Adult Height and Risk of Colorectal Cancer: A Pooled Analysis of 10 Population-based Cohort Studies in Japan.

BACKGROUND: While tall stature has been linked to an increase in the risk of colorectal cancer (CRC), its association with cancer in the colorectum and its subsites remains unclear among Asians. METHODS: We conducted a pooled analysis of 10 population-based cohort studies among adults in Japan. Each study estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for CRC incidence associated with adult height were estimated using Cox proportional hazards regression with adjustment of the same set of covariates were then pooled to estimate summary HRs incidence using random-effect models. RESULTS: We identified 9,470 CRC incidences among 390,063 participants during 5,672,930 person-years of follow-up. Men and women with tall stature had a higher risk of CRC and colon cancer. HRs for CRC, colon cancer, and distal colon cancer for the highest versus lowest height categories were 1.23 (95% CI, 1.07-1.40), 1.22 (95% CI, 1.09-1.36), and 1.27 (95% CI, 1.08-1.49), respectively, in men and 1.21 (95% CI, 1.09-1.35), 1.23 (95% CI, 1.08-1.40), and 1.35 (95% CI, 1.003-1.81), respectively, in women. The association with proximal colon cancer and rectal cancer was less evident in both sexes. CONCLUSION: This pooled analysis confirms the link between tall stature and a higher risk of CRC and colon cancer (especially distal colon) among the Japanese and adds evidence to support the use of adult height to identify those at a higher risk of CRC.

Comparison of waist circumference and waist-to-height ratio as predictors of clustering of cardiovascular risk factors among middle-aged people in rural Khanh Hoa, Vietnam.

OBJECTIVE: Given the population-level variation in stature, a universal cut-off for waist circumference (WC) may not be appropriate for some populations. We compared the performance of WC and waist-to-height ratio (WHtR) to detect the clustering of cardiovascular disease (CVD) risk factors in rural Vietnam. METHODS: We obtained data from a baseline survey of the Khanh Hoa Cardiovascular Study comprising 2942 middle-aged residents (40-60 years). We used areas under the receiver operating characteristics curve (AUROC), net reclassification index (NRI), and integrated discrimination improvement (IDI) to compare the performance of WC and WHtR in predicting CVD risk clustering (≥2 of the following risk factors: hypertension, diabetes, dyslipidemia, and elevated C-reactive protein). RESULTS: The optimal cut-off values for WC were 81.8 and 80.7 cm for men and women, respectively. Regarding the clustering of CVD risk factors, the AUROC (95% CI) of WC and WHtR were 0.707 (0.676 to 0.739) and 0.719 (0.689 to 0.749) in men, and 0.682 (0.654 to 0.709) and 0.690 (0.663 to 0.717) in women, respectively. Compared with WC, WHtR had a better NRI (0.229; 0.102-0.344) and IDI (0.012; 0.004-0.020) in men and a better NRI (0.154; 0.050-0.257) in women. CONCLUSIONS: The optimal WC cut-off for Vietnamese men was approximately 10 cm below the recommended Asian cut-off. WHtR might perform slightly better in predicting the clustering of CVD risk factors among the rural population in Vietnam.

Perceptions on violence against women and its impacts on mental health and response mechanisms among community-based stakeholders: a qualitative study from Nepal.

BACKGROUND: Violence against women (VAW) is a significant public health problem. With the emergence of the COVID-19 pandemic, the frequency and severity of VAW has escalated globally. Approximately one in four women in Nepal have been exposed to either physical, psychological, and/or sexual violence in their lifetime, with husbands or male partners being the perpetrators in most cases. VAW prevention has been under-researched in low- and middle-income countries, including Nepal. This study aims to explore the perspectives of local stakeholders, including healthcare providers and survivors of violence in Madhesh Province. The overarching goal is to provide insights for designing prevention and support programs that are acceptable to communities and cater to the needs of survivors. METHODS: An explorative qualitative study was conducted in Madhesh Province, southern Nepal. A total of 21 interviews, including 15 in-depth interviews (IDIs) with health care providers, three IDIs with women seeking general or maternal and child health services at health care centres, three key informant interviews with the local stakeholders working in the field of VAW, and one focus group discussion with violence survivors, were conducted in Nepali by trained field interviewers. Interviews were recorded, transcribed, translated into English, and analysed using content analysis. RESULTS: VAW, particularly physical violence, was a common experience in the study area. Sociocultural traditions such as dowry, child marriages and son preference were identifiable triggers for VAW, causing significant physical injuries and mental health problems, including suicide. Health care providers reported that violence survivors often hide their experiences of violence and do not seek any kind of help. Women feared that violence would increase in frequency and intensity if their perpetrators found out that they had disclosed their experiences of violence to health care providers. Local stakeholders emphasized the importance of engaging community leaders and garnering support from both women and men in interventions designed to reduce VAW and its impacts on mental health. CONCLUSIONS: Participants reported that verbal and physical violence is often perceived as a normal part of women's lives. Women should be made aware of available support services and empowered and supported to increase access and uptake of these services. Additionally, more individual-based counselling sessions that encourage women to escape violence and its mental health consequences while maintaining privacy and confidentiality are recommended.

Parental absence during childhood and weight status in adulthood among middle-aged community dwellers in rural Vietnam.

OBJECTIVES: While adverse childhood experiences (ACEs) have been shown to be associated with adulthood obesity, less is known about their association with underweight. We examined the associations between parental absence (i.e., a major component of ACEs) and both underweight and excess weight among middle-aged rural community dwellers in Vietnam, where experiences of parental absence was not uncommon during and after the Vietnam War (1955-1975). METHODS: Data came from 3000 middle-aged adults who participated in the baseline survey of Khánh Hòa Cardiovascular Study. Parental absence was defined as parental absence due to death, divorce, or out-migration. Using information on the timing of such events, we categorized participants into those who experienced parental absence before the age of 3, between the ages of 3 and 15, and those without such experiences. BMI was calculated based on measured height and weight (kg/m2 ) and categorized into three groups: underweight <18.5; normal 18.5-24.9; excess weight ≥ 25. Multinomial logistic regression was then used to investigate the association between parental absence and adult weight status. RESULTS: Parental absence that occurred before the age of 3 was marginally significantly associated with underweight (relative risk ratio [RRR] = 1.44, 95% confidence interval [CI] 0.95, 2.20) but not with overweight/obesity. Parental divorce was associated with overweight/obesity (RRR = 2.48, 95% CI 1.28, 4.81), but not parental absence due to migratory work. CONCLUSIONS: While previous studies in Western settings focused almost exclusively on the risk of obesity in relation to exposure to ACEs, our findings point to the potential importance of considering the risk of underweight in low- and middle-income countries.

Eating speed and abdominal adiposity in middle-aged adults: a cross-sectional study in Vietnam.

BACKGROUND: Several studies have associated fast eating speed with the risk of general obesity, but there are inadequate data on the association between eating speed and abdominal adiposity which may pose a higher threat to health than general obesity. The present study aimed to investigate the association between eating speed and abdominal obesity in a Vietnamese population. METHODS: Between June 2019 and June 2020, the baseline survey of an ongoing prospective cohort study on the determinants of cardiovascular disease in Vietnamese adults was conducted. A total of 3,000 people aged 40-60 years old (1,160 men and 1,840 women) were recruited from eight communes in the rural district of Cam Lam, Khanh Hoa province, in Central Vietnam. Self-reported eating speed was assessed on a 5-point Likert scale, and responses were collapsed into the following three categories: slow, normal, and fast. Abdominal obesity was defined as a waist-to-height ratio of ≥ 0.5. Poisson regression with a robust variance estimator was used to assess the association between eating speed and abdominal obesity. RESULTS: Compared with slow eating speed, the adjusted prevalence ratio (95% confidence interval) for abdominal obesity was 1.14 (1.05, 1.25)1.14 (1.05, 1.25) for normal eating speed and 1.30 (1.19, 1.41) for fast eating speed (P for trend < 0.001). CONCLUSION: A faster eating speed was associated with a higher prevalence of abdominal obesity in a middle-aged population in rural Vietnam.

Different associations of occupational and leisure-time physical activity with the prevalence of hypertension among middle-aged community dwellers in rural Khánh Hòa, Vietnam.

BACKGROUND: In contrast to high-income countries where physical activity (PA), particularly leisure-time PA, has been shown to be protective against hypertension, few studies have been conducted in low- and middle-income countries. We examined the cross-sectional association between PA and hypertension prevalence among rural residents in Vietnam. METHODS: We used data collected in the baseline survey of a prospective cohort study, among 3000 people aged 40-60 years old residing in rural Khánh Hòa, Vietnam. Hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, or the use of antihypertensive medication. We assessed occupational PA and leisure-time PA using the Global Physical Activity Questionnaire. A robust Poisson regression model was used to investigate the associations, with adjustment for covariates. RESULTS: The prevalence of hypertension was 39.6%. After adjusting for socio-demographic and lifestyle-related variables, leisure-time PA was positively associated with hypertension prevalence (prevalence ratio [PR]: 1.03 per 10 MET-hour/week, 95% confidence interval [CI] 1.01-1.06). Occupational PA was inversely associated with hypertension prevalence (PR: 0.98 per 50 MET-hour/week, 95% CI = 0.96-0.996). After adjusting for BMI and other health-related variables, the association related to occupational PA became statistically non-significant, while the association related to leisure-time PA remained statistically significant. CONCLUSION: In contrast to previous studies in high-income countries, we found that leisure-time PA was positively associated with hypertension prevalence and occupational PA was associated with a lower hypertension prevalence. This suggests that the association between PA and hypertension might differ depending on the context.

The association between experience of COVID-19-related discrimination and psychological distress among healthcare workers for six national medical research centers in Japan.

BACKGROUND: Discrimination is an important determinant of negative mental health outcomes. This study determined the association between the experience of COVID-19-related discrimination and psychological distress among healthcare workers (HCWs) in Japan. METHODS: This cross-sectional study conducted a health survey among 5703 HCWs of six national medical and research centers in Japan from October 2020 to March 2021. COVID-19-related discrimination was defined either when participants or their family members were badmouthed or when they felt discriminated against in some way. We used the Kessler Psychological Distress Scale (K6) to assess the presence of severe psychological distress (≥ 13 points). We used logistic regression models to examine the association between discrimination and psychological distress. We also identified factors associated with discrimination. RESULTS: Of the participants, 484 (8.4%) reported COVID-19-related discrimination and 486 (8.5%) had severe psychological distress. HCWs who were female vs. male (adjusted odds ratio [AOR] = 1.41, 95% confidence interval [CI] = 1.28-1.55), had high vs. low viral exposure (AOR = 2.31, 95% CI = 1.81-2.93), and worked for 11 or more hours/day vs. 8 or less hours/day (AOR = 1.42, 95% CI = 1.35-1.49) were more likely to have experienced COVID-19-related discrimination. The AOR (95% CI) of severe psychological distress was 1.83 (1.29-2.59) among those who experienced discrimination. In the stratified analysis by sociodemographic and job-related factors, all the interactions did not reach statistical significance (p for interaction > 0.20). CONCLUSION: Experience of COVID-19-related discrimination was associated with severe psychological distress among HCWs. During the pandemic, effective measures should be taken to prevent the development of negative mental health outcomes in HCWs who experience discrimination.

Adult height in relation to the risk of colorectal cancer among the Japanese population: an evaluation based on systematic review and meta-analysis.

OBJECTIVE: The association between adult-attained height and risk of colorectal cancer remains elusive among the Japanese population. We performed a systematic review and meta-analysis of epidemiological studies in Japan. METHODS: We systematically searched the MEDLINE (PubMed) and Ichushi databases and complemented it with manual search to identify eligible studies. We extracted relative risks or odds ratios from the selected studies and conducted meta-analysis to estimate the summary relative risk with 95% confidence interval. We made the final judgment based on a consensus of the research group members considering both epidemiological evidence and biological plausibility. RESULTS: This systematic review identified four cohort and one case-control studies among the Japanese. The meta-analysis of these five studies showed the summary relative risk of 1.21 (95% confidence interval: 1.07-1.35) of overall colorectal cancer for the highest vs. lowest categories of height. In the analysis by the cancer subsite, the association was significant for colon cancer with a summary relative risk of 1.26 (95% confidence interval: 1.10-1.45) but not for rectal cancer 1.05 (95% confidence interval: 0.71-1.54). In the analysis by sex, tall stature was associated with a significantly increased risk of overall colorectal cancer in both sexes; the summary relative risk was 1.21 (95% confidence interval: 1.04-1.41) in men and 1.20 (95% confidence interval: 1.00-1.44) in women, respectively. CONCLUSIONS: The evidence to support that adult-attained height is associated with increased risk of colorectal cancer (colon cancer) among the Japanese population is 'probable'.

Social and structural factors associated with depression and suicidality among men who have sex with men and transgender women in Nepal.

INTRODUCTION: The prevalence of depression and suicidality is high among men who have sex with men (MSM) and transgender women (TGW) worldwide. Stigma and discrimination are likely contributing factors. More research is needed in low-income, non-English speaking countries to assess the effects of social and structural factors on depression and suicidality among MSM and TGW. METHODS: Nepalese MSM and TGW (n = 340) were recruited using a respondent-driven sampling design and filled out a survey questionnaire. The outcomes were depression and suicidality. Data was analyzed using bivariate and multivariable logistic regression. RESULTS: More than half of the participants (59%) suffered from depression. Severe depression was more common among TGW compared to MSM (41 and 20%, respectively). When it comes to suicidality, TGW had higher lifetime prevalence of suicidal thoughts compared to MSM (32 and 5%, respectively). Depression was positively associated with sex work both for MSM (AOR: 7.9; 95% CI 3.4-18.2) and TGW (AOR: 6.5; 95% CI: 2.3-18.2). MSM who were evicted by family had high odds of suicidal thoughts (AOR: 6.2; 95% CI: 1.3-28.8). For TGW, suicidality was associated with being cheated and threatened (AOR: 3.9; 95% CI: 1.2-12.5) and having forced to marry a female (AOR: 2.2; 95% CI 1.1-5.1). CONCLUSIONS: Nepalese MSM and TGW suffer from a high degree of mental and psychosocial health issues. Future studies should focus on intervention research and on collecting data from a larger variety of gender and sexual minorities.

Drivers of Food Choice among Children and Caregivers in Post-earthquake Nepal.

Food systems in many countries are experiencing a shift from traditional foods toward processed foods high in sugar, fat and salt, but low in dietary fiber and micronutrients. There is an urgent need to better understand drivers of changing food behavior, particularly for lower-income countries. This study analyzes drivers of food choice among children and parents in rural Nepal. It uses qualitative data collected through key informant interviews and focus group discussions with school children, parents and teachers. The study reveals substantial changes in food behavior during the past decade with increased consumption of rice, meat, and highly processed snack foods while an increased consumption of fruit and vegetables is not evident. It identifies cash availability is the main driver of increased rice, meat and snack food consumption. The second driver is the 2015 Nepal earthquake, which accelerated the transition from homegrown food to purchased food as people got habituated to eating more meat and snack foods while reconstruction tripled local wages and changed the food environment. This shows how humanitarian assistance in the wake of extreme shocks can unintentionally contribute to unhealthy eating habits. An integrated school and home garden intervention appears to contribute to healthier diets.

Home-grown school feeding: assessment of a pilot program in Nepal.

BACKGROUND: The Nepal School Meals Program reached 600,000 schoolchildren in basic education in 2017 and plays a key role in the government's strategy to increase children's academic and nutritional outcomes. A large part of the program is implemented through cash transfers with schools responsible for the school meal delivery. Home-grown school feeding, an approach in which local communities are given greater control over the school meals program and part of the food is sourced locally, may strengthen local ownership and improve meal quality, but there is a lack of evidence for impact. METHODS: This study piloted home-grown school feeding in 30 schools reaching nearly 4000 children in Sindhupalchok and Bardiya districts in Nepal with the aim to assess operations and outcomes in comparison to the regular cash-based school meals program. The study used a one-time post evaluation with a mixed methods approach. Qualitative data were collected through 12 focus group discussions and 28 key informant interviews with government and school staff, parents, cooks, cooperative members, World Food Programme representatives and other stakeholders involved in the pilot program. The quantitative part applied a quasi-experimental design and used cross-sectional data collected from 1512 children in 30 pilot and 30 control schools. RESULTS: The quantitative data indicated that children in the pilot schools had a significantly higher provision of midday school meals (+ 19%; p < 0.01) and a higher school meal quality in terms of dietary diversity (+ 44%; p < 0.01) and nutritional content (e.g. a 21%-points higher consumption of vitamin A-rich fruit and vegetables; p < 0.01). The qualitative data identified key drivers of these positive outcomes as the use of standard meal options, capacity building of local stakeholders, strengthened community ownership and accountability mechanisms, and local food supply chains. Maintaining the observed gains would require a 20-33% increase in the current budget per school meal in addition to the cost of capacity building. CONCLUSIONS: This study for Nepal shows that home-grown school feeding strengthened operations of the school meals program and led to a significantly higher meal provision and quality of school meals.

Clostridium scindens ATCC 35704: Integration of Nutritional Requirements, the Complete Genome Sequence, and Global Transcriptional Responses to Bile Acids.

In the human gut, Clostridium scindens ATCC 35704 is a predominant bacterium and one of the major bile acid 7α-dehydroxylating anaerobes. While this organism is well-studied relative to bile acid metabolism, little is known about the basic nutrition and physiology of C. scindens ATCC 35704. To determine the amino acid and vitamin requirements of C. scindens, the leave-one-out (one amino acid group or vitamin) technique was used to eliminate the nonessential amino acids and vitamins. With this approach, the amino acid tryptophan and three vitamins (riboflavin, pantothenate, and pyridoxal) were found to be required for the growth of C. scindens In the newly developed defined medium, C. scindens fermented glucose mainly to ethanol, acetate, formate, and H2. The genome of C. scindens ATCC 35704 was completed through PacBio sequencing. Pathway analysis of the genome sequence coupled with transcriptome sequencing (RNA-Seq) under defined culture conditions revealed consistency with the growth requirements and end products of glucose metabolism. Induction with bile acids revealed complex and differential responses to cholic acid and deoxycholic acid, including the expression of potentially novel bile acid-inducible genes involved in cholic acid metabolism. Responses to toxic deoxycholic acid included expression of genes predicted to be involved in DNA repair, oxidative stress, cell wall maintenance/metabolism, chaperone synthesis, and downregulation of one-third of the genome. These analyses provide valuable insight into the overall biology of C. scindens which may be important in treatment of disease associated with increased colonic secondary bile acids.IMPORTANCEC. scindens is one of a few identified gut bacterial species capable of converting host cholic acid into disease-associated secondary bile acids such as deoxycholic acid. The current work represents an important advance in understanding the nutritional requirements and response to bile acids of the medically important human gut bacterium, C. scindens ATCC 35704. A defined medium has been developed which will further the understanding of bile acid metabolism in the context of growth substrates, cofactors, and other metabolites in the vertebrate gut. Analysis of the complete genome supports the nutritional requirements reported here. Genome-wide transcriptomic analysis of gene expression in the presence of cholic acid and deoxycholic acid provides a unique insight into the complex response of C. scindens ATCC 35704 to primary and secondary bile acids. Also revealed are genes with the potential to function in bile acid transport and metabolism.

Correlation of anterior overbite with root position and buccal bone thickness of maxillary anterior teeth: a CBCT study.

PURPOSE: To investigate the correlation of anterior overbite with the sagittal root position (SRP) and buccal bone thickness (BBT) of the maxillary anterior teeth. METHODS: Cone-beam computed tomography (CBCT) data of southern Chinese patients who underwent CBCT examinations between November 2016 and December 2016 were collected. The anterior overbite was the predictor variable while the SRP and the BBT at 4 mm apical to the cementoenamel junction (CEJ-4) and midpoint of the root of the maxillary anterior teeth were set as the primary and secondary outcome variables, respectively. All measurements were done by two calibrated examiners. Correlations between variables were analyzed by the Spearman's correlation coefficient. The significance level was set at P < 0.05. RESULTS: CBCT data of 146 patients (65 men and 81 women) with a mean age of 44.2 ± 13.4 years were analyzed, and of the 876 maxillary anterior teeth evaluated, 9.8% were presented with deep overbites. Most of roots of the anterior teeth (94.9%) were positioned against the buccal cortical plate, of which, in 63.8% of them the apex was not covered by bone along the long axis of the tooth. The mean BBT at CEJ-4 was 0.89 mm at the central incisor, 0.85 mm at the lateral incisor and 0.84 mm at the canine. The overbite was positively correlated with SRP Class I subtypes and the BBT at CEJ-4 (P < 0.05). CONCLUSION: Deep overbite was more frequently accompanied by bone fenestration in the anterior maxillary areas.

Clinical and Radiologic Outcomes of Submerged and Nonsubmerged Bone-Level Implants with Internal Hexagonal Connections in Immediate Implantation: A 5-Year Retrospective Study.

PURPOSE: To evaluate the 5-year clinical and radiologic outcome of immediate implantation using submerged and nonsubmerged techniques with bone-level implants and internal hexagonal connections and the effects of potential influencing factors. MATERIALS AND METHODS: A total of 114 bone-level implants (XiVE S plus) with internal hexagonal connections inserted into 72 patients were included. Patients were followed up for 5 years. A t-test was used to statistically evaluate the marginal bone loss between the submerged and nonsubmerged groups. The cumulative survival rate (CSR) was calculated according to the life table method and illustrated with Kaplan-Meier survival curves. Comparisons of the CSR between healing protocols, guided bone regeneration, implants with different sites, lengths, and diameters were performed using log-rank tests. RESULTS: The 5-year cumulative implant survival rates with submerged and nonsubmerged healing were 94% and 96%, respectively. No statistically significant differences in terms of marginal bone loss, healing protocol, application of guided bone regeneration, implant site, or length were observed. CONCLUSIONS: High CSRs and good marginal bone levels were achieved 5 years after immediate implantation of bone-level implants with internal hexagonal connections using both the submerged and nonsubmerged techniques. Factors such as implant length, site, and application of guided bone regeneration did not have an impact on the long-term success of the implants.

Gaps in Migrants' Access to Contraceptive Services: A Survey of Nepalese Women and Men in Japan.

While all modern contraceptive methods are available for free or at minimal cost in Nepal, contraceptive devices in Japan are mainly limited to condoms, requiring Nepalese migrant women to rely on their male partners for their use. Therefore, Nepalese migrants often seek contraceptive devices from Nepal or request friends or relatives to send them from their home country. This study aimed to identify the gaps and challenges associated with Nepalese migrants' needs for sexual and reproductive health services (SRHSs), particularly contraceptives, before and after their migration to Japan. A mixed-methods study was adopted, an explanatory sequential design (ESD) combining quantitative and qualitative approaches, and data were collected from 186 Nepalese migrants (80 females and 106 males) through an online survey and from two focus-group discussions (FGDs) conducted among 24 participants (14 females and 10 males). This study highlighted the obstacles faced by Nepalese migrants in accessing contraceptive services, such as limited options, language barriers, and high costs. The study also revealed the importance of pre-departure training in Nepal and organizing post-arrival training in Japan to increase Nepalese migrants' awareness of the SRHSs available in Japan, thereby helping to prevent SRH-related health problems, including unintended pregnancies and abortions, in Japan.

Assessing the Nepalese health system's readiness to manage gender-based violence and deliver psychosocial counselling.

Violence against women (VAW), particularly intimate partner violence (IPV) or domestic violence, is a major public health issue, garnering more attention globally post-coronavirus disease 2019 (COVID-19) lockdown. Health providers often represent the first point of contact for IPV victims. Thus, health systems and health providers must be equipped to address survivors' physical, sexual and mental health care needs. However, there is a notable lack of evidence regarding such readiness in Nepal. This study, utilizing a concurrent triangulation design, evaluated the readiness of public health facilities in Nepal's Madhesh Province in managing VAW, focusing on providers' motivation to offer psychosocial counselling to survivors. A cross-sectional study was conducted across 11 hospitals and 17 primary health care centres, where 46 health care providers were interviewed in February-April 2022. The study employed the World Health Organization's tools for policy readiness and the Physician Readiness to Manage IPV Survey for data collection. Quantitative and qualitative data were collected via face-to-face interviews and analysed using descriptive and content analysis, respectively. Only around 28% of health facilities had trained their staff in the management of VAW. Two out of 11 hospitals had a psychiatrist, and a psychosocial counsellor was available in four hospitals and two out of 17 primary health care centres. Two-thirds of all health facilities had designated rooms for physical examinations, but only a minority had separate rooms for counselling. Though a few health facilities had guidelines for violence management, the implementation of these guidelines and the referral networks were notably weak. Hospitals with one-stop crisis management centres demonstrated readiness in VAW management. Health providers acknowledged the burden of IPV or domestic violence and expressed motivation to deliver psychosocial counselling, but many had limited knowledge. This barrier can only be resolved through appropriate training and investment in violence management skills at all tiers of the health system.

Survival on antiretroviral treatment among adult HIV-infected patients in Nepal: a retrospective cohort study in Far-western region, 2006-2011.

BACKGROUND: Though financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal. METHODS: This retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality. RESULTS: The median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II). CONCLUSIONS: High mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

Better learning in schools to improve attitudes toward abstinence and intentions for safer sex among adolescents in urban Nepal.

BACKGROUND: School-based sex education is an effective medium to convey health information and skills about preventing sexually transmitted infections (STIs) and unwanted pregnancies among adolescents. However, research on school-based sex education is limited in many developing countries, including Nepal. This study thus had two main objectives: (1) to assess students' evaluation of school-based sex education, and (2) to examine the associations between students' evaluations of school-based sex education and their (a) attitudes toward abstinence and (b) intentions for safer sex. METHODS: This cross-sectional study was conducted among 634 students from six schools in the Kathmandu Valley during May-June 2010. We used a self-administered questionnaire to assess students' evaluations of school-based sex education, attitudes toward abstinence, and intentions for safer sex. The data were then analyzed using multiple linear regression models. RESULTS: Regarding "information on HIV and sexual health", many students perceived that they received the least amount of information on HIV counseling and testing centers (mean 2.29, SD 1.00) through their schools. In terms of "support and involvement of teachers and parents" in sex education, parents' participation ranked as the lowest (mean 1.81, SD 1.01). Audiotapes were reported as the least used among the listed "teaching aids for sexual health education" (mean 1.54, SD 0.82). In multivariate analysis, receiving more "information on HIV and sexual health" was positively associated with more positive "attitudes toward abstinence" (ß = 0.11, p = <0.018) and greater "intentions for safer sex" (ß = 0.17, p = <0.001) among students. Similarly, increased "support and involvement from teachers and parents" was also positively associated with more positive "attitudes toward abstinence" (ß = 0.16, p = <0.001) and greater "intentions for safer sex" (ß = 0.15, p = <0.002). CONCLUSION: Our results suggest that students' needs and expectations regarding HIV and sexual health education are not being met through their schools. Moreover, comprehensive information on HIV and sexual health along with increased support and involvement of teachers and parents in sex education might help to improve adolescents' attitudes toward abstinence and intentions for safer sex. Adapting future school-based interventions to incorporate such elements may thus be an effective strategy to promote adolescent sexual health.

Feasibility and Effectiveness of an Intervention to Reduce Intimate Partner Violence and Psychological Distress Among Women in Nepal: Protocol for the Domestic Violence Intervention (DeVI) Cluster-Randomized Trial.

BACKGROUND: Intimate partner violence (IPV) disproportionately affects people in low-and middle-income countries (LMICs), such as Nepal. Women experiencing IPV are at higher risk of developing depression, anxiety, and posttraumatic stress disorder. The shortage of trained frontline health care providers, coupled with stigma related to IPV and mental health disorders, fuels low service uptake among women experiencing IPV. The Domestic Violence Intervention (DeVI) combines the Problem Management Plus counseling program developed by the World Health Organization with a violence prevention component. OBJECTIVE: This study aims to implement and evaluate the feasibility, acceptability, and effectiveness of DeVI in addressing psychological distress and enabling the secondary prevention of violence for women experiencing IPV. METHODS: A parallel cluster-randomized trial will be conducted across 8 districts in Madhesh Province in Nepal, involving 24 health care facilities. The study will include women aged 18-49 years who are either nonpregnant or in their first trimester, have experienced IPV within the past 12 months, have a 12-item General Health Questionnaire (GHQ-12) score of 3 or more (indicating current mental health issues), and have lived with their husbands or in-laws for at least 6 months. A total sample size of 912 was estimated at 80% power and α<.05 statistical significance level to detect a 15% absolute risk reduction in the IPV frequency and a 50% reduction in the GHQ-12 score in the intervention arm. The health care facilities will be randomly assigned to either the intervention or the control arm in a 1:1 ratio. Women visiting the health care facilities in the intervention and control arms will be recruited into the respective arms. In total, 38 participants from each health care facility will be included in the trial to meet the desired sample size. Eligible participants allocated to either arm will be assessed at baseline and follow-up visits after 6, 17, and 52 weeks after baseline. RESULTS: This study received funding in 2019. As of December 29, 2022, over 50% of eligible women had been recruited from both intervention and control sites. In total, 269 eligible women have been enrolled in the intervention arm and 309 eligible women in the control arm. The trial is currently in the recruitment phase. Data collection is expected to be completed by December 2023, after which data analysis will begin. CONCLUSIONS: If the intervention proves effective, it will provide evidence of how nonspecialist mental health care providers can address the harmful effects of IPV in resource-constrained settings with a high burden of IPV, such as Nepal. The study findings could also contribute evidence for integrating similar services into routine health programs in LMICs to prevent IPV and manage mental health problems among women experiencing IPV. TRIAL REGISTRATION: ClinicalTrials.gov NCT05426863; https://clinicaltrials.gov/ct2/show/NCT05426863. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45917.

Meningococcemia in an 11 Months Old Infant.

Meningococcemia is the infection of the blood caused by Neisseria meningitidis. Herein, we report a case of meningococcemia in an 11 months old infant who had a high-grade fever, nonblanching purpuric rash over the face and limbs, low blood pressure, tachycardia, and prolonged capillary refill time, but without neck rigidity and focal neurologic signs. He recovered after supportive care and treatment with antibiotics (intravenous ceftriaxone, vancomycin, and teicoplanin). Therefore, in a febrile, ill-looking child in shock with a nonblanching rash, meningococcal disease should be suspected. The study shows the importance of vaccination against meningococcal disease.