Cutaneous drug reaction secondary to antitubercular regimen: A case report from Nepal.

Cutaneous adverse drug reactions are known side effects of first-line antitubercular therapy, which ranges from mild pruritus to life-threatening toxic epidermal necrolysis. Severe cutaneous adverse drug reactions can lead to antitubercular therapy discontinuation and further complicates tuberculosis treatment. Here we present the case of a 49-year-old obese male who developed a generalized maculopapular rash within 24 hours of initiation of therapy followed by bullae over palms in 3 days. Antitubercular therapy was immediately discontinued, and he was managed with antihistamines, intravenous fluid, and electrolyte supplementation. He was discharged on antihistamines, a short course of systemic steroids, moxifloxacin, and bedaquiline (second-line antitubercular therapy (ATT)). Proper guidelines about rechallenge therapy will enormously aid in managing cutaneous adverse drug reactions, and efficient treatment of tuberculosis in these patients, and ceasing its progression to multisystemic complications. This article aims to discuss the presentation and management of cutaneous adverse drug reactions in the setting of Nepal.

Perioperative Outcomes of Systematic Mesopancreas Dissection for Pancreatic and Periampullary Carcinoma at a Tertiary Referral Center From a Low Middle-Income Country.

Introduction Systematic mesopancreas dissection (SMD) is an emerging surgical approach in pancreatic cancer surgery. There is still debate about early postoperative and pathological outcomes using SMD in pancreatic cancer surgery. This study has been conducted to compare the perioperative outcomes, the lymph node yield, and the margin status in patients who underwent standard pancreaticoduodenectomy (ST-PD) and SMD-PD for pancreatic and periampullary carcinoma. Methods A retrospective comparative study was conducted in patients who underwent PD for pancreatic and periampullary carcinoma in a single unit of gastrointestinal and hepatopancreatobiliary surgery at Tribhuvan University Teaching Hospital, Nepal. Early perioperative and pathological outcomes were compared between the SMD-PD and ST-PD. Results The demographic data of 30 patients who underwent SMD-PD was comparable with the historical data of 40 patients who underwent ST-PD. The intraoperative blood loss and postoperative complications were found to be comparable between ST-PD and SMD-PD. However, the median operative time for SMD-PD was longer than ST-PD (360 minutes [IQR: 90 minutes] vs. 360 minutes [IQR: 60 minutes]). The rate of margin negative resection was similar between both groups. The median lymph node yield was significantly high in patients who underwent SMD-PD (17.5 (IQR: 6.5) vs. 11 [IQR-10.75]; p < 0.05). Conclusion SMD is safe and feasible for treating periampullary carcinoma and is particularly helpful in increasing lymph node yield.

Arteriovenous Malformation of the Jejunum, Causing Massive Gastrointestinal Bleeding, Treated With Intraoperative Enteroscopy Guidance: A Case Report.

Arteriovenous malformations of the small intestine are an important differential in cases of occult gastrointestinal bleeding. Localization of the source of gastrointestinal bleeding can be a difficult task, especially in resource-limited settings where balloon-assisted enteroscopy or video capsule endoscopy are unavailable. We herein report the use of intraoperative enteroscopy to help localize and resect a short bowel segment containing a bleeding arteriovenous malformation of the jejunum in a 50-year-old man who presented with hematochezia and pallor leading to hemorrhagic shock. Esophagogastroduodenoscopy and colonoscopy showed no abnormalities, but a contrast-enhanced computed tomography scan of the abdomen revealed a contrast blush in the proximal jejunum. Angiography with coil embolization failed to control his symptoms, and he underwent exploratory laparotomy with intraoperative enteroscopy to try and localize the bleeding, followed by resection of the diseased segment and anastomosis of the small bowel, which led to the successful resolution of the patient's issues.

Enhancement of Feed Source through Three Dimensional Printing.

The three-dimensional printed wideband prototype (WBP) was proposed, which is able to enhance the horn feed source by generating a more uniform phase distribution that is obtained after correcting aperture phase values. The noted phase variation obtained without the WBP was 163.65∘ for the horn source only, which was decreased to 19.68∘, obtained after the placement of the WBP at a λ/2 distance above the feed horn aperture. The corrected phase value was observed at 6.25 mm (0.25λ) above the top face of the WBP. The use of a five-layer cubic structure is able to generate the proposed WBP with dimensions of 105 mm × 105 mm × 37.5 mm (4.2λ× 4.2λ× 1.5λ), which can improve directivity and gain by 2.5 dB throughout the operating frequency range with a lower side lobe level. The overall dimension of the 3D printed horn was 98.5 mm × 75.6 mm × 192.6 mm (3.94λ× 3.02λ× 7.71λ), where the 100 % infill value was maintained. The horn was painted with a double layer of copper throughout its surface. In a design frequency of 12 GHz, the computed directivity, gain, side lobe level in H- and E- planes were 20.5 dB, 20.5 dB, -26.5 dB, and -12.4 dB with only a 3D printed horn case and, with the proposed prototype placed above this feed source, these values improved to 22.1 dB, 21.9 dB, -15.5 dB, and -17.5 dB, respectively. The realized WBP was 294 g and the overall system was 448 g in weight, which signifies a light weight condition. The measured return loss values were less than 2, which supports that the WBP has matching behavior over the operating frequency range.

Marine Submicron Aerosols from the Gulf of Mexico: Polluted and Acidic with Rapid Production of Sulfate and Organosulfates.

We measured submicron aerosols (PM1) at a beachfront site in Texas in Spring 2021 to characterize the "background" aerosol chemical composition advecting into Texas and the factors controlling this composition. Observations show that marine "background" aerosols from the Gulf of Mexico were highly processed and acidic; sulfate was the most abundant component (on average 57% of total PM1 mass), followed by organic material (26%). These chemical characteristics are similar to those observed at other marine locations globally. However, Gulf "background" aerosols were much more polluted; the average non-refractory (NR-) PM1 mass concentration was 3-70 times higher than that observed in other clean marine atmospheres. Anthropogenic shipping emissions over the Gulf of Mexico explain 78.3% of the total measured "background" sulfate in the Gulf air. We frequently observed haze pollution in the air mass from the Gulf, with significantly elevated concentrations of sulfate, organosulfates, and secondary organic aerosol associated with sulfuric acid. Analysis suggests that aqueous oxidation of shipping emissions over the Gulf of Mexico by peroxides in the particles might potentially be an important pathway for the rapid production of acidic sulfate and organosulfates during the haze episodes under acidic conditions.

Prevalence of Loss of Smell and Loss of Taste in COVID-19 Infected Patients.

BACKGROUND: The clinical presentations of COVID-19 have been variable, with atypical presentations being reported worldwide. Different studies have shown that olfactory and gustatory symptoms are present in confirmed COVID-19 cases, who may not have had other nasal complaints earlier. The high prevalence of these symptoms, exhibiting olfactory dysfunction before the appearance of others, is a relevant finding to aid for early detection of COVID-19. In this study, we aim to find out about the prevalence of anosmia and ageusia in COVID-19 and its correlation with age, sex, and severity of disease in the Nepalese population. METHODS: Patients with laboratory-confirmed COVID-19 infection by reverse transcription-polymerase chain reaction (RT-PCR) done at Shukraraaj Tropical and Infectious Disease Hospital, Kathmandu were recruited. Questionnaires based on loss of taste and loss of smell components including age, sex, ethnicity, comorbidities were prepared, and the patients were interviewed retrospectively by phone contact. RESULTS: A total of 300 patients were enrolled in our study. The mean age of the patients was 38.36±14.24 years. Prevalence of loss of smell was 54%(N=162) and loss of taste was 53% (N=159). Both of the symptoms were present in 45% of patients. The severity of the disease has a statistically significant effect on the loss of smell and taste whereas gender and smoking history has no significant difference over it. CONCLUSIONS: More than half of the COVID-19 positive patients in our cohort had either loss of taste or loss of smell with the severity of disease having a significant effect on it.

Traffic, transport, and vegetation drive VOC concentrations in a major urban area in Texas.

The population of Texas has increased rapidly in the past decade. The San Antonio Field Study (SAFS) was designed to investigate ozone (O3) production and precursors in this rapidly changing, sprawling metropolitan area. There are still many questions regarding the sources and chemistry of volatile organic compounds (VOCs) in urban areas like San Antonio which are affected by a complex mixture of industry, traffic, biogenic sources and transported pollutants. The goal of the SAFS campaign in May 2017 was to measure inorganic trace gases, VOCs, methane (CH4), and ethane (C2H6). The SAFS field design included two sites to better assess air quality across the metro area: an urban site (Traveler's World; TW) and a downwind/suburban site (University of Texas at San Antonio; UTSA). The results indicated that acetone (2.52 ± 1.17 and 2.39 ± 1.27 ppbv), acetaldehyde (1.45 ± 1.02 and 0.93 ± 0.45 ppbv) and isoprene (0.64 ± 0.49 and 1.21 ± 0.85 ppbv; TW and UTSA, respectively) were the VOCs with the highest concentrations. Additionally, positive matrix factorization showed three dominant factors of VOC emissions: biogenic, aged urban mixed source, and acetone. Methyl vinyl ketone and methacrolein (MVK + MACR) exhibited contributions from both secondary photooxidation of isoprene and direct emissions from traffic. The C2H6:CH4 demonstrated potential influence of oil and gas activities in San Antonio. Moreover, the high O3 days during the campaign were in the NOx-limited O3 formation regime and were preceded by evening peaks in select VOCs, NOx and CO. Overall, quantification of the concentration and trends of VOCs and trace gases in a major city in Texas offers vital information for general air quality management and supports strategies for reducing O3 pollution. The SAFS campaign VOC results will also add to the growing body of literature on urban sources and concentrations of VOCs in major urban areas.

Profiling the Cytopathological Diagnosis of Enlarged Lymph Nodes on Fine Needle Aspiration Cytology.

BACKGROUND: This study aimed to assess the distribution of fine-needle-aspiration-cytology or biopsy findings through cytopathological patterns of lymph nodes aspirations in different age groups of the population visiting a tertiary level hospital in Kathmandu. METHODS: The retrospective study was conducted on the database of the 226 lymphadenopathy cases that underwent biopsy fine needle aspiration cytology from 1 January 2016 to 31 December 2019 at the Department of pathology of Helping Hand's Community Hospital, Kathmandu. A descriptive analysis was performed yielding proportions and counts for the quantitative variables. Chi-squared test was used to compare the proportions.  Point estimates and confidence intervals for measures of association were assessed with 95% confidence interval and p-value ?0.05 was considered statistically significant. RESULTS: The 20-40 years were the most common age group undergoing biopsy fone needle aspiration cytology procedures. Males recorded majority of cases (68%, 153 of 226). The highest incidence of Reactive lymphadenitis was obtained (50%, 113 of 226) and it was the most common findings in the age group of <20 and 40-60 years. The Cervical lymph node (86%) was the most common anatomical location followed by axillary lymph nodes (8%). Squamous cell carcinoma and Adenocarcinoma accounted for more than half (53%, 20 of 38) of all the diagnosed malignancy. The incidence of Non-Hodgkin lymphoma and Hodgkin lymphoma were 8% (n = 3 of 38) and 5% (n = 2 of 38) respectively. CONCLUSIONS: Lymph node enlargement is associated with a wide range of etiologies with Reactive lymphadenitis as the most common cause and cervical lymph node as the common site.

Miniaturized Wideband Antenna Prototype Operating over the Ku-Band.

A wideband antenna is proposed based on three-dimensional printing technology. The antenna was designed using the PREPERM 10 material, with permittivity ϵr = 10, where the overall height of the proposed prototype was maintained as 12.83 mm (0.51λ), having a lateral dimension of 60 mm × 60 mm, at an operating frequency of 12 GHz (λ = 25 mm). The proposed antenna achieved a wide frequency bandwidth with a voltage standing-wave ratio (VSWR) of less than two, from 10 GHz to 15 GHz in the Ku-band, where the maximum directivity was 20 dBi over a reflection coefficient bandwidth of 50%. It showed a miniaturized non-uniform metasurface of 2.4λ × 2.4λ × 0.51λ that was placed at 16.5 mm (0.66λ) above the ground plane, which was 2.4λ × 2.4λ × 0.04λ in dimension. Thus, the overall height of the proposed antenna system from the feed source was 29.33 mm (1.17λ). The total weight of the system including the designed structures made of PREPERM 10 and ABS with copper-painted prototypes was 96 g and 79 g, respectively. The measured results were consistent with the simulated results, demonstrating the feasibility and effectiveness of the proposed method.

Ileal perforation as an initial manifestation of systemic lupus erythematosus: A case report.

INTRODUCTION AND IMPORTANCE: Lupus enteritis is uncommon in patients with SLE and usually presents with anorexia, vomiting, and abdominal pain. Intestinal perforation as an initial manifestation of SLE is rare and can have a grave prognosis if not timely diagnosed. CASE HISTORY: We report an unusual case of a 22-year-old regularly menstruating female who presented with features of perforation peritonitis as an initial manifestation of lupus enteritis. Intraoperatively, a gangrenous ileal segment with multiple perforations was present. Thus, with an intraoperative diagnosis of perforation peritonitis, a gangrenous segment of the small bowel was resected and a double-barrel jejuno-ileostomy was created. DISCUSSION: Lupus enteritis manifesting initially as bowel perforation can be an uncommon cause of acute abdomen. A plain chest X-ray can show gas under the diaphragm suggesting bowel perforation. A contrast-enhanced CT scan of the abdomen is the gold standard in diagnosing lupus enteritis with a good prognosis on steroids. CONCLUSION: Primary closure, resection, and anastomosis of small gut or diverting stoma are required for management of perforation. A high degree of clinical suspicion is required for early diagnosis thus preventing the grave prognosis of such an entity.

Guillain Barre Syndrome associated with COVID-19 Infection: A Case Report.

Coronavirus Disease has become a global pandemic after its emergence at the end of 2019 as a cluster of pneumonia. Apart from respiratory symptoms, neurologic complications are also common, mostly in hospitalized patients. More than 80 percent of patients have neurological symptoms during their disease course of which most common is encephalopathy. However, data on neurological complications like Guillain-Barré syndrome associated with coronavirus-2019 are scarce. Here, we report a case of a 64-years-old female patient with typical clinical and electrophysiological manifestations of Acute motor axonal neuropathy variant, who was reported positive with polymerase chain reaction for severe acute respiratory syndrome coronavirus-2, 13 days before the onset of acute bilateral weakness of extremities, areflexia, and normal sensory examination. Cerebrospinal fluid and electrophysiological examination were also suggestive. The neurological symptoms improved during treatment with immunoglobulins. Quick recognition of symptoms and diagnosis is important in the management of Guillain-Barré syndrome associated with coronavirus-2019.

Intra-abdominal propylene suture fragment leading to complete small bowel obstruction: A case report.

INTRODUCTION: Propylene sutures are non-absorbable sterile surgical sutures, which when present intra-abdominally act as a foreign body leading to adhesion formation. Post-operative adhesions are a common cause of bowel obstruction, with complete closed loop obstruction presenting as a surgical emergency. CASE DETAILS: A 66-year-old man who had undergone a laparotomy for bowel obstruction two years back, presented to our emergency department with features of complete bowel obstruction. Midline laparotomy revealed propylene suture and intra peritoneal adhesions acting as a constricting band around the jejunum to be the cause. DISCUSSION: Adhesions are common perturbing problem after surgeries. The presence of a foreign body further incites the process of adhesion formation by causing hindrance to the fibrinolysis process. In this case, the adhesive bands acted synergistically with the encircling prolene suture material from the previous surgery in causing a complete loop obstruction. CONCLUSION: Propylene sutures used in routine surgical procedures can migrate intra-abdominally, and lead to adhesion formation. Adhesions along with the non-absorbable suture can cause complete bowel obstruction.

Concomitant hilar cholangiocarcinoma with choledochal cyst and cholelithiasis in an asymptomatic patient: A case report.

INTRODUCTION AND IMPORTANCE: Choledochal cyst is an important risk factor for cholangiocarcinoma. Concomitant hilar cholangiocarcinoma with choledochal cyst with cholelithiasis is a rare finding. CASE PRESENTATION: A 52-year-old male presented with non-specific complaints of generalized weakness for 3 months. Transabdominal ultrasound showed dilated common bile duct with hyperechoic mass at hilar region; further evaluation with magnetic resonance cholangiopancreatography and contrast-enhanced computer tomography of abdomen and pelvis revealed concomitant intraductal hilar cholangiocarcinoma (Bismuth Corlette type 1) with Choledochal cyst (type IVa) with cholelithiasis. After optimization patient underwent left hepatectomy with common bile duct excision with cholecystectomy with Roux-en-Y hepaticojejunostomy. Histopathological examination confirmed it to be well-differentiated adenocarcinoma, intestinal type at the hilar confluence. CLINICAL DISCUSSION: An asymptomatic male patient with the concomitant finding of perihilar cholangiocarcinoma (Bismuth Corlette type I) with choledochal cyst type IVa with cholelithiasis is a rare finding. The patient was managed with surgical excision of the common bile duct with Roux-en-Y hepaticojejunostomy and cholecystectomy. Diagnostic evaluation should be proper not to miss or overlook such a synchronous lesion. CONCLUSION: Incidental finding of concomitant perihilar cholangiocarcinoma with the choledochal cyst is rare. Proper evaluation of the patient with CECT abdomen and pelvis and MRCP is necessary for the diagnosis. Proper surgical resection with adequate lymph node removal is important for surgical clearance.

Squamous cell carcinoma arising within choledochal cyst managed by pancreaticoduodenectomy: A case report.

INTRODUCTION AND IMPORTANCE: Choledochal cysts (CC) are rare cystic dilatation of the biliary trees. Malignancy is one of the important significant findings in CC and its incidence increases with age. Associated squamous cell carcinoma of the choledochal cyst is an uncommon pathological finding. CASE PRESENTATION: We present a 21-year-old male diagnosed with type 1 CC and planned for excision of the cystic dilated extrahepatic biliary tract with hepaticojejunal anastomosis in Roux-en-Y but underwent pancreaticoduodenectomy due to intraoperative palpable mass of CC which was adhered to the duodenum and pancreatic head. Histopathology of the excised specimen revealed squamous cell carcinoma (SCC) of the choledochal cyst. DISCUSSION: CC represents a rare biliary cystic disease. Though infrequent, malignant transformation in CC includes cholangiocarcinoma, adenocarcinoma, and rarely SCC. The post-operative management for SCC in CC is ill-defined and carries a grave prognosis. CONCLUSION: The choledochal cyst should be completely excised wherever possible to avoid the possible malignant transformation in CC including SCC.

Jejunal varices with extra hepatic portal vein obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. PRESENTATION OF CASE: We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. DISCUSSION: Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. CONCLUSION: Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.

High-temperature optical properties of indium tin oxide thin-films.

Indium tin oxide (ITO) is one of the most widely used transparent conductors in optoelectronic device applications. We investigated the optical properties of ITO thin films at high temperatures up to 800 °C using spectroscopic ellipsometry. As temperature increases, amorphous ITO thin films undergo a phase transition at ~ 200 °C and develop polycrystalline phases with increased optical gap energies. The optical gap energies of both polycrystalline and epitaxial ITO thin films decrease with increasing temperature due to electron-phonon interactions. Depending on the background oxygen partial pressure, however, we observed that the optical gap energies exhibit reversible changes, implying that the oxidation and reduction processes occur vigorously due to the low oxidation and reduction potential energies of the ITO thin films at high temperatures. This result suggests that the electronic structure of ITO thin films strongly depends on temperature and oxygen partial pressure while they remain optically transparent, i.e., optical gap energies > 3.6 eV.

Abundances and concentrations of brominated azo dyes detected in indoor dust.

Dust samples were collected from four indoor environments, including childcare facilities, houses, hair salons, and a research facility from the USA and were analyzed for brominated compounds using full scan liquid chromatography high-resolution mass spectrometry. A total of 240 brominated compounds were detected in these dust samples, and elemental formulas were predicted for 120 more abundant ions. In addition to commonly detected brominated flame retardants (BFRs), nitrogen-containing brominated azo dyes (BADs) were among the most frequently detected and abundant. Specifically, greater abundances of BADs were detected in indoor dusts from daycares and salons compared to houses and the research facility. Using authentic standards, a quantitative method was established for two BADs (DB373: Disperse Blue 373 and DV93: Disperse Violet 93) and 2-bromo-4,6-dinitroaniline, a commonly used precursor in azo dye production, in indoor dust. Generally, greater concentrations of DB373 (≤3850 ng/g) and DV93 (≤1190 ng/g) were observed in indoor dust from daycares highlighting children as a susceptible population to potential health risk from exposure to BADs. These data are important because, to date, targeted analysis of brominated compounds in indoor environments has focused mainly on BFRs and appears to underestimate the total amount of brominated compounds.

Building back better? Taking stock of the post-earthquake mental health and psychosocial response in Nepal.

BACKGROUND: The World Health Organization's 'building back better' approach advocates capitalizing on the resources and political will elicited by disasters to strengthen national mental health systems. This study explores the contributions of the response to the 2015 earthquake in Nepal to sustainable mental health system reform. METHODS: We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis. RESULTS: While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts. CONCLUSIONS: Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.

Ambient endotoxin in PM10 and association with inflammatory activity, air pollutants, and meteorology, in Chitwan, Nepal.

BACKGROUND: Endotoxin associated with ambient PM (particulate matter) has been linked to adverse respiratory symptoms, but there have been few studies of ambient endotoxin and its association with co-pollutants and inflammation. OBJECTIVES: Our aim was to measure endotoxin associated with ambient PM10 (particulate matter with aerodynamic diameter<10µm) in summer 2016 at four locations in Chitwan, Nepal, and investigate its association with meteorology, co-pollutants, and inflammatory activity. METHODS: PM10 concentrations were recorded and filter paper samples were collected using E-samplers; PM1, PM2.5, black carbon (BC), methane (CH4), and carbon monoxide (CO) were also measured. The Limulus amebocyte lysate (LAL) assay was used for endotoxin quantification and the nuclear factor kappa B (NFκB) activation assay to assess inflammatory activity. RESULTS: The mean concentration of PM10 at the different locations ranged from 136 to 189µg/m3, and of endotoxin from 0.29 to 0.53EU/m3. Pollutant presence was positively correlated with endotoxin. Apart from relative humidity, meteorological variations had no significant impact on endotoxin concentration. NF-κB activity was negatively correlated with endotoxin concentration. CONCLUSIONS: To the best of our knowledge, this study provides the first measurements of ambient endotoxin associated with PM10 in Nepal. Endotoxin and co-pollutants were positively associated indicating a similar source. Endotoxin was negatively correlated with inflammatory activity as a result of a time-limited forest fire event during the sampling period. Studies of co-pollutants suggested that the higher levels of endotoxin related to biomass burning were accompanied by increased levels of anti-inflammatory agents, which suppressed the endotoxin inflammatory effect.