Deaths among Women of Reproductive Age: an Explorative Case Study among Abortion Seekers.

In Nepal, abortion was legalized in 2002. Yet many women are denied abortion services. Women denied abortion services may either continue their pregnancies or find abortion care elsewhere. However, what is not known is the consequences on women, and their children after accessing abortion services or after being denied abortion services. This comment aims to understand the cause of death of women who sought abortion services between 2019 and 2020 and were enrolled in a longitudinal nationwide study of the consequences of legal abortion access in Nepal. Women were interviewed 6 weeks and every 6 months for 3 years after seeking abortion. During the follow-up interviews, the field research assistants were informed about the death of the clients. Once the death was reported, a trained senior research staff visited the deceased persons house and interviewed family members including husbands, maternal parents or in-laws to explore the cause of death. A total of nine deaths were reported between April 2019 and December 2022. Out of nine deceased women, four received abortions while five of them were initially denial abortion services. The majority of the deaths were due to suicide followed by tuberculosis. None of the deaths were caused by abortion or birth. Keywords: Death; Nepal; reproductive ages; womens health.

Denial of legal abortion in Nepal.

INTRODUCTION: In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied. METHODS: We used data from a prospective longitudinal study with 1835 women aged 15-45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level. RESULTS: Among those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care. CONCLUSION: Denial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.

Dyslipidemia in Patients with Xanthelasma Palpebrarum Visiting the Department of Dermatology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Xanthelasma palpebrarum refers to lipid deposition that occurs on eyelids and inner canthi. It is an important cutaneous manifestation of hyperlipidemia, atherosclerosis and coronary artery disease. Few studies have been done in Nepal regarding lipid abnormality in xanthelasma patients. The aim of this study was to find out the prevalence of dyslipidemia among patients with xanthelasma palpebrarum visiting the Department of Dermatology of a tertiary care centre. Methods: This is a descriptive cross-sectional study conducted among 80 patients from January, 2021 to February, 2022 in the Department of Dermatology of a tertiary care centre. Ethical approval was taken from the Institutional Review Committee (Reference number: 60512021). Convenience sampling was used. Lipid profile analysis was done among patients with clinical diagnosis of xanthelasma palpabrarum. Data was collected using Microsoft Excel for Mac version 16.16.27 and analyzed using the Statistical Package for the Social Sciences version 22.0. Point estimate at 90% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Out of 80 patients with xanthelasma palpebrarum, the prevalence of dyslipidemia was 64 (80.00%) (74-86 at 90% Confidence Interval). Among them, 29 (45.31%) were males and 35 (54.69%) were females. Conclusions: In our study, the prevalence of dyslipidemia among patients with xanthelasma palpebrarum was found to be higher than in similar studies conducted in similar settings. Keywords: dyslipidemia; gender; lipid.

A Case of Painless Subacute Thyroiditis Presenting as Fever of Unknown Origin.

Subacute thyroiditis (SAT) is characterized by severe pain in the anterior aspect of the neck and tenderness is present during the thyroid gland's palpation. It is commonly caused by viruses including mumps, measles, rubella, coxsackievirus, influenza, and Epstein-Barr virus (EBV). Painless subacute thyroiditis is rare and can present as a fever of unknown origin (FUO). Our case reports an unusual case of SAT as our patient did not have any neck pain. Laboratory investigations show low thyroid-stimulating hormone (TSH), poor or no uptake of radioactive iodine by the thyroid, and elevated erythrocyte sedimentation rate (ESR). Clinicians should be aware that painless SAT can present as a fever of unknown origin.

Metformin-Associated Lactic Acidosis: A Case Report and Review.

Metformin is widely prescribed as the first-line medication for type II diabetes mellitus. While the gastrointestinal side effects of metformin such as nausea, vomiting, diarrhea, and heartburn are quite common, one dangerous side effect of metformin, lactic acidosis, is extensively discussed yet rarely reported. Here, we discuss a 53-year-old female with type II diabetes mellitus who presented to an emergency department (ED) with chief complaints of dizziness and lightheadedness. The patient had chronic kidney disease (CKD) with a baseline estimated glomerular filtration rate (eGFR) of 45 mL/minute/1.73 m2. Initial laboratory results showed acute kidney injury (AKI) with hyperkalemia and lactic acidosis of 20 mmol/L. The patient was admitted to the ICU requiring emergent dialysis. Later, she was diagnosed with metformin-associated lactic acidosis (MALA). Her AKI and lactic acidosis subsequently improved. Metformin-associated lactic acidosis (MALA) is a rare but serious side effect of metformin. It is primarily reported in patients with chronic renal failure; therefore, it should be used with caution in these patients. Renal replacement therapy (RRT) is the critical management option for patients with MALA. Because of this, physicians prescribing metformin should carefully monitor all patients and assess the risk of developing severe side effects.

Predictors of prior unsuccessful pharmacy abortion attempts among women presenting for abortion in government certified clinics in Nepal.

OBJECTIVE: Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly-selected government approved abortion health facilities across Nepal. METHODS: Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n = 1160) completed research staff-administered baseline surveys. We used multivariable mixed-effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. RESULTS: Almost one in seven (14%) women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10-1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20-3.70) had increased odds of having tried to access abortion through a pharmacy. CONCLUSION: Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Warts among Patients Visiting the Outpatient Department of Dermatology in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Warts are benign epithelial proliferations caused by a double-stranded deoxyribonucleic acid virus called human papillomavirus. They may cause significant concern and frustration on the part of the patient affecting social activities as lesions can be uncomfortable, and treatment is often painful and frustratingly ineffective. The study aimed to find out the prevalence of warts among patients visiting the outpatient Department of Dermatology in a tertiary care centre. METHODS: This descriptive cross-sectional study was conducted in a tertiary care centre from 20 January 2021 to 21 February 2022. The ethical approval was taken from the Institutional Review Committee (Reference number: IRC-NMCTH 588/2021). A convenience sampling technique was used. A detailed history including distribution, size, morphology, progression and duration of the lesions was taken. Point estimate and 95% Confidence Interval were calculated. RESULTS: Out of 4802 outpatients, 140 (2.92%) (2.44-3.40, 95% Confidence Interval) had warts. Genital wart was found in 24 (17.14%) and non-genital warts in 116 (82.85%) patients. CONCLUSIONS: The prevalence of warts among outpatients was similar when compared to other studies from similar settings.

Hypercalcemia and Renal Mass: A Diagnostically Challenging Case.

Hypercalcemia of malignancy frequently occurs in patients with solid tumors as a paraneoplastic syndrome known as humoral hypercalcemia of malignancy (HHM), caused by the secretion of parathyroid hormone-related peptide (PTHrP). On the other hand, 1,25-dihydroxyvitamin D [1,25(OH)2D]-mediated hypercalcemia is a less common cause of hypercalcemia of malignancy and is mostly observed in lymphoma patients. Here, we report an interesting case of a 77-year-old male nursing home resident with suspected renal cell carcinoma (RCC) presenting with severe hypercalcemia (18.7 mg/dL), which was initially presumed to be HHM. However, workup revealed nonsuppressed parathyroid hormone, low PTHrP, and elevated 25-hydroxyvitamin D and 1,25(OH)2D levels. Steroids were initiated due to an inadequate response to bisphosphonate therapy and elevated vitamin D metabolites, resulting in further reduction in serum calcium levels. This case highlights the need to consider multiple concurrent etiologies in the differential diagnosis of severe hypercalcemia, including the possible role of calcitriol-mediated hypercalcemia in RCC.