Bi-maxillary Protrusion: An Orthodontic Management.

Bi-maxillary protrusion is a condition with protrusive and proclined upper and lower incisors and the patient is not able to close lips without strain. The presented case reported with the chief complaint of forwardly placed teeth, with skeletal class II malocclusion, and Angle's class I malocclusion with protrusive and forwardly placed upper and lower incisors. The treatment was performed with the extraction of all first premolars and retraction under absolute anchorage. The retraction of upper and lower lips of about 3 mm and 3.5 mm was achieved respectively and the patient was able to close lips without strain. With proper anchorage preparation, bi-maxillary protrusion can be successfully managed orthodontically.

Acquired Constricting Band Syndrome.

The superstitious beliefs of gaining a good fortune led to wearing rubber bands around the hand leading to the development of the constricting band syndrome. Acute compartment syndrome is a limb-threatening condition characterized by elevated interstitial pressure in a confined fascial compartment and if left untreated, it results in tissue necrosis, irreversible nerve and muscle injury and permanent functional impairment. We report a 46 years old male with history of wearing rubber hand on all his fingers, who presented late with gangrene and autoamputation.

Knowledge, Attitude and Practice Regarding Environmental Tobacco Smoke among Pregnant Women of Sunsari.

Background Second hand tobacco smoke or Environmental Tobacco Smoke (ETS), contains toxic substances and carcinogens that cause serious health effects in humans. Studies show that ETS exposure during pregnancy is injurious to the mother-infant pair with long term consequences. Limited studies are found in context of ETS in pregnancy in Nepal. Objective To explore the knowledge about harmful effect of ETS exposure in pregnant women and to know the behavior of avoidance from exposure to ETS during pregnancy. Method A cross sectional study was conducted among 303 pregnant women attending antenatal clinics at the District Hospital Inaruwa and BPKIHS Dharan. A pre-tested semi-structured questionnaire was used to collect data regarding socio-demographic characteristics, knowledge, attitude and practice regarding Environmental tobacco smoke. Data was entered in Excel and analyzed in SPSS 11.5. Result The mean age of the respondents was 23.86±4.68 years. The proportion of primigravida was 53.5% and multi-gravida was 46.5%. Among the respondents, 14% were illiterate and 91% were unemployed. A similar proportion of the husbands (12%) were illiterate. Three-fourth (75%) of the respondents lived in joint family. It was found that 86% of their husbands were smokers. There were 61% of pregnant women who had heard about ETS, mainly through television (35%) and radio (30%). There was 86% of the households who had initiated some measures to prevent smoking inside the house. Conclusion The pregnant women in this study are aware about ETS. However a significant number of them believe that ETS is not harmful compared to active smoking. There is a need for further studies to identify interventions to avoid ETS exposure among the pregnant women.

Fetal Ductus Venosus Pulsatility Index and Diameter during Second and Third Trimester of Gestation.

INTRODUCTION: The ductus venosus is a small funnel shaped vessel found posterior to the fetal liver connecting the intra-abdominal umbilical vein and the inferior vena cava. It is one of the three physiological shunts in the fetus. The main objective of this study is to construct the reference table and normogram for fetal ductus venosus Pulsatility Index and diameter with gestational age. METHODS: This was a prospective cross sectional study conducted during August 2011 to July 2012 taking 294 uncomplicated pregnancies using systemic random sampling method. Three measurements were made for ductus venosus diameter and Pulsatility Index in each fetus during period of fetal quiescence. RESULTS: The ductus venosus diameter at <20weeks, 20-25 weeks, 25-30 weeks, >30 weeks were 1.16, 1.31, 1.62, 1.81 and Pulsatility Index at <20weeks, 20-25 weeks, 25-30 weeks, >30 weeks were 0.41, 0.44, 0.41 and 0.41 respectively. CONCLUSIONS: The mean diameter of the ductus venosus was linear across gestational age. The Pulsatility Index shows a scattered distribution across the gestational age.

A Study of Occupational Characteristics and their Association with Cardiovascular Disease among Industrial Workers in Eastern Nepal.

Background An understanding of occupational characteristics of a worker is essential to establish policies, legislation in order to protect the health of the worker. The concept of Occupational Safety and Health is in initial stage in our country. Work-related cardiovascular disease (CVD) is caused by occupational factors that increase the oxygen requirements of the heart or decrease the capacity of the heart to use oxygen. It can be very difficult to link a specific work-related exposure to the development of cardiovascular disease in an individual person. This is because of issues of latency, multiple possible risk factors, lack of specific work-related features and various factors that influence diagnosis. Objective To study occupational characteristics and their association with cardiovascular disease among relatively young male industrial workers between 20-59 years of age in Sunsari-Morang industrial corridor of Eastern Nepal. Method A cross sectional study was conducted among men between 20 -59 years of age in two randomly selected industries in the Sunsari-Morang corridor of Eastern Nepal from July 2012 to July 2013. The data was collected using a pre-tested semi-structured questionnaire. Systematic random sampling was done to select the required number of samples. Chi-square and Fisher Exact tests were used. Crude and adjusted analyses were done. Result Majority (85%) were day shift workers. About 40% of the workers worked for 70-80 hrs/week. Most of them have stress sometimes at work. Noise was experienced by 40.9% of the workers. Earplug was used by only 5% of the workers. Hypertriglyceridaemia was seen in 49.3% of the workers. Long working hours, not using earplug and financial stress were seen to be associated with cardiovascular disease on bi-variate analysis. However, only earplug was significant in multivariate analysis. Conclusion Risk of cardiovascular disease was seen more among those who worked for more hours; those who did not use earplug and those who had financial stress. The results need further exploration to establish a causal association between occupational characteristics of the workers and cardiovascular disease in industrial set-up of eastern Nepal.

Teaching District Concept of BP Koirala Institute of Health Sciences: An Inter-disciplinary Community Based Medical Education and Health Service Delivery Model in Rural Nepal.

Community based education trains health professional students to deal with the community health problems. The attitude and skills they gain as planners for health care provision are applicable in both hospital and community settings. BP Koirala Institute of Health Sciences has implemented a model of Community based education which encompasses the health institutions, organisations and the communities of the sixteen districts in eastern Nepal and refers to this concept as the 'Teaching District" concept of B P Koirala Institute of Health Sciences. This paper seeks to describe the concept and its implementation. Almost 20 years have passed since first initiated; and pending a comprehensive evaluation, this concept has gathered a great deal of experience to serve as a model for partnership between academic health sciences institutions with the district health system of Nepal.

Electronic Health Literacy Skills among Medical and Dental Interns at B P Koirala Institute of Health Sciences.

BACKGROUND: Appropriate use of the available electronic resources is important for decision making in health. The use of electronic resources in health care is universal. The study measures the eHealth literacy skills among the medical and dental interns of the B P Koirala Institute of Health Sciences (BPKIHS), Nepal. METHODS: Self administered electronic Health Literacy Scale (eHEALS) was used to collect data from 125 medical and dental interns at BPKIHS. The interns represent immediate past medical student and soon to be professional doctor. RESULTS: A quarter of interns are not sure about the usefulness of internet resources for health. The interns have limited knowledge about right resources in the internet. They are not equipped to tell useful resources from the not-useful ones in the internet. CONCLUSIONS: There is a need to pay attention to the eHealth Literacy needs of the interns. Further research may be needed to generate evidence on what interventions may be specific to meet the ehealth literacy needs of the medical and dental interns.

Adherence to Antihypertensive Medications: Population Based Follow up in Eastern Nepal.

BACKGROUND: Poor adherence toward antihypertensive drugs is a worldwide problem that results in poor health outcomes and increased health care costs. Community based study related to adherence to antihypertensive medication is limited in context of Nepal. METHODS: This study was conducted to explore the extent of adherence towards prescribed antihypertensive treatment and to identify the factors of non adherence. Community based cross sectional study was conducted in Dharan Municipality of Eastern Region of Nepal from September 2009 to February 2010. Out of 975 hypertensive patients, 154 calculated samples were selected following simple random sampling method. Data was collected by interview method and adherence was measured by using four items Morisky Medicine adherence scale. Data was analyzed using SPSS by descriptive and inferential (Chi square and logistic regression analysis) Statistical method. RESULTS: Among the 154 hypertensive patients, only 56.5% patients were adherent to antihypertensive medication. The important predictors of non adherence by logistic regression analysis at 95% Confidence Interval were illiteracy (OR 5.34, CI= 1.23 -23 , P=0.025), expensive price of medicine (OR 5.14, CI=1.1-23.9, P=0.037), missed medicine due to cost (OR 0.143,CI=0.02-0.78, P= 0.025), no family history of hypertension (OR 4.46,CI= 1.21-16.4, P=0.024), irregular follow up (OR 6.39,CI=1.22-33.3, P=0.028), more than one pills per day ( OR 5.33,CI=1.19-23.7, P= 0.028). CONCLUSIONS: Around half of the population was non adherent towards antihypertensive medications so identified gap need to be addressed to increase adherence level.

Antibiotic Use, Its Resistance in Nepal and Recommendations for Action: A Situation Analysis.

Antibiotics are crucial, life-saving medicines in the fight against infectious disease, but resistance to these drugs is growing all over. This article presents key findings from a detailed situation analysis produced by the Global Antibiotic Resistance Partnership (GARP)-Nepal working group. In the absence of nationally-representative surveillance, it is not possible to fully describe antibiotic resistance in the country, but many important bacterial pathogens are highly resistant to most first-line and some second-line antibiotics, according to available reports. In credible studies, more than half of Escherichia coli, Klebsiella pneumoniae and Streptococcus pneumoniae isolates tested, and over 30 percent of some Shigella spp. and Vibrio cholerae isolates were resistant to first-line antibiotics. The findings for Neisseria gonorrheae and hospital-acquired Staphylococcus aureus are similar. Antibiotic use in animal food is poorly documented in Nepal, but it is commonly acknowledged to be widespread, contributing to the overall antibiotic resistance burden. The volume of veterinary antibiotic sales in Nepal rose over 50 percent from 2008 to 2012, most through retailers without veterinarian prescription. Antibiotics are necessary to treat infections in animals, but they are also used extensively for preventing disease, a use that can be restricted without jeopardizing animal or human health. They may also be used for promoting animal growth, which can be eliminated with no health consequences. Nepal has made important advances in reducing mortality and morbidity and increasing health coverage, but has not yet taken steps to address antibiotic resistance. The GARP-Nepal working group outlines the components of a national strategy on antibiotic resistance, consistent with the recent call by the World Health Organization for national action plans, to be developed collaboratively with stakeholders and partners from government and all relevant sectors.

Understanding socio economic contexts of female sex workers in eastern Nepal.

The present focus is mostly laid on high risk behavior of commercial sex workers without any consideration of their location, educational status and other socio-cultural norms. Thus, we designed a study to understand socio demographic characteristics, lifestyle of female sex workers and search for driving factors for prostitution in eastern Nepal. A descriptive study was conducted in three districts of Eastern Nepal in 2012 over the period of six months. The data regarding their socio demographic characteristics, income, reason for joining sex trade and future choice regarding the profession were recorded from 210 female sex workers through face-to-face interviews. Majority (53.3%) of respondents belonged to the productive age group of 20-29 years, more than one thirds (43.3%) had not received any form of formal education and were unmarried. More than half (53.80%) were presently living alone and about one thirds of the women (31.90%) were minors when they joined this profession. Major portion of the sample (94.80%) worked more than three days a week with median income of 15 thousand per month and 41 percent had sex with more than or equal to ten clients per week. Poor economic condition was the most frequent (47.6%) factor leading to joining of sex trade however, more than two thirds, (72.80%) wanted to quit the profession. Given low level of education, relatively low income, and young age among this population, empowerment and alternative employment/education opportunities should be created to develop this part of Nepalese society.

Malnutrition Status Among Under-5 Children in a Hill Community of Nepal.

BACKGROUND: Malnutrition, especially under nutrition puts children at increased risk of morbidity and mortality and remains a serious barrier in child growth, development and survival. This is a major public health problem among under- 5 children in Nepal particularly in rural areas. OBJECTIVE: To assess the burden and contributing factors for malnutrition in hill community of Ilam district in eastern Nepal. METHOD: A cross sectional study was conducted in rural hill communities of Ilam district, Nepal with a sample of 240 under- 5 children. Anthropometric measurements were used as per WHO guidelines to asses three nutritional status: Underweight, Stunting, and Wasting using descriptive statistics and chi square test was applied using SPSS 12.0 to assess social and predisposing factors. RESULT: Seventeen percent of under- 5 children were moderately and 10.4 % were severely underweight. Similarly, 22.9%, and 17.5% were found to be moderately and severely stunted respectively. Less than 10% were found to be moderately and severely wasted. Older age group of children, education level of mother, not exclusive breast feeding practice had significant (p <0.05) effect on stunting. More than 50% children were affected with stunting, underweight and wasting at the same time. CONCLUSION: Significant proportion of under - 5 children were malnourished in the communities of the hilly areas. The study unveiled the importance of literacy and exclusive breast feeding for the prevention of malnutrition in under- 5 children.

Factors contributing to antenatal care and delivery practices in Village Development Committees of Ilam district, Nepal.

BACKGROUND: Proper antenatal care and good delivery practice helps to prevent the complications of childbirth and ensures a wholesome maternal and child health in the future. Almost half of the births in the developing countries take place without a skilled birth attendant. OBJECTIVES: To assess the antenatal care (ANC) and delivery practices in the Village Development Committees (VDC) of Ilam district, Nepal and to identify the relationship with the socio-demographic factors. METHOD: Cross sectional study of 262 mothers of reproductive age group having at least one child of less than five years of age, selected by simple random sampling, was carried out over different VDCs of Ilam by face to face interview using semi-structured questionnaire. RESULTS: Among 262 mothers, 34.7% were married before the age of 18 years. 69.5% of the mothers had attended four antenatal care visits. Nearly 47% of the deliveries were conducted at home out of which only 33.6% were conducted by skilled birth attendant. Number of children and maternal education were found to significantly affect the ANC visit and place of delivery. Age at marriage and age at first pregnancy were significantly associated with the place of delivery. CONCLUSION: Large proportion of mothers still do not have adequate antenatal visits and this is supported by the fact that nearly half of the deliveries were conducted at home. Motivation and incentives are required for pregnant mothers especially in rural areas regarding importance of adequate antenatal visits and delivery in health institutions. Population policies should be aimed at reducing proportion of women marrying and giving birth in their teens.

Mucopolysaccharidosis type II with inguinal hernia.

Mucopolysaccharidosis Type II (Hunter syndrome) is a rare X-linked recessive storage disorder caused by deficiency of lysosomal enzyme iduronate-2-sulfatase, causing excess accumulation of glycosaminoglycans in the lysosomes resulting in cellular damage, organ failure and death. Severe subtype develops characteristic clinical features and cognitive impairment early and die in second decade of life. In a resource poor setting, we report a case of Hunter syndrome, severe subtype, based on global development delay, coarse facies, short stature, hepatosplenomegaly and dysostosis multiplex on X-ray with unusual large congenital inguinal hernia. The diagnosis was important because of risk of recurrence of hernia after repair.

Worm infestation among the school children of Dhankuta District.

Intestinal parasitic infections (IPI) cause serious public health problem in Nepal. They are more prevalent in the poor segments of the population with low household income, poor handling of personal and environmental sanitation, overcrowding and limited access to clean water. The objective of the study is to assess knowledge and practice about worm infestation and to find out the relation of knowledge and practice with the selected variables. A cross-sectional study was conducted in 200 students of Grade 9 and 10 in Government and private schools of Dhankuta. The chi-square test was used to measure the association of knowledge and practice about worm infestation. The knowledge regarding risk factors of worm infestation due to unhygienic pig farming practices is significantly higher in female (66.4%) than male (44.8%). All the risk factors were found to be significantly higher in knowledge among the private school as compared to Government school. Regarding Fathers occupation, unemployed (100.0%) believe it is due to poor personal hygiene and very less of labor (50%) which is significantly associated. Regarding Mother Group, students never eat raw meat and vender food whose mothers have skilled worker. The school going students of Dhankuta were aware of the knowledge regarding the worm infestation but had less knowledge among the school children of Government as compared to private.

A study of prevalence of Taenia infestation and associated risk factors among the school children of Dharan.

BACKGROUND: Taenia prevalence has remained high among certain ethnic groups and occupational diseases in Nepal. Taenia saginata and Taenia solium species are worldwide in distribution. Infection is found most often in rural areas of developing countries with poor hygiene and living in close contact with pigs and eating undercooked pork meats. This allows the tapeworm infection to be completed and its cycle to continue. OBJECTIVES: To measure the prevalence of taenia infestation and to identify risk factors associated with taenia infestation among the school children of Dharan. METHODS: A cross sectional study was conducted among 935 Government and private school going children of Grade VI, VII, and VIII of Dharan during 2007 to 2008. Stratified random sampling method was applied to choose the schools and the study subjects. The prevalence was calculated, Chi-square test was used to measure the association of risk factors and taenia infestation. RESULTS: Taenia species was found to be high (5.5%) among the school children of Dharan. Infection rate of taenia among the male children (6.0%) was slightly higher than female (4.8%). There were no cases of taenia infestation found among children washing hands with soap. Regarding meat consumption in the non-vegetarian group, taenia infestation was found higher (6.5%) among pork eating than nonpork eating (4.7%). No significant relationship was traced among the factors in the causation of taenia infestation although slight indications present. CONCLUSION: Taenia species was found very high among the school children of Dharan. No such association was found with the risk factors.

Outbreak of cholera in Tilathi VDC Saptari Nepal.

BACKGROUND: On 2011, Cluster of cholera cases was reported in the Tilathi VDC of Saptari, Nepal. OBJECTIVE: The outbreak was investigated to identify the etiological agent and possible source of infection and guiding the prevention and control measures. METHODS: Demographic and clinical details were collected from the suspected case-patients, and the outbreak was described by time, place, and person. Focus group discussion and Key informant interview were conducted to assess the practice of sanitation, source of drinking water and probable cause of diarrheal disease. Five stool samples and 10 water samples of tube well and ponds were collected and microbiological study was done in BPKIHS Dharan. RESULTS: A total of 111 persons suffered with diarrhea and 02 died of it (attack rate 3.05%, case fatality rate 1.8%). All age groups were affected with disease (median age 26 yrs) and males were affected more than females. Descriptive epidemiology suggested the clustering of cases were around the pond where they clean utensils, take bath and wash clothes. The Vibrio cholerae 01 El Tor, Ogawa serotype was isolated in 03 out of 05 suspected stool samples and in all three of the pond water samples. They reported that most of the houses do not have the toilet and people do not wash their hands regularly with soap and water after defecation. CONCLUSION: Vibrio cholerae was the causative agent behind the outbreak and probable source of infection was the problematic pond water which they used for different purpose. Immediate chlorination of the pond was recommended to halt further spread of the epidemics.

Impact and determinants of gender preference in Duhavi VDC of eastern Nepal.

INTRODUCTION: Gender equality has been a priority area of demographic research. One of the major reasons for high fertility and low acceptance of family planning is the prevalence of gender preference among couples. The objectives of this study were to identify the determinants and examine the extent of gender preference on fertility. METHODS: This is a cross-sectional study carried from June 2008 to July 2009 in Duhavi VDC of Sunsari district of Nepal. Three hundred and five randomly selected ever-married women of 15 - 49 years, who had at least one child were the subjects of the study. A questionnaire covering the areas on gender and fertility preference and methods and use of contraception was given and filled up. RESULTS: The study showed that 42.6% of the ever-married women belonged to the 25 - 29 years age group. Around 92% of women whose last child was a male were using family planning methods whereas only 40% of women whose last child was a female were using family planning methods. This difference was statistically significant (P < 0.0001). CONCLUSIONS: The contraception use among the women having a female child was low, showing a desire for a male child which is one of the factors in the increase of family size in our society. Due to the patrilineal society, women are discouraged in the practice of contraception. Effective intervention programs need to be planned and conducted to rectify this situation.

The patterns of refractive errors among the school children of rural and urban settings in Nepal.

INTRODUCTION: The uncorrected refractive error is an important cause of childhood blindness and visual impairment. OBJECTIVE: To study the patterns of refractive errors among the urban and rural school going children of Nepal. SUBJECTS AND METHODS: A total of 440 school children of urban and rural schools within the age range of 7-15 years were selected for this study using multi-stage randomization technique. RESULTS: The overall prevalance of refractive error in school children was 19.8 %. The commonest refractive error among the students was myopia (59.8 %), followed by hypermetropia (31.0 %). The children of age group 12-15 years had the higher prevalence of myopia as compared to the younger counterparts (42.5 % vs 17.2 %). The prevalence of myopia was 15.5 % among the urban students as compared to 8.2 % among the rural ones (RR = 1.89, 95 % CI = 1.1-3.24). The hypermetropia was more common in urban students than in rural ones (6.4 %) vs 5.9 %, RR = 1.08 (95 % CI: 0.52-2.24). CONCLUSION: The prevalence of refractive error in the school children of Nepal is 19.8 %. The students from urban settings are more likely to have refractive error than their rural counterparts.

Study of enteric fever and antibiogram of Salmonella isolates at a teaching hospital in Kathmandu Valley.

Enteric fever is one of the common public health problems in Nepal. This study was carried out at Nepal Medical College Teaching Hospital located at peri-urban area in Kathmandu Valley to find out the prevalence of enteric fever and the sensitivity pattern of the Salmonella isolates. A total of 479 patients with fever were included in the study. Venous blood samples collected aseptically were subjected to culture and were studied following the standard bacteriological procedure. The overall prevalence of enteric fever was 5.4% (26/479). Of them more than half (65.4%) were caused by S. paratryphi A whereas remaining (34.6%) by S. typhi. The positive rate was higher in children aged 1-15 years (8.9%) followed by 15-30 years of age (4.3%) and others (1.9%). Gender wise, females to male ratio was 1.4:1. The occurrence of infections was higher in Dalit (7.1%), Khas (Brahmin and Chhetri) (5.9%) and Madeshi (5.9%) whereas lowest was in Adibasi Janajati (4.8%). Prevalence rate of enteric fever among different sex, age and ethnic group was not significant (p > 0.05). Isolates were highly sensitive to Amikacin (100.0%) and Ciprofloxacin (96.1%) whereas least sensitive to Gentamycin (68.7%).