Risk Factors Associated with Ninety Day Readmission in Chronic Obstructive Pulmonary Disease Exacerbation at a Tertiary Care Hospital: A retrospective cohort study.

Background Chronic obstructive pulmonary disease (COPD) exacerbation is a leading cause of frequent hospital admission. Globally, several studies have reported potential risk factors associated with COPD exacerbations which are largely unknown in Nepalese health care setting. Objective To identify the risk factors associated with hospital readmission within ninety days of discharge in acute COPD exacerbation. Method This is a hospital based retrospective cohort study conducted at Tribhuvan University Teaching Hospital. COPD patients admitted in respiratory ward from August 2019 to November 2019 were followed up till 90 days after discharge. Logistic regression analysis was performed at 95% Confidence Interval (CI) to identify risk factors for readmission in COPD exacerbation. Statistical analysis was performed using SPSS version 20.0. Result Of total 86 patients hospitalized for COPD, 42 (48.8%) had at least one subsequent readmission during post-discharge follow-up period of 90 days. Mean age of patients was 70.55±10.98 years. There were 45 (52.3%) males. Logistic regression analysis revealed preadmission domiciliary oxygen use (Odds Ratio (OR) 2.93; 95% CI 1.195- 7.202; p=0.019), admission in intensive care unit (ICU) (OR 3.060; 95% CI 1.145- 8.179; p=0.026), previous hospital admission for COPD exacerbation (OR 3.230; 95% CI 1.219-8.556; p=0.018), age (OR 0.946; 95% CI 0.905-0.988; p=0.012) and duration of hospital stay (OR 0.901; 95% CI 0.819-0.992; p=0.034) were independently associated with ninety day readmission in COPD patients. Conclusion Five clinical factors were found to be independently associated with COPD readmission in this study. Large multi-centre study at various health care levels is recommended to validate the potential risk factors in different populations and health care settings in Nepal.

Pulmonary azygous lobe--an anatomical variant.

Pulmonary azygous lobe is one of the common lung malformations. There is only few article about azygous lobe. Its a small accessory lobe sometimes found on the upper part of the right lung, separated from the rest of the upper lobe by a deep groove lodging the ayzygous vein. This reports decribes the presence of azygous lobe, a rare anatomical variant, encounted during chest x-ray discussion. We describe here the anatomical basis and the clinical significance of azygous lobe.

Spatial and temporal diversity of begomoviral complexes in papayas with leaf curl disease.

Old World, monopartite begomoviruses associated with satellite DNA ß were observed in papaya showing symptoms of leaf curl disease sampled randomly over five years from within a radius of 250 km in north-central India. Three groups of DNA A sequences were evident. One group resembled chili leaf curl virus infecting tomatoes (ChiLCuV). Another group resembled tomato leaf curl New Delhi virus (ToLCuNDV). The third group was novel (tentatively named papaya leaf crumple virus, PaLCrV), with less than 89% identity to known begomovirus sequences in the GenBank database. At least seven DNA A sequences were putative recombinants. The AC4-encoding regions exhibited highest numbers of non-synonymous substitutions. Most DNA ß sequences resembled tomato leaf curl virus-associated DNA ßs. A few DNA ß sequences were similar to that of croton yellow vein mosaic virus-associated DNA ß (CroYVMVß). One DNA ß sequence was novel and showed <65% similarity to its counterparts. Mixed infections and sequence diversity among 25 cloned av1 genes indicated that papayas grown in plantations, kitchen gardens and feral patches in the region are vulnerable to disease outbreak. No geographic or temporal patterns were discernable in the distribution of these viruses.

Understanding of tobacco and lung cancer among medical students in Kathmandu University School of Medical Sciences (KUSMS).

BACKGROUND: Often, lung cancer is diagnosed at terminal stages. Poor awareness about the symptoms or risk factors of lung cancer among medics may be one of the factors for delayed diagnosis. OBJECTIVE: We explored the knowledge of medical students and their behavior with the patients of lung cancer. METHOD: Qualitative and quantitative approaches were used for data collection from 153 medical student of Kathmandu University School of Medical Sciences from December 2011 to May 2012. RESULTS: Among the results, eighty-nine students had over 80% knowledge of the 14 cancer warning signs, among them 83% knew the nine risk factors for lung cancer. Twenty-three students told lung cancer can be hereditary. Sixty five percent of all participants believed that lung cancer can be detected at early stage; of them 81% told that it can be treated. About 24% of the total students were current or exsmokers and about half of them believed that lung cancer does not occur in light smokers. Only 10% have heard of Framework Convention on Tobacco Control in Nepal. CONCLUSION: Study finds that all medical students who know about any cancers may not necessarily have knowledge about lung cancers. Their perception about the cause of lung cancer may be influenced by their smoking behavior and there was little knowledge of public health measures for smoking control. Awareness about national policies needs to be increased.

A fatal presentation of dermatomyositis.

Dermatomyositis (DM) is an autoimmune disease that mainly affects the skin, muscle, and lung. The pathogenesis of skin inflammation in DM is not well understood. We present a 40-year-old male who presented with four months history of generalized skin lesion, pain and weakness. He had elevated transaminases with detectable muscle weakness. This case highlights the need to consider dermatomyositis with skin lesion and weakness; and the use of aggressive immunosuppressive therapies due to its associated vasculopathies.

Association of systemic lupus erythematosus with C8orf13-BLK and ITGAM-ITGAX.

BACKGROUND: Systemic lupus erythematosus (SLE) is a clinically heterogeneous disease in which the risk of disease is influenced by complex genetic and environmental contributions. Alleles of HLA-DRB1, IRF5, and STAT4 are established susceptibility genes; there is strong evidence for the existence of additional risk loci. METHODS: We genotyped more than 500,000 single-nucleotide polymorphisms (SNPs) in DNA samples from 1311 case subjects with SLE and 1783 control subjects; all subjects were North Americans of European descent. Genotypes from 1557 additional control subjects were obtained from public data repositories. We measured the association between the SNPs and SLE after applying strict quality-control filters to reduce technical artifacts and to correct for the presence of population stratification. Replication of the top loci was performed in 793 case subjects and 857 control subjects from Sweden. RESULTS: Genetic variation in the region upstream from the transcription initiation site of the gene encoding B lymphoid tyrosine kinase (BLK) and C8orf13 (chromosome 8p23.1) was associated with disease risk in both the U.S. and Swedish case-control series (rs13277113; odds ratio, 1.39; P=1x10(-10)) and also with altered levels of messenger RNA in B-cell lines. In addition, variants on chromosome 16p11.22, near the genes encoding integrin alpha M (ITGAM, or CD11b) and integrin alpha X (ITGAX), were associated with SLE in the combined sample (rs11574637; odds ratio, 1.33; P=3x10(-11)). CONCLUSIONS: We identified and then confirmed through replication two new genetic loci for SLE: a promoter-region allele associated with reduced expression of BLK and increased expression of C8orf13 and variants in the ITGAM-ITGAX region.

Mercury contamination in the riparian zones along the East Fork Poplar Creek at Oak Ridge.

Oak Ridge (Tennessee, USA) has a history of mercury (Hg) contamination in its aquatic and soil environment associated with past nuclear-weapons production activities at its Department of Energy (DOE) sites. Three different riparian zones along the Lower East Fork Poplar Creek were investigated in order to study Hg distribution and transformation in surface soils. The surface soil samples collected from these areas showed higher total Hg on an average (129.08 mg/kg) and higher total organic carbon (5.50%) in the upstream soils compared to the other two downstream locations that contained only 31.78 and 19.98 mg/kg total Hg and 2.88% and 1.65% of TOC on average, respectively. Further, methyl Hg concentrations were also comparatively higher in case of the upstream soils (30.10 µg/kg) than that of the downstream sites (5.69 and 4.05 µg/kg). The study showed a plume-like dispersion of Hg in the terrestrial environment along the creek, with decreasing Hg concentrations with distance from the Hg source zone. Also, the transformation of Hg in the soils was found to have been influenced by the soil TOC contents.

A genomewide association study of skin pigmentation in a South Asian population.

We have conducted a multistage genomewide association study, using 1,620,742 single-nucleotide polymorphisms to systematically investigate the genetic factors influencing intrinsic skin pigmentation in a population of South Asian descent. Polymorphisms in three genes--SLC24A5, TYR, and SLC45A2--yielded highly significant replicated associations with skin-reflectance measurements, an indirect measure of melanin content in the skin. The associations detected in these three genes, in an additive manner, collectively account for a large fraction of the natural variation of skin pigmentation in a South Asian population. Our study is the first to interrogate polymorphisms across the genome, to find genetic determinants of the natural variation of skin pigmentation within a human population.

Unusual site of metastasis of bronchogenic carcinoma.

Metastasis of bronchogenic carcinoma to the chest wall and axillary lymphnodes is a rare occurrence. This study reports the case of a patient presenting with chest wall swelling as initial symptom which on evaluation was found to be a lymphnode metastasis. The patient also had axillary lymphnode metastasis on the same side as the chest swelling with a contralateral pleural effusion. Here, we discuss the pathways and possible mechanisms of contra lateral axillary and chest wall lymphnode involvement without ispilateral nodal involvement in bronchogenic carcinoma.

Upper gastro-intestinal bleeding: aetiology and demographic profile based on endoscopic examination at Dhulikhel Hospital, Kathmandu University Hospital.

BACKGROUND: The upper gastrointestinal bleeding (UGIB) is defined as bleeding within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the ligament of Treitz. It is one of the important medical emergencies worldwide. OBJECTIVE: The objective of this study is to study the aetiology of upper gastrointestinal bleeding based on endoscopic examination findings in patients of various demographic characteristics. MATERIALS AND METHODS: This is a retrospective observational study. The endoscopic record book from 2007 January to 2009 October was reviewed for all the cases who underwent oesophago-gastro-duodenoscopic examination for upper GI bleeding. The clinico-epidemiological data of all the patients was reviewed and analyzed in concert with the aetiology of bleeding. RESULTS: A total of 90 patients (58 males, 32 females; mean age 45.32+ 18.47 years) of upper gastrointestinal bleeding was studied and analyzed in terms of aetiology of bleeding and demographic profile. Among the ethnic groups, Aryan 46 (51%) was the most common ethnic group to have upper GI bleeding followed by Newars 24 (27%), Mongolians 16 (18%), Dalits 3 (3%) and others 1 (1%). Out of 90 patients, 47( 52.2%) cases was less than 45 years of age, 30(33.3%) of 46 to 65 age ; and 13(14.4 %) more than 65 years of age. Gastric ulcer 23(25.6%) was the most common endoscopic finding, followed by oesophageal varices 14 (15.6%), acute erosive/haemorrhagic gastropathy 11 (12.2%), duodenal ulcer 9(10%), growth 7(7.8%), vascular lesions 3(3.3%), Mallory-Weiss tear 1(1.1%), fundal varices 1(1.1%) and, no cause was identified in 21(23.3%) cases. The peptic ulcer bleeding was the most common finding in Aryan 22(47.9%), whereas oesophageal varices and growth were more common in Newar 7(29.2%) and 3 (12.5%) respectively. CONCLUSION: Peptic ulcer disease is the most common cause of upper GI bleeding which was most commonly found in Aryan population; followed by oesophageal varices and growth as second and third most common causes and were more prevalent in Newar and Mongolian people.

Young people's knowledge, attitude, and behaviour on STI/HIV/AIDS in the context of Nepal: a systematic review.

BACKGROUND: Sexual and reproductive health of young people has become a major health problem in recent decades. Recent and rapidly increasing Human Immune Deficiency Virus (HIV) rates show an urgent need for Sexually Transmitted Infections (STIs) and HIV prevention interventions in Nepal. OBJECTIVES: This paper attempts to assess knowledge, attitude and behaviour on STIs/HIV/AIDS in the context of young peoples of Nepal. METHOD AND MATERIAL: A systematic review based on the available literature was carried out including both qualitative and quantitative studies. RESULTS: Our findings indicate that the overall knowledge regarding STIs and HIV/AIDS is high although the level of knowledge seems to differ according to education, gender, and area of residence. Knowledge about condoms was also very high but practice of correct and consistent use in premarital and extramarital sexual relations with non-regular partners seems to be lower. The overall sexual behaviour among young people is unsafe. CONCLUSION: This suggests that young people's sexual and reproductive health issues need to be further addressed and explored in order to promote safer and responsible sexual behaviour.

Direct conversion of carbon nanofibers and nanotubes into diamond nanofibers and the subsequent growth of large-sized diamonds.

We report a pulsed laser annealing method to convert carbon fibers and nanotubes into diamond fibers at ambient temperature and pressure in air. The conversion of carbon nanofibers and nanotubes into diamond nanofibers involves melting in a super undercooled state using nanosecond laser pulses, and quenching rapidly to convert into phase-pure diamond. The conversion process occurs at ambient temperature and pressure, and can be carried out in air. The structure of diamond fibers has been confirmed by selected-area electron diffraction in transmission electron microscopy, electron-back-scatter-diffraction in high-resolution scanning electron microscopy, all showing characteristic diffraction lines for the diamond structure. The bonding characteristics were determined by Raman spectroscopy with a strong peak near 1332 cm-1, and high-resolution electron-energy-loss spectroscopy in transmission electron microscopy with a characteristic peak at 292 eV for σ* for sp3 bonding and the absence of π* for sp2 bonding. The Raman peak at 1332 cm-1 downshifts to 1321 cm-1 for diamond nanofibers due to the phonon confinement in nanodiamonds. These laser-treated carbon fibers with diamond seeds are used to grow larger diamond crystallites further by using standard hot-filament chemical vapor deposition (HFCVD). We compare these results with those obtained without laser treating the carbon fibers. The details of diamond conversion and HFCVD growth are presented in this paper.

Comparative Raman and HRTEM study of nanostructured GaN nucleation layers and device layers on sapphire (0001).

Raman spectroscopy in conjunction with high-resolution transmission electron microscopy (HRTEM) has been used to study structural characteristics and strain distribution of the nanostructured GaN nucleation layer (NL) and the GaN device layer on (0001) sapphire substrates used for light-emitting diodes and lasers. Raman peaks corresponding to the cubic and the hexagonal phase of GaN are observed in the Raman spectrum from 15 nm and 45 nm NLs. A comparison of the peak intensities for the cubic and hexagonal phases of GaN in the NLs suggests that the cubic phase is dominant in the 15 nm NL and the hexagonal phase in the 45 nm NL. An increase in the density of stacking faults in the metastable cubic GaN (c-GaN) phase with increasing growth time lowers the system energy as well as locally converts c-GaN phase into hexagonal GaN (h-GaN). It also explains the observation of the more intense peaks of h-GaN in the 45 nm NL compared to c-GaN peaks. For the sample wherein an h-GaN device layer was grown at higher temperatures on the NL, narrow Raman peaks corresponding to only h-GaN were observed, confirming the high-quality of the films. The peak shift of the E2(H)(LO) mode of h-GaN in the NLs and the h-GaN film suggests the presence of a tensile stress in the NL which is attributed to defects such as stacking faults and twins, and a compressive stress in high-temperature grown h-GaN film which is attributed to the thermal-expansion mismatch between the film and the substrate. The peak shifts of the substrate also reveal that during the low temperature growth of the NL the substrate is under a compressive stress which is attributed to defects in the NL and during the high temperature growth of the device layer, there is a tensile strain in the substrate as expected from differences in coefficients of thermal expansion of the film and the substrate during the cooling cycle.

Nanostructured GaN nucleation layer for light-emitting diodes.

This paper addresses the formation of nanostructured gallium nitride nucleation (NL) or initial layer (IL), which is necessary to obtain a smooth surface morphology and reduce defects in h-GaN layers for light-emitting diodes and lasers. From detailed X-ray and HR-TEM studies, researchers determined that this layer consists of nanostructured grains with average grain size of 25 nm, which are separated by small-angle grain boundaries (with misorientation approximately 1 degrees), known as subgrain boundaries. Thus NL is considered to be single-crystal layer with mosaicity of about 1 degrees. These nc grains are mostly faulted cubic GaN (c-GaN) and a small fraction of unfaulted c-GaN. This unfaulted Zinc-blende c-GaN, which is considered a nonequilibrium phase, often appears as embedded or occluded within the faulted c-GaN. The NL layer contained in-plane tensile strain, presumably arising from defects due to island coalescence during Volmer-Weber growth. The 10L X-ray scans showed c-GaN fraction to be over 63% and the rest h-GaN. The NL layer grows epitaxially with the (0001) sapphire substrate by domain matching epitaxy, and this epitaxial relationship is remarkably maintained when c-GaN converts into h-GaN during high-temperature growth.

Scrotal haematoma: the most common complication of no-scalpel vasectomy.

OBJECTIVE: to study the complications of no scalpel vasectomy such as scrotal haematoma, infection, scrotal sinus, and failure, recanalization, and sperm granuloma. MATERIALS AND METHODS: A retrospective, descriptive study carried out in Dept. of Obs/ Gyn, Tribhuvan University Teaching Hospital Kathmandu Nepal. RESULT: Among 926 no scalpel vasectomy clients 5(0.53%) had scrotal haematoma, 4(0.43%) with had infection, 3(0.32%) had scrotal sinus; there were 2 cases each vasectomy failure who could not achieve azospermia and 2 with recanalization while there was only one case of sperm granuloma. CONCLUSION: the most common complication of no-scalpel vasectomy was scrotal haematoma and other complications are wound infection, scrotal sinus, vasectomy failure and sperm granuloma. Key words: no scalpel vasectomy, scrotal haematoma, scrotal sinus, sperm granuloma.

Unresolving Pneumonia with Pleural effusion: Pulmonary Paragonimiasis.

Paragonimiasis is a zoonosis caused by many species of Paragonimus commonly P. westermani. Human get infected by eating raw, salted, pickled, smoked, partially cooked crustaceans (crayfish or crabs). Clinical manifestations ranges from non-specific symptoms like pain abdomen, diarrhea, urticarial rashes, fever to pleuropulmonary symptoms like cough, hemoptysis, chest pain and dyspnea. A 48 years, female presented at TUTH emergency with fever on and off for nine months, cough and shortness of breath for three months, lethargy, malaise and urticaria with history of raw crab intake one month prior to the onset of symptoms. Blood and pleural fluid analysis revealed raised total counts with eosinophilia and x-ray showed bilateral infiltration of lower lobes with pleural effusion. Diagnosis was confirmed by microscopic examination of sputum for Paragonimus. She responded well to Praziquantel. Pulmonary paragonimiasis must be considered in the differential diagnosis of unresolving pneumonia and unexplained hypereosinophilia.

Changing picture of acute kidney injury in pregnancy: Study of 259 cases over a period of 33 years.

The incidence of acute kidney injury (AKI) in pregnancy is declining in developing countries but still remains a major cause of maternal and fetal morbidity and mortality. The aim of the study was to analyze the changing trends in pregnancy related AKI (PR-AKI) over a period of thirty-three years. Clinical characteristics of PR-AKI with respect to incidence, etiology and fetal and maternal outcomes were compared in three study periods, namely 1982-1991,1992-2002 and 2003-2014. The incidence of PR-AKI decreased to 10.4% in 1992-2002, from 15.2% in 1982-1991, with declining trend continuing in 2003-2014 (4.68%).Postabortal AKI decreased to 1.49% in 2003-2014 from 9.4% in 1982-1991of total AKI cases. The AKI related to puerperal sepsis increased to 1.56% of all AKI cases in 2003-2014 from 1.4% in 1982-1991. Preeclampsia/eclampsia associated AKI decreased from 3.5% of total AKI cases in 1982-1991 to 0.54% in 2003-2014. Pregnancy associated - thrombotic microangiopathy and acute fatty liver of pregnancy were uncommon causes of AKI. Hyperemesis gravidarum associated AKI was not observed in our study. Incidence of renal cortical necrosis (RCN) decreased to 1.4% in 2003-2014 from 17% in 1982-1991.Maternal mortality reduced to 5.79% from initial high value 20% in 1982-1991. The progression of PR-AKI to ESRD decreased to1.4% in 2003-2014 from 6.15% in 1982-1991. The incidence of PR-AKI has decreased over last three decades, mainly due to decrease in incidence of postabortal AKI. Puerperal sepsis and obstetric hemorrhage were the major causes of PR-AKI followed by preeclampsia in late pregnancy. Maternal mortality and incidence and severity of RCN have significantly decreased in PR-AKI. The progression to CKD and ESRD has decreased in women with AKI in pregnancy in recent decade. However, the perinatal mortality did not change throughout study period.

Intestinal microsporidiosis in renal transplant recipients: Prevalence, predictors of occurrence and genetic characterization.

PURPOSE: Intestinal microsporidiosis, which occurs in immunocompromised states such as acquired immunodeficiency syndrome, has rarely been studied in patients with renal transplantation (RT) on immunosuppressive therapy. MATERIALS AND METHODS: Three hundred and twenty-four consecutive RT recipients on immunosuppressive treatment and 170 healthy subjects were evaluated for intestinal microsporidiosis and other parasites by modified trichrome staining, wet mount using normal saline, iodine and polymerase chain reaction (PCR). Clinical, demographic and laboratory parameters associated with occurrence of intestinal microsporidiosis were studied using univariate and multivariate analysis. The species of microsporidia were studied using PCR-restriction fragment length polymorphism (RFLP). Patients were treated with albendazole (400 mg twice daily for 2 weeks). RESULTS: Of 324 RT recipients initially screened, 52 were excluded from final analysis due to incomplete data. Patients with RT [n=272, age 42±12.54 years, 222 (81.6%) male] more often had microsporidiosis than healthy subjects by modified trichrome stain and PCR [n=170, age 33.8±6.7 years, 123 (72.3%) male] [16/272 (5.8%) vs. 0/170 (0%), P<0.001]. Patients with intestinal microsporidiosis were younger (33.9±8.3 years vs. 42.3±12.6 years; P=0.009), had diarrhoea more often (13/16, 81% vs. 123/256, 48%; P=0.02), which was longer in duration (60, 32.5-105 days vs. 12, 6.2-18 days; P<0.001) and had associated giardiasis (2/16, 12.5% vs. 2/256, 0.8%; P=0.018). Younger age, presence of diarrhoea and associated giardiasis were significant on multivariate analysis. Enterocytozoon bieneusi was detected in 15/16 (93%) patients with intestinal microsporidiosis. CONCLUSION: Intestinal microsporidiosis occurs frequently in patients with RT on immunosuppressive treatment, particularly among younger patients with longer diarrhoea duration and associated giardiasis. E. bieneusi is the major species identified among these patients.