The UK Divide: Does Having a Pembrolizumab-Chemotherapy Option in Head and Neck Cancer Matter? Real-world Experience of First-line Palliative Pembrolizumab Monotherapy and Pembrolizumab-Chemotherapy Combination in Scotland.

AIMS: The Scottish Medical Consortium recently approved first-line pembrolizumab monotherapy or in combination with chemotherapy for head and neck squamous cell carcinoma in the palliative setting, contrasting with the decision made by the National Institute for Health and Care Excellence, who approved monotherapy alone in England and Wales. The aim of this study was to provide real-world performance data for first-line pembrolizumab-containing treatments for head and neck squamous cell carcinoma in the palliative setting in Scotland. MATERIALS AND METHODS: We analysed the electronic records of patients who started pembrolizumab-containing treatment between 1 March 2020 and 30 September 2021. Outcomes included overall survival, progression-free survival (PFS), the duration of response and the disease control rate. Data were compared with the KEYNOTE-048 study and clinical factors were evaluated for association with survival. RESULTS: Our cohort included 91 patients (median follow-up 10.8 months). Patient characteristics were similar to those in the KEYNOTE-048 study, although our cohort had a higher proportion of patients with newly diagnosed, non-metastatic disease. For patients receiving monotherapy (n = 76), 12- and 24-month overall survival were 45% and 27%, respectively. For patients receiving pembrolizumab-chemotherapy (n = 15), 12-month overall survival was 60% (24-month overall survival had not yet been reached). Experiencing one or more immune-related adverse event (irAE; versus no irAEs), of any grade, was associated with favourable overall survival and PFS for patients receiving monotherapy in both univariable Log-rank analysis (median overall survival 17.4 months versus 8.6 months, respectively, P = 0.0033; median PFS 10.9 months versus 3.0 months, respectively, P < 0.0001) and multivariable analysis (Cox proportional hazards regression: overall survival hazard ratio 0.31, P = 0.0009; PFS hazard ratio 0.17, P < 0.0001). CONCLUSION: Our real-world data support the KEYNOTE-048 study findings and the value of combination treatment options. Additionally, our data show that irAEs of any grade, as reported in routine clinical records, are associated with better outcomes in this patient group, adding to the growing body of evidence showing that irAEs are generally a positive marker of programmed death-ligand 1 (PD-L1) inhibitor response.

Cross-cultural Adaptation and Psychometric Properties of Nepali Version of Developmental Coordination Disorder Questionnaire.

Background Revised developmental coordination disorder questionnaire (DCDQ'07) is the best available population-based screening tool to identify developmental coordination disorder and being a parent reported tool, it needs to be available in Nepali language for its application in Nepali population. Objective The objective of this study was to cross-culturally adapt developmental coordination disorder questionnaire into Nepali (DCDQ-NP). The psychometric properties of Nepali version of Developmental coordination disorder questionnaire were established. Method The adaptation was done following Beaton's guideline and the psychometric properties was studied in the community sample of 165 parents of school going children of 5-15 years. Fifty parents were asked to refill the questionnaire after the two weeks period. The study determines internal consistency, test retest reliability, floor and ceiling effect and construct validity. Result Significant cultural adaptation was required to obtain relevant Nepali version. The Nepali version of Developmental coordination disorder questionnaire demonstrates high internal consistency (α = 0.912), excellent test-retest reliability (IC = 0.901) and the floor and ceiling effect were acceptable. Principal component analysis showed three factor structure accounting 62% of variance. Conclusion The developmental coordination disorder questionnaire into Nepali were successfully translated and culturally adapted preserving its original concept. It showed good psychometric properties in a Nepali population. The adapted questionnaire shall be of significance in carry out further research in developmental coordination disorder in Nepal.

Central Pancreatectomy for Bilobed Solid Pseudopapillary Tumor of Pancreas.

Solid-pseudopapillary tumor of pancreas is a rare pancreatic tumor that occurs predominantly in a young female with only a small minority concerning children. These tumors have low malignant potential, found incidentally which are usually single lobed. Surgical resection remains the mainstay of treatment. Our case is 26 years female with vomiting and abdominal pain localized to the right upper quadrant. Computerized tomography scans showed two well-defined hypodense lesions at neck and body of the pancreas with greatest diameter of six centimeter. The patient underwent central pancreatectomy and histopathology confirmed solid-pseudopapillary tumor with complete resection with all resected margin free of tumor. Symptoms may be present such as abdominal pain or vomiting due to compression, mainly in large tumors. In benign cases parenchyma sparing surgery such as central pancreatectomy can preserve the exocrine and endocrine function of pancreas which helps patient to have better postoperative quality of life.

Sensitivity and Specificity of Lateral Flow Antigen Test Kits for COVID-19 in Asymptomatic Population of Quarantine Centre of Province 3.

Background Nearly after 6 months of the spread of Corona Virus Disease 19, along with the world Nepal is still trying to control the spread and prevent general population from acquiring it. With limited resources in manpower, technology and evidence it has been a difficult battle. But with time and more understanding of the virus new technology to detect the virus are coming up. It is a major breakthrough in the diagnostic field as this helps us in not only detecting the virus but also helps us to mobilize our human resources. This comes in a time where the cases are increasing at an alarming rate. Although numbers of Polymerase Chain Reaction testing have increased but due to the time consuming and the cost wise, we need a faster and equally reliable alternative. Antigen test approved by different countries can be used for point of care, screening and surveillance depending upon the requirements after calculating its sensitivity, specificity and accuracy. Objective To find out sensitivity and specificity of the Antigen test kit for COVID-19. Method Antigen tests were compared with Reverse Transcription Polymerase Chain Reaction as a reference standard in calculated sample size of 113 subjects in a high risk population. Both Reverse Transcription Polymerase Chain Reaction and antigen test were performed in a same subject with in maximum of 2 days' interval. Convenience sampling technique was used to select the subjects. Ethical approval was taken from Nepal Health Research Council before data collection. Study was done from August to September 2020 from Quarantine center of Province 3. Result There were total of 113 test carried out, among those 47 were positive and 66 were negative in Reverse Transcription Polymerase Chain Reaction. After preparing two by two table, Sensitivity and specificity of the tested was calculated which came out to be 85% and 100% respectively, with accuracy of 93.80%. Conclusion Even though the sensitivity and specificity came to be higher, this test should be interpreted cautiously depending upon the prevalence of Corona Virus Disease 19 in that particular community and the clinical and epidemiological context of the person who has been tested. When in doubt by clinical correlation should be confirmed with Reverse Transcription Polymerase Chain Reaction.

Safety and Efficacy of Spinal Anaesthesia in Percutaneous Nephrolithotomy.

INTRODUCTION: Renal stone is one of the common entities occurring in our population. There are different treatment modalities of stones; out of those percutaneous nephrolithotomy is one of the most popular and effective for the renal and upper tract stones. This study is based to compare the safety and efficacy of spinal anaesthesia and general anaesthesia in PCNL. METHODS: In a randomized prospective study 60 patients were divided in two groups; group 1 (n=30) underwent PCNL in general anaesthesia and group 2 (n=30) underwent PCNL in spinal anaesthesia in prone position with the conventional technique. Demographic, operative data, post operative complications, patients' satisfaction rate and follow up complications were recorded and analyzed between two groups. RESULTS: Mean age in group 1 was 39.10±12.45years and 36.10±14.18 in group 2 (P=0.100). Mean stone size in group 1 was 3.75±1.27cm and 3.23±1.36cm in group 2 (P=0.129).Similarly the operative time was 89.10 ± 49.38 min and 62.53±35.91 min in group 1 and group 2 respectively (P=0.042). There was no significant difference between the complications regarding the anaesthesia. Post operative nausea and vomiting were significantly higher in group 1 and headache in group 2 (p=<0.001). Overall patient satisfaction rate was higher in group 2 then in group 1 (p=0.01). Hospital stay in group 1 was 5.27±1.87 days and 4.53±1.88 days in group 2 (p = 0.07). Stone success rate was similar in each group (p =0.50). CONCLUSIONS: Spinal anaesthesia is a safe and effective method in performing PCNL.

Access to Drugs and Out of Pocket Expenditure in Primary Health Facilities.

BACKGROUND: The Government of Nepal promulgated health as a human right via Interim constitution and implemented Free Health Service Program in 2008 as a commitment to universalize basic health care services. So, the aim of this study was to understand reported access to medicine and health care services received by outpatients in public primary facilities. METHODS: The study followed cross sectional study design. Two hundred and thirty-four For data 234 out patients were interviewed on the day of the field visit in March and October 2014 across 28 primary health facilities of seven purposively selected districts representing three ecological belts and five development regions of the country. RESULTS: Our study revealed that the average number of medicines prescribed per patient was 2.65 per case in primary public health facilities, of which 91.2% were dispensed. Around 86.6% dispensed medicines were appropriately labeled and 84% of outpatients had proper knowledge of dosage and timing of medicine use. Around 55.6% of outpatients purchased some or all prescribed medicines from nearby private facilities which were not available in public facilities. Around 40% of them travelled more than half an hour to reach the facility. CONCLUSIONS: The gap in medicines prescribed and dispensed, Out of Pocket expenditure coupled with opportunity cost of travelling, appear as hurdles in access to basic health care services. So increasing free medicines list in public primary facilities with all round the year availability might answer major part of the problem.

Ultrasound-guided transvaginal radiofrequency myolysis for symptomatic uterine myomas.

OBJECTIVE: To investigate the feasibility, efficacy and safety of ultrasound-guided transvaginal radiofrequency myolysis for symptomatic uterine myomas. STUDY DESIGN: Forty-six premenopausal women with symptomatic uterine myomas received ultrasound-guided transvaginal radiofrequency myolysis as an outpatient procedure. Outcomes were assessed by measuring myoma volume at baseline and at 3-, 6- and 12-month follow-up; and by calculating the myoma volume reduction rate. Clinical improvement was assessed by calculating the menorrhagia score, the symptom severity score and the health-related quality-of-life score (Uterine Fibroids Symptom and Health-related Quality-of-life Questionnaire) before and after myolysis. RESULTS: The mean age of patients was 40.8 [standard deviation (SD) 6.5] years. The mean diameter of the dominant myoma at baseline was 4.8 (SD 1.1) cm and the mean volume of the dominant myoma at baseline was 67.4 (SD 51.1)cm(3). The size of the myoma decreased gradually and an overall volume reduction rate of 83.0% was achieved at 12-month follow-up. The mean symptom severity score decreased and mean health-related quality-of-life score increased; the Uterine Fibroids Symptom and Health-related Quality-of-life Questionnaire showed a significant clinical improvement after myolysis compared with baseline (p<0.001). The menorrhagia score decreased significantly from baseline (p<0.05), showing an improvement in menorrhagia at 3-, 6- and 12-month follow-up. No major complications were observed or reported. The re-operation rate was 8.7%. Fifteen and eighteen months after myolysis, two patients delivered infants with no complications during or after delivery. CONCLUSION: Ultrasound-guided transvaginal radiofrequency myolysis may be a safe, effective and minimally invasive outpatient procedure for the treatment of symptomatic uterine myomas.

Sharing schistosomes: the elephant schistosome Bivitellobilharzia nairi also infects the greater one-horned rhinoceros (Rhinoceros unicornis) in Chitwan National Park, Nepal.

Because the digenetic trematode fauna of Nepal is poorly known, we began to search for schistosomes in and around Chitwan National Park (CNP) of southern Nepal. Both domestic and wild Indian elephants (Elephus maximus) are present, and we found one of two dung samples from wild elephants and 1 of 22 (4.5%) dung samples from domestic elephants to be positive for schistosome eggs. The morphology of the eggs and both cox1 and 28S sequences derived from the eggs/miracidia were consistent with Bivitellobilharzia nairi, reported here for the first time from Nepal. Also, 7 of 14 faecal samples from the Asian or greater one-horned rhinoceros (Rhinoceros unicornis) contained viable eggs indistinguishable from those of B. nairi. This identification was confirmed by comparison with both cox1 and 28S sequences from B. nairi eggs/miracidia derived from Nepalese and Sri Lankan elephants. This represents the first sequence-verified identification of a schistosome from any species of rhinoceros, and the first verified occurrence of a representative of Bivitellobilharzia (a genus of 'elephant schistosomes') in mammals other than elephants. Our work suggests that elephants and rhinos share B. nairi in CNP, even though these two members of the 'charismatic megafauna' belong to unrelated mammalian families. Their shared life style of extensive contact with freshwater habitats likely plays a role, although the snail intermediate host and mode of definitive host infection for B. nairi have yet to be documented. This report also supports Bivitellobilharzia as a monophyletic group and its status as a distinct genus within Schistosomatidae.

Routine Measurement of Serum Amylase in Acute Abdomen.

BACKGROUND: Acute abdominal pain is a common condition presenting to both the emergency department (ED) and surgical admission unit. Increase in serum amylase levels are found in much gastrointestinal pathology. Serum amylase level is consistently high in acute pancreatitis though high values are not pathognomonic of pancreatitis .The aim of this study to assess the level of serum amylase in various diseases presenting with acute abdominal pain and to evaluate the role of routine measurement of serum amylase in the screening of patient with acute abdominal pain for the diagnosis of acute pancreatitis in a prospective series. METHODS: A prospective observational study was performed from 15th May 2014 - 15th Nov 2014 (6 months) at Department of Surgery of Kathmandu medical College Teaching Hospital; Kathmandu. All consecutive patients presented at emergency department and required admissions in surgical ward were included. A multivariate analysis was performed to assess the level of serum amylase in various diseases presenting with acute abdominal pain including acute pancreatitis. RESULTS: Overall, 318 patients were included during a period of 6 months among them 48 patients were excluded. 34 cases (12.6 %) were diagnosed of acute pancreatitis. three cases (1.1%) of non pancreatic pathology with raised serum amylase level (> 1000 U\L). CONCLUSIONS: Routine assessment of serum amylase is helpful in excluding differential diagnosis of patient presenting with acute abdomen and this study identified serum amylase as a good screening tool if done in cases with clinical suspicion.

Reasons for failure of nonsurgical root canal treatment in Nepali population.

Non surgical root canal treatment is carried out to salvage the teeth in oral cavity. Although the success rate is found to be ranging from 81-95%, for variety of reasons failure of root canal is still seen in day to day practice. This is a cross sectional study done in Nepali population to evaluate the causes for such failures. It was found that inadequate obturation (45%) was the major cause of failure followed by missed canal, (32%) and fractured or dislodged restoration (14%). This study shows that the basis for successful non surgical root canal treatment depends on operators knowledge on individual tooth anatomy and skill to properly clean, shape, obturate and restore the tooth in function.