Comparison of Nasal Colonization of Methicillin-Resistant Staphylococcus aureus in HIV-Infected and Non-HIV Patients Attending the National Public Health Laboratory of Central Nepal.

BACKGROUND: Staphylococcus aureus is a cardinal source of community- and hospital-acquired infection. HIV infection is a well-recognized risk factor for methicillin-resistant S. aureus (MRSA) carriage and infection. Intrinsically developed antibiotic resistance has sharply increased the burden of MRSA which is often associated with morbidity and mortality of the patients. Moreover, nasal carriage of S. aureus plays a significant role in spread of community-associated (CA) S. aureus infections. METHODS: This study was conducted from June 2016 to December 2016 at National Public Health Laboratory (NPHL), Kathmandu, with an aim to assess the rate of S. aureus nasal carriage and MRSA carriage among HIV-infected and non-HIV patients. A total of 600 nonrepeated nasal swabs were analyzed following standard microbiological procedures, where 300 swabs were from HIV-infected patients while remaining 300 were from non-HIV patients. The isolates were identified on the basis of colony characteristics and a series of biochemical tests. The antibiotic susceptibility test (AST) was performed by the modified Kirby-Bauer disc diffusion method. Inducible clindamycin resistance in isolates was confirmed by the D-test method. RESULTS: Overall, out of 600 nasal swabs of patients tested, 125 (20.8%) were S. aureus nasal carriers which included 80 out of 300 (26.66%) among HIV-infected patients and 45 (15%) out of 300 among non-HIV patients, and the result was statistically significant (p=0.0043). Among the isolated S. aureus, 11 (13.8%) MRSA were confirmed in HIV-infected while 3 (6.7%) MRSA were detected from non-HIV patients. A higher number of S. aureus carriers was detected among HIV-infected males 40 (26.49%), whereas MRSA carriage was more prevalent among HIV-infected females 7 (5.1%). Among the HIV-infected, patients of age group 31-40 years were the ones with highest carriage rate 36 (45%), while in non-HIV patients, the highest rate 13 (28.9%) of carriage was detected among the patients of age group 21-30 years. Statistically significant difference was found between S. aureus carriage and HIV infection in patients (p < 0.05). Higher rate 2/3 (66.7%) of inducible clindamycin resistance in MRSA was detected from non-HIV patients in comparison to HIV-infected patients 7/11 (63.63%) while the result was statistically insignificant (p > 0.05). All the MRSA isolates (100%) were resistant against co-trimoxazole while ciprofloxacin showed high rate of sensitivity towards both MSSA and MRSA. None of the isolates were detected as VRSA. The major factors associated with nasal colonization of S. aureus were close personal contact, current smoking habit, and working or living in a farm (p < 0.05). CONCLUSION: Regular surveillance and monitoring of MRSA nasal carriage and antibiotic susceptibility pattern are of prime importance in controlling S. aureus infections especially in high risk groups like HIV-infected patients.

Use of viber app: a fast, easy and cost effective method of communication in neurosurgery.

OBJECTIVE: Neurosurgeons often have to rely on judgments of junior staffs to decide on patients whom they cannot attend immediately. Viber is a free to use application for image transfer on Internet. We evaluated the use of viber in neurosurgical scenario, to show it is cheap, fast, accessible, reliable and feasible. MATERIALS AND METHODS: We conducted a prospective study from March 2013 to July 2013. Residents were taught to take sharp pictures and upload them immediately using viber on Internet. Primary endpoints were discordance between opinion of residents and consultants on viber images and subsequent actual image evaluation and time delay in decision-making. Discordance was considered significant if it changed management decision. RESULTS: During the study period, 120 (mean age: 42 years, 58% males) patients were enrolled. Wi-Fi is freely available in the institute and thus no costs were involved. Decision could be made on images received on viber at an average of 20 min. There was discordance in 56.7% cases between residents' reports and images on viber, which was significant in 88.2% cases. However in 5% cases decision changed after actual images were reviewed. Of all imaging modalities, computed tomography angiographic images were associated with statistically significant discordance (P <0.05). CONCLUSION: This study suggests that the use of viber app in neurosurgery can be an easy fast reliable and almost free mode of communicating images enabling a quick decision. However this cost-effective method should be used with caution particularly with imaging modalities, which require processing and review on console.

Intraspinal periosteal chondroma in upper thoracic spine causing cord compression and myelopathy: A case report.

INTRODUCTION: Chondromas are slow-growing cartilage-forming benign tumors, rarely occurring in the spine. Generally, most spinal chondromas are asymptomatic; however, with slow progressive growth, these lesions may enlarge and expand and cause compressive neurological symptoms, resulting in radiculopathy or more commonly myelopathy due to direct neural compression. PRESENTATION OF CASE: A 15-year-old male adolescent presented to Emergency Department with history of fall (slippage) on concrete ground while playing three months back. On neurological examination, the motor power in bilateral upper limbs was 5/5 while it was 1/5 in both lower extremities. Some muscle wasting was noted in the lower limbs. The planter reflexes were upgoing; and the sensory loss was below T6 spinal level. CT scan of dorsolumbar spine demonstrated a well-defined high-density lesion in lateral aspect of spinal canal at T2-T3 vertebral level adjacent to left T2-T3 facet joint. MRI of dorsal spine revealed a 3 × 2 × 1 cm3-sized, well-defined, non-enhancing T1 low to isointense and T2/STIR heterogeneous hyperintense lesion with osseous and cartilaginous components in the left lateral aspect of spinal canal at T1-T3 level, causing compression and contralateral displacement of spinal cord. The patient was then subjected to posterior laminectomy, complete excision, followed by laminoplasty using minicranial plates and screws. Histopathology of the mass showed bony trabeculae with hematopoietic elements and attached lobules of hyaline cartilage, chondroid matrix and lobules of mature chondrocyte and myxoid changes. Postoperatively his power was improved slightly and he was able to stand up with some assistance. On six-month follow up, patient showed significant neurological improvement. He was able to walk independently with minimal assistance. He was able to control bowel and bladder functions. DISCUSSION: Chondromas occurring in the spine are rare, accounting for only about 3% of all chondromas. Spinal chondromas are commonly encountered in the thoracic spine as in our case. CONCLUSION: Complete en bloc surgical excision is generally recommended as the treatment of choice for cases with local and/or neurological symptoms.

Clinical Characteristics and Outcome of Patients with Multiple Intracranial Aneurysms from a University Hospital in Nepal.

Objective The risk factors, management strategies, and outcomes of patients with multiple intracranial aneurysms (MIAs) are different compared with that of patients with a single aneurysm. Data are scarce regarding patients with MIAs from developing countries. The objective of this study was to describe the clinical characteristics, management strategies, and outcomes of patients treated microsurgically from Nepal. Methods The clinical records of patients confirmed to have MIAs and microsurgically clipped between July 2014 and December 2019 were retrospectively reviewed. Data on demographic and clinical characteristics, computed tomography findings, multiplicity and location of aneurysms, management strategies, and the 1-year outcome were abstracted and analyzed. Results Two hundred cerebral aneurysms were microsurgically clipped in 170 consecutive patients during the study period. Twenty-six (13.0%) patients harbored 60 aneurysms. The mean age of the patients was 58.5 (43-73) years. Smoking and hypertension were found in 20 (76.9%) and 16 (61.5%) patients, respectively. The majority of patients [17 (65.4%)] were in good grades at presentation. Twenty-one patients had two aneurysms, four had three aneurysms, and one patient had five aneurysms. The middle cerebral artery was the commonest (20) followed by distal anterior cerebral artery (14) and anterior communicating artery (13) involved in multiplicity. A single-stage surgery was performed on 17 patients. Serial clipping was performed in six patients. In three patients, a single aneurysm on the contralateral side was left untreated for various reasons. The favorable outcome was achieved in 23 (88.5%) patients whereas three (11.5%) patients had an unfavorable outcome. One patient died. Conclusion The demographic and clinical characteristics of patients in our series are comparable with those described in the published literature from other countries. With an individualized treatment strategy, an acceptable outcome can be achieved in the majority of the patients.

Temporal Delay in Neurosurgical Patients and Outcome in a Tertiary Care Center in Nepal.

BACKGROUND: Neurosurgery is a field where time from the incident to get treatment is very crucial. In low-income countries, the referral system is not well developed. In our country, a proper referral system is in the initial phase of development. We conducted a study assessing the number of visits a neurosurgery patient made before finally reaching to our center. METHODS: This is a prospective observational study involving seventy patients, conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Demographic characteristics, neurological diagnosis, and numbers of other centers the patients visited and outcome at discharge and in one month was assessed. RESULTS: Thirty-five (50%) patients were males. Thirty-three (47.1%) patients were admitted due to head injury and 13 (18.5%) were diagnosed with subarachnoid hemorrhage. Surgery was done in 32 (45.7%) patients. Fifty-three (75.7%) patients were transferred from other hospitals. Out of 53 patients, 30 (56.6%) and 17 (32%) had visited to one and two hospitals respectively. Unavailability of the neurosurgery facility was the main reason (77.4%) for the transfer. Overall mortality was 12.9%. The trend for mortality and length of hospital stay was higher in the group who visited other centers before coming to us than those who came directly. CONCLUSIONS: Visiting multiple hospitals where there is no neurosurgical service available is an important reason for delay. There is a need to develop neurosurgical facilities in the different parts of the country along with establishment of an effective referral mechanism.

Clinical Specimens are the Pool of Multidrug- resistant Pseudomonas aeruginosa Harbouring oprL and toxA Virulence Genes: Findings from a Tertiary Hospital of Nepal.

The multidrug- or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa carrying some virulence genes has become a global public health threat. However, in Nepal, there is no existing report showing the prevalence of oprL and toxA virulence genes among the clinical isolates of P. aeruginosa. Therefore, this study was conducted for the first time in the country to detect the virulence genes (oprL and toxA) and antibiotic susceptibility pattern of P. aeruginosa. A total of 7,898 clinical specimens were investigated following the standard microbiological procedures. The antibiotic susceptibility testing was examined by the modified disc diffusion method, and virulence genes oprL and toxA of P. aeruginosa were assessed using multiplex PCR. Among the analyzed specimens, 87 isolates were identified to be P. aeruginosa of which 38 (43.68%) isolates were reported as MDR. A higher ratio of P. aeruginosa was detected from urine samples 40 (45.98%), outpatients' specimens 63 (72.4%), and in patients of the age group of 60-79 years 36 (41.37%). P. aeruginosa was more prevalent in males 56 (64.36%) than in female patients 31 (35.63%). Polymyxin (83.90%) was the most effective antibiotic. P. aeruginosa (100%) isolates harboured the oprL gene, while 95.4% of isolates were positive for the toxA gene. Identification of virulence genes such as oprL and toxA carrying isolates along with the multidrug resistance warrants the need for strategic interventions to prevent the emergence and spread of antimicrobial resistance (AMR). The findings could assist in increasing awareness about antibiotic resistance and suggest the judicious prescription of antibiotics to treat the patients in clinical settings of Nepal.

Arsenic disturbs the gut microbiome of individuals in a disadvantaged community in Nepal.

Arsenic is ubiquitous in nature, highly toxic, and is particularly abundant in Southern Asia. While many studies have focused on areas like Bangladesh and West Bengal, India, disadvantaged regions within Nepal have also suffered from arsenic contamination levels, with wells and other water sources possessing arsenic contamination over the recommended WHO and EPA limit of 10 µg/L, some wells reporting levels as high as 500 µg/L. Despite the region's pronounced arsenic concentrations within community water sources, few investigations have been conducted to understand the impact of arsenic contamination on host gut microbiota health. This study aims to examine differential arsenic exposure on the gut microbiome structure within two disadvantaged communities in southern Nepal. Fecal samples (n = 42) were collected from members of the Mahuawa (n = 20) and Ghanashyampur (n = 22) communities in southern Nepal. The 16S rRNA gene was amplified from fecal samples using Illumina-tag PCR and subject to high-throughput sequencing to generate the bacterial community structure of each sample. Bioinformatics analysis and multivariate statistics were conducted to identify if specific fecal bacterial assemblages and predicted functions were correlated with urine arsenic concentration. Our results revealed unique assemblages of arsenic volatilizing and pathogenic bacteria positively correlated with increased arsenic concentration in individuals within the two respective communities. Additionally, we observed that commensal gut bacteria negatively correlated with increased arsenic concentration in the two respective communities. Our study has revealed that arsenic poses a broader human health risk than was previously known. It is influential in shaping the gut microbiome through its enrichment of arsenic volatilizing and pathogenic bacteria and subsequent depletion of gut commensals. This aspect of arsenic has the potential to debilitate healthy humans by contributing to disorders like heart and liver cancers and diabetes, and it has already been shown to contribute to serious diseases and disorders, including skin lesions, gangrene and several types of skin, renal, lung, and liver cancers in disadvantaged areas of the world like Nepal.