher CVD rate than adult without diabetes. Low density lipoprotein cholesterol (LDL-C) is primarily used as the marker of cardiovascular risk in diabetes despite its several limitations. Although several newer markers of CVD are emerging, no marker has been established in Nepal. OBJECTIVES: The study was designed to evaluate the non-high-density-lipoprotein- cholesterol(Non-HDL-C) and Total Cholesterol to High density lipoprotein cholesterol (TC:HDL-C ratio) as CVD risk marker in diabetes mellitus. METHODS: The study was conducted in the Department of Biochemistry, Kathmandu University School of Medical Sciences. The study comprised of 76 diabetic subjects and 60 non-diabetic subjects. The anthropometric and biochemical parameters were measured. The Non-HDL-C and TC:HDL-C ratio were also calculated employing their respective formula. RESULTS: Body mass index (BMI), waist circumference (WC), blood pressure and lipid parameters were significantly different between diabetic subjects and non-diabetic subjects. There was increased non-HDL-C and TC:HDL-C ratio in subjects with diabetes mellitus. Furthermore, statistically significant correlations of non-HDL-C and TC:HDL-C ratio were obtained with BMI, WC, total cholesterol, HDL-C and LDL-C in diabetic subjects. CONCLUSIONS: The present study observation revealed that the Non-HDL-C and TC: HDL-C strongly correlate with established independent risk factors such as obesity(WC), elevated blood pressure, HDL-C and LDL-C in diabetes. Thus, the evaluation of Non-HDL-C and TC: HDL-C ratio can be used as the simple, cost-effective and cumulative marker of cardiovascular risk in diabetes mellitus.

Clinical profiling and use of loop-mediated isothermal amplification assay for rapid detection of Mycobacterium tuberculosis from sputum.

BACKGROUND: Tuberculosis is a global health problem and the situation is worsening with newer incidences of drug resistance and HIV association. Diagnosis of tuberculosis can be done by many methods and test, culture of sputum being the ideal one. Nucleic acid amplification (NAA) assay are more time efficient one, that amplify and detect specific nucleic acid sequences allows rapid, sensitive and specific detection of M. tuberculosis in sputum samples. OBJECTIVES: The present study intends to compile the clinical presentations of the pulmonary tuberculosis (PTB) patients and to evaluate the efficacy of in-house loop-mediated isothermal amplification (LAMP) in detecting Mycobacterium tuberculosis in sputum samples by comparing with microscopy and culture. MATERIALS AND METHODS: Two hundred two sputum samples were collected from 202 patients at National Tuberculosis Center, Bhaktapur, Nepal. Complete clinical profiling, epidemiological data and record on BCG vaccination were noted and the samples were subjected for microscopy, culture and in-house LAMP with six primers specific for 16S RNA gene of Mycobacterium tuberculosis. RESULT: Of the 176 cases of clinical profiling, productive cough was most common symptom in 147 (83.52%), followed by chest pain 136 (77.27%), fever 133 (75.56%) and haemoptysis 61 (34.66%). There was a statistically significant association between BCG vaccination and development of TB (chi(2)=5.33, P=0.02). Of 202 cases, 115 (56.93%) were chest X-ray positive, 101(50%) were direct smear-positive and 100 (49.51%) were culture positive. LAMP had a sensitivity of 97% and specificity of 94.12% while comparing with culture. In addition, its sensitivity and specificity were 91.09% and 89.11% respectively with reference to microscopy. CONCLUSION: As in our previous study, overall, the result of present study further confirms that the in-house LAMP is a simple, rapid, sensitive and specific DNA amplification technique for PTB diagnosis. Because of rapidity of microscopy and specificity of culture, in-house LAMP assay can be used as a very powerful and useful supplementary tool with complete clinical profiling of the patients for rapid diagnosis of TB in both AFB-positive and negative cases who are suspected as PTB in disease endemic country like Nepal.

Irrational fixed dose combinations in Nepal: need for intervention.

A large proportion of drugs available are of little importance in terms of fulfilling primary healthcare needs. Combination drugs increase the risk of side effects, lead to an ineffective dosage and liability to abuse and may also needlessly increase the cost. Drug combinations make it more difficult to find the causative agent responsible for the adverse reactions. In many cases their stability is doubtful, reducing the efficacy of many preparations. The Fifteenth WHO model list of essential medicines (March 2007) contains only 25 approved fixed dose combinations, whereas in Nepal, there are innumerable examples of irrational drug combinations, which are easily available and can be bought even without a prescription. A system of screening the drug combinations that are already licensed and available in the market is implemented in many developed and developing countries. Rational combinations can be of immense help to the health care system. These combinations may improve the quality of life for many and increase compliance. But irrational fixed dose combination products can be equally harmful.