Metabolic syndrome and biochemical changes among non-alcoholic fatty liver disease patients attending a tertiary care hospital of Nepal.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is mutually and bidirectionally linked with metabolic syndrome (MetS) of which it is both the cause and the consequences. Worldwide, 6.3 to 33% of the general populations are estimated to suffer from the disease with even higher prevalence in the group sharing metabolic co-morbidities. Hence, this study aims to recognize various risk factors including metabolic components and blood parameters to predict the possible incidence of the disease. METHODS: Total of 429 (219 NAFLD and 210 control) subjects were conveniently selected for study during the period of 9 months. Diagnosis of non-alcoholic fatty liver disease was done by liver imaging and based on liver enzymes. Assessment of metabolic syndrome was done by International Diabetic Federation (IDF) and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. All biochemical and hematological parameters and liver enzymes were estimated by using standard guideline. Mean comparison of quantitative data in different groups were performed using analysis of variance (one-way ANOVA). Risk estimation of NAFLD associated with each character was verified by Chi-square test. RESULTS: There was significant high levels of body mass index (BMI), waist circumference (WC) and lipid profiles in NAFLD patients in comparison to control population (p < 0.001). Further, according to the NCEP ATP III criteria, 13.6% of NAFLD were present with MetS where risk estimate was significant (OR = 2.15). Whereas, other criteria (IDF) for MetS showed higher frequency (30.1%) with higher risk (OR = 29.75) for the presence of MetS in NAFLD patients. The change in triglycerides (TG) and HDL-C (high density lipoprotein cholesterol) was also statistically significant in different grades of NAFLD. High risk for NAFLD was associated with existing co-morbid conditions like cardiovascular risk patients (3.18 times) followed by obese patients (1.72 times) and Diabetes Mellitus patients (1.68 times) at a significant level. CONCLUSION: The result of this study suggests that there is an increased prevalence of all the components of MetS and significant changes in biochemical markers in cases of NAFLD. Timely diagnosis would help in delaying its complications and co-morbidities.

Ugly bugs in healthy guts! Carriage of multidrug-resistant and ESBL-producing commensal Enterobacteriaceae in the intestine of healthy Nepalese adults.

BACKGROUND: Fecal carriage of multidrug-resistant and extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae is one of the important risk factors for infection with antibiotic-resistant bacteria. In this report, we examined the prevalence of multidrug-resistant and ESBL-producing common enterobacterial strains colonizing the intestinal tract of apparently healthy adults in Kathmandu, Nepal. METHODS: During a 6-month period (February-July 2016), a total of 510 stool specimens were obtained from apparently healthy students of Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal. Stool specimens were cultured, and the most common enterobacterial isolates (Escherichia coli and Klebsiella species) were subjected to antimicrobial susceptibility tests according to the standard microbiologic guidelines. Multidrug-resistant isolates were selected for ESBL confirmation by combined disk test and E-test methods. Molecular characterization of plasmid-borne ESBL genes was performed by using specific primers of cefotaximase Munich (CTX-M), sulfhydryl variant (SHV), and temoniera (TEM) by polymerase chain reaction. RESULTS: Among 510 bacterial strains, E. coli (432, 84.71%) was the predominant organism followed by Klebsiella oxytoca (48, 9.41%) and K. pneumoniae (30, 5.88%). ESBLs were isolated in 9.8% of the total isolates including K. oxytoca (29.17%), E. coli (7.87%), and K. pneumoniae (6.67%). Among ESBLs, bla-TEM was the predominant type (92%) followed by bla-CTX-M (60%) and bla-SHV (4%). CONCLUSION: Multidrug-resistant and ESBL-producing enterobacterial commensal strains among healthy individuals are of serious concern. Persistent carriage of ESBL organisms in healthy individuals suggests the possibility of sustained ESBL carriage among the diseased and hospitalized patients. We recommend similar types of epidemiologic surveys in larger communities and in hospital settings to ascertain the extent of ESBL resistance.

Enteric Fever Caused by Salmonella enterica Serovars with Reduced Susceptibility of Fluoroquinolones at a Community Based Teaching Hospital of Nepal.

Enteric fever continues to be an important public health problem especially in developing countries of the tropical region including Nepal. In this study, we aimed to investigate the incidence of enteric fever associated with Salmonella enterica and determine its antimicrobial susceptibilities to therapeutic antimicrobials in a community based teaching hospital of Nepal. A total of 2,304 blood samples from suspected enteric fever patients attending Manmohan Memorial Teaching Hospital were processed with standard microbiological methods for the isolation and identification of bacterial pathogens. The Salmonella enterica clinical strains were subjected to antimicrobial susceptibility testing by Kirby-Bauer disk diffusion method, and the results were interpreted according to the criteria suggested by the Clinical and Laboratory Standards Institute (CLSI). A total of 245 (10.6%) cases of enteric fever associated with Salmonella enterica were confirmed by blood culture. Out of them, 162 (66.1%) were caused by Salmonella Typhi and 83 (33.9%) by Salmonella Paratyphi. On Kirby-Bauer disk diffusion antimicrobial susceptibility testing, Salmonella isolates were highly susceptible to cefixime (100%), ceftriaxone (100%), ampicillin (97.9%), cotrimoxazole (94.6%), azithromycin (96.7%), tetracycline (95.5%), and chloramphenicol (97.5%), respectively. Two hundred twenty-six (92.2%) of Salmonella isolates were nalidixic acid resistant with reduced susceptibility to ciprofloxacin (36.7%) and ofloxacin (54.8%), respectively. Although the rate of MDR Salmonella strains was very low (<5%), their reduced susceptibility to fluoroquinolones has restricted their routine empirical use. Third generation cephalosporins are the safest choice for empirical use but ampicillin, cotrimoxazole, azithromycin, and chloramphenicol can be effective alternatives.

Effect of age and estrogen on biochemical markers of bone turnover in postmenopausal women: a population-based study from Nepal.

BACKGROUND: Osteoporosis, a common disease worldwide, is characterized by low bone mass and architectural deterioration of bone tissue, leading to enhanced bone fragility and increase in fracture risks. Both menopause and aging are related factors leading to greater risk of bone disease, particularly among postmenopausal women. Hence, the main purpose of this study was to investigate the differences in biochemical markers of bone turnover and to evaluate the association of hormones and age-related factors with biochemical markers between pre- and postmenopausal women. METHODS: A descriptive cross-sectional study was conducted over a period of 6 months among the female population of Dholahity community, Lalitpur, Nepal. A total of 496 healthy women were selected based on the questionnaire strategy. Among them, 244 were premenopausal and 252 were postmenopausal women. Different bone markers were evaluated as per the guideline provided by the reagent manufacturer, and hormonal assay, particularly estradiol level assessment, was performed by chemiluminescence immunoassay-based technique. RESULTS: A significant decrease in serum calcium level and estradiol level was observed in postmenopausal women as compared to premenopausal women, whereas a significant increase in serum phosphorus and alkaline phosphatase (ALP) levels was seen among postmenopausal (p<0.001). Age was significantly correlated with bone markers (ALP and calcium) in postmenopausal group (p<0.005), while there was no significant correlation in premenopausal group. In addition, there was significant positive correlation between calcium and estradiol in postmenopausal women, while ALP was negatively correlated with estradiol in that group. Further, no significant correlation was demonstrated between estradiol and bone markers in postmenopausal women in body mass index and age-adjusted partial correlation analysis. CONCLUSION: Timely diagnosis of osteoporosis in women would be of significant benefit for effective care for required populations and help to minimize mortality rate and financial burden of our country.

Renaissance of Conventional First-Line Antibiotics in Salmonella enterica Clinical Isolates: Assessment of MICs for Therapeutic Antimicrobials in Enteric Fever Cases from Nepal.

Enteric fever caused by Salmonella enterica is a life-threatening systemic illness of gastrointestinal tract especially in tropical countries. Antimicrobial therapy is generally indicated but resistance towards commonly used antibiotics has limited their therapeutic usefulness. Therefore, we aimed to determine the antimicrobial susceptibility pattern by minimum inhibitory concentration method of common therapeutic regimens against Salmonella enterica from enteric fever clinical cases. Salmonella enterica clinical isolates recovered from the patients with suspected enteric fever whose blood samples were submitted to microbiology laboratory of Manmohan Memorial Community Hospital, Kathmandu, from March 2016 to August 2016, were studied. These isolates were subjected to antimicrobial susceptibility testing against common therapeutic antimicrobials by Kirby-Bauer disk diffusion method. The minimum inhibitory concentration of ciprofloxacin, azithromycin, chloramphenicol, and cefixime was determined by Agar dilution method based on the latest CLSI protocol. A total of 88 isolates of Salmonella enterica were recovered from blood samples of enteric fever cases. Out of them, 74 (84.09%) were Salmonella Typhi and 14 (15.91%) were Salmonella Paratyphi A. On Kirby-Bauer disk diffusion antimicrobial susceptibility testing, entire isolates were susceptible to cotrimoxazole, cefixime, ceftriaxone, azithromycin, and chloramphenicol. Sixty-four (72.7%) Salmonella enterica isolates were nalidixic acid resistant and nonsusceptible to ciprofloxacin and levofloxacin. On MIC determination, four Salmonella isolates were ciprofloxacin resistant with MIC 1 µg/ml and two isolates were ciprofloxacin intermediate with MIC 0.5 µg/ml. The MIC range of azithromycin was from 0.125 µg/ml to 2.0 µg/ml, whereas that for chloramphenicol was 2.0 µg/ml-8.0 µg/ml and for cefixime was 0.0075-0.5 µg/ml, respectively. Despite global surge of antimicrobial resistance among Salmonella enterica clinical isolates, the level of drug resistance in our study was not so high. However, higher level of NARST strains limits therapeutic use of fluoroquinolones and necessitates the routine monitoring of such resistance determinants in order to effectively and rationally manage enteric fever cases.

Elevated Cardiovascular Risks among Postmenopausal Women: A Community Based Case Control Study from Nepal.

Cardiovascular disease (CVD) is one of the leading causes of death worldwide which is more prevalent in women after menopause. Hormonal changes associated with menopause are accountable for dyslipidemic pattern that causes CVD and associated complications. Therefore, the present study was commenced to compare the lipid profile in pre- and postmenopausal women. A descriptive cross-sectional study was conducted at Manmohan Memorial Institute of Health Sciences (MMIHS) from February 2016 to July 2016. A total of 260 fasting samples were collected from healthy women, 130 from premenopausal and 130 from postmenopausal women, and analyzed for Total Cholesterol (TC), Triacylglycerol (TAG), High Density Lipoprotein Cholesterol (HDL-C), and Low Density Lipoprotein Cholesterol (LDL-C) as per the guideline provided by the reagent manufacturer (Human, Germany). All the parameters were analyzed by Stat Fax 3300 semi auto analyzer. TC, TAG, HDL-C, and LDL-C were highly significantly increased in postmenopausal women when compared to premenopausal women. LDL/HDL ratio was significantly elevated in postmenopausal women than in premenopausal women. BMI was significantly positively correlated with TC and TAG in both pre- and postmenopausal population and it was positively correlated with HDL-C in premenopausal population while negatively correlated in postmenopausal population. Since more of the atherogenic lipid parameters are increased in postmenopausal women, they appear to be more prone to have CVD and associated complications in near future. Hence, it is mandatory to monitor and manage dyslipidemic pattern in every woman experiencing menopause.

Shigellosis Caused by CTX-M Type ESBL Producing Shigella flexneri in Two Siblings of Rural Nepal: First Case Report from the Country.

Shigellosis is an acute infectious disease characterized as severe bloody diarrhea (dysentery) and is accountable for a significant burden of morbidity and mortality especially in children under the age of 5 years. Antimicrobial therapy is required in the cases of severe dysentery associated with Shigella. However, emergence of multidrug resistant (MDR) strains of Shigella spp. over the last two decades has restricted the use of common therapeutic antimicrobials. In MDR strains, the third-generation cephalosporins have been used for the treatment, but, unfortunately, emerging reports of enzyme mediated ß-lactam resistance among Shigella isolates from various parts of the world have greatly compromised the therapy of pediatric dysentery. In Nepal, drug resistant strains of Shigella spp. have been reported, but MDR and extended spectrum ß-lactamase (ESBL) producing strains were previously unknown. Here, we report two Shigella flexneri isolates harboring ESBL genotype-CTX-M associated with acute dysentery in two siblings which were presented and treated in a tertiary care teaching hospital of Kathmandu, Nepal.

Isolation of Potential Phages against Multidrug-Resistant Bacterial Isolates: Promising Agents in the Rivers of Kathmandu, Nepal.

Bacteriophages are being the subject of interest for alternative antimicrobial therapy for infectious diseases in recent years. Therapeutic effectiveness regarding phage therapy is a matter of concern since it is the most promising biological treatment of this era. Hence, the present study was aimed to isolate the potential bacteriophages present in river water samples and to analyze their host range among clinical strains of bacteria. Ten different locations of Kathmandu valley were selected for the collection of river water for the detection of probable phages. Bacteriophages were isolated from water samples using the double agar overlay method. Isolated phages were purified by diluting in the SM-buffer and filtering through 0.22 µm filter. Purified lysate was further processed for analyzing its host range by using spot method. Their host range was characterized against 20 bacterial strains, including multidrug-resistant. Total 67 different phages were isolated against 8 different host organisms. Out of them, forty-seven phages were selected for analyzing its host range. Among them, Serratia phages (ΦSER) had the broad host range infecting 17 different bacterial strains including multidrug-resistant harboring ESBL and MBL genotypes. However, Klebsiella phages (ΦKP) had narrow host range in comparison to other phages. Isolated phages had the potential effect against clinical strains of bacteria along with their broader host spectrum. Most importantly, promising effect against MDR pathogens in this study has raised the probable chances of the utility of these phages for biological control of bacterial infection including MBL and ESBL strains.

Bacteremia caused by a rare pathogen - Chromobacterium violaceum: a case report from Nepal.

Chromobacterium violaceum is a gram negative saprophytic bacterium, prevalent in tropical and subtropical climates. Infections caused by C. violaceum are very uncommon, yet it can cause severe systemic infections with higher mortality when entered into the bloodstream through open wound. A case of symptomatic bacteremia in a woman caused by C. violaceum was identified recently at a tertiary care teaching hospital in Nepal. Timely diagnosis by microbiological methods and rapid administration of antimicrobials led to a successful treatment of this life-threatening infection in this case. From this experience, we suggest to include this bacterium in the differential diagnosis of sepsis, especially when abraded skin is exposed to soil or stagnant water in tropical areas. The precise antimicrobial selection and timely administration should be considered when this infection is suspected.