Work-related Respiratory Symptoms and Associated Factors among Cement Factory Workers in Rupandehi District, Nepal.

Background Cement factory workers are exposed to cement dust at workplace. It leads to a greater prevalence of chronic respiratory signs and symptoms. Objective To identify the prevalence of Work-related respiratory symptoms, its association with various risk factors, and to assess the outcomes like hospitalization and sickness absenteeism. Method Cross-sectional study was conducted in the Argakhanchi Cement factory among 190 workers with minimum work experience of 1 year. Census method was used for data collection. To assess the respiratory symptoms, sputum samples were collected; smears prepared by pick and smear method, and later stained by Leishman and pap stain. Smears devoid of alveolar macrophages were considered unsatisfactory for evaluation. Result The mean age of respondents with standard deviation was 35.56±11.45 years. The prevalence of Work-related respiratory symptoms was 31.6%. Age, no. of years worked, working in the raw materials department, burner and clinker department, cleaning department and wearing mask were the significant risk factors. On cytological analysis of the sputum sample, mild inflammatory cell noticed in 71.6%, moderate inflammation in 23.7%, and dense inflammation in 4.2%. Fungal spores were seen in 3.7%, fungal pseudohyphae in 0.5%, and bacterial colonies in 27% of the sputum samples. Out of 190 participants, 8(4.2%) of them had to be hospitalized and 17(8.9%) were on sick leave due to respiratory symptoms. Conclusion Pre-employment and periodic medical examination, frequent work shift, training on occupational health and safety, use of appropriate personnel protective equipment is recommended to reduce respiratory symptoms.

YAP/TAZ regulates the expression of proteoglycan 4 and tenascin C in superficial-zone chondrocytes.

The roles of cell division control protein 42 homologue (CDC42) and actin polymerisation in regulating the phenotype of superficial-zone chondrocytes (SZCs) have been demonstrated in vitro; however, the signalling pathway(s) downstream have yet to be fully elucidated. The study hypothesis was that Yes-associated protein (YAP) and transcriptional co-activator with PDZ-binding motif (TAZ) act downstream to regulate proteoglycan 4 (PRG4) and tenascin C (TNC). Bovine SZCs grown in monolayer were treated with ML141 (CDC42 inhibitor) or the actin depolymerising agents, latrunculin B and cytochalasin D, to determine the effect on YAP/TAZ. Verteporfin (YAP/TAZ inhibitor) and YAP/TAZ siRNA-mediated knockdown were used to determine their role in regulating PRG4 and TNC. ML141 treatment reduced total YAP/TAZ protein, nuclear TAZ levels and the YAP/TAZ target gene, connective tissue growth factor (CTGF) mRNA levels. Latrunculin B decreased nuclear TAZ, while cytochalasin D treatment trended towards increased nuclear TAZ (p = 0.06), correlating with decreased and increased CTGF mRNA levels, respectively. Verteporfin treatment decreased PRG4 and TNC expression, with no effect on actin polymerisation. siRNA-mediated knockdown of YAP/TAZ revealed that PRG4 was regulated by YAP/TAZ while TNC was regulated by TAZ only. As cytochalasin D can activate myocardin-related transcription factor-A (MRTF-A), siRNA-mediated knockdown was performed to determine the role of MRTF-A in regulating YAP/TAZ. Although nuclear TAZ decreased, no significant changes in total protein levels were observed. Findings suggested that CDC42 and actin polymerisation regulated SZCs through multiple actin-regulated pathways. Understanding the regulation of these chondroprotective molecules may have important implications for prevention/treatment of osteoarthritis.

Sonography in acute ureteric colic: an experience in Dhulikhel Hospital.

BACKGROUND: Computed tomography is considered as an imaging modality of choice in acute ureteric colic. However due to concerns regarding radiation exposure, sonograms are re-emerging as imaging methods in such situations. OBJECTIVES: To evaluate the role of sonography in detection of calculus in acute ureteric colic. METHODS: Total 384 patients were enrolled. Hydronephrosis was graded as mild, moderate or severe. Calculus was detected as an intraluminal echogenic focus with distal shadowing with twinkling artifact. Number, size and position of the calculi were assessed. Patients were categorized into four groups:I. ureteric colic only II. ureteric colic with hematuria III. ureteric colic with hydronephrosis and IV. ureteric colic with hematuria and hydronephrosis and then the possibility of detection of calculi has been compared among these groups. RESULTS: Out of 384 patients, 254 were found to have calculi ranging between 2.7-27 mm. Nineteen had in the pelvis/ pelviureteric junction, 64 in proximal ureter, 125 in distal ureter, 6 at iliac crossing and 40 at vesicoureteric junction. Two hundred forty one had single and 14 had multiple calculi. Calculus detection is easier in category III and IV patients. The sensitivity and specificity of ultrasonography were 87.98% and 93.07%. Degree of hydronephrosis is strongly correlated with the number of calculi but weakly correlated with the size of the calculus. CONCLUSION: Sonogram can be used in all cases of acute ureteric colic. Hydronephrosis is the most important finding because it paves the way out for the detection of calculus.

Role of ultrasound as compared with ERCP in patient with obstructive jaundice.

BACKGROUND: The diagnosis of obstructive jaundice relies on proper history taking, clinical examination, laboratory investigations and different non invasive imaging modalities like Ultrasonography (USG), Cholangio Computed Tomography (CCT), Magnetic resonance Imaging (MRI) with Magnetic Resonance Cholangio Pancreatography (MRCP) and invasive modalities like endoscopic retrograde cholangiography (ERCP) and percutaneous trans hepatic cholangiography (PTC). OBJECTIVE: To compare the role of ultrasound with endoscopic retrograde cholangiography and to determine the major causes of obstructive jaundice in our prospect. METHODS: This was a prospective, analytical study conducted on 88 patients presenting to Department of Radiodiagnosis and Imaging at Dhulikhel Hospital-Kathmandu University hospital from March 2011 to August 2012 with clinical diagnosis of obstructive jaundice. Sonographic evaluation was performed in Siemens acusion x-150 and x-300. The final diagnosis was made by endoscopic retrograde cholangiography and /or surgery and confirmed histopathologically. RESULTS: The most common benign causes of obstructive jaundice were choledocholithiasis (63%), CBD stricture (12.3%), cholangitis (8%) and pancreatitis (6.85%) whereas cholangio carcinoma (6.85%) and carcinoma head of pancreas (4%) comprised of the malignant causes . Ultrasonography had sensitivity of 100% and specificity of 89% in detecting choledocholithiasis. It was found to be 98.78% sensitive and 83.33% specific in cholangiocarcinoma. Similarly in pancreatitis, the sensitivity of ultrasonography was 97.59% and sensitivity was 66.67%. CONCLUSION: Ultrasonography acts as a valuable diagnostic imaging modality in detecting the causes of obstructive jaundice. Due to its easy availability, non invasive nature and cost effectiveness, it can be considered as the first line imaging technique/ tool. ERCP is the invasive imaging tool and can be used for both diagnostic and therapeutic purpose.

Nuchal translucency in normal fetus and its variation with increasing crown rump length (CRL) and gestational age.

BACKGROUND: Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies. OBJECTIVE: To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus. METHODS: Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis. RESULTS: The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p <0.001). There was increase in the incidence of NT thickness more than or equal to 2.5mm; 1.7% in fetus between 12-12.9 weeks of gestation to 15.1% in fetus between 14.0-14.9 weeks. CONCLUSION: Our study offers normative data of NT thickness in normal fetus, which can be used as reference to screen various chromosomal and congenital abnormalities between 11- 14 weeks of gestation. NT thickness increased with increasing CRL and a false positive rate increases with increasing gestational age.

Best practice in the management of venous leg ulcers.

Leg ulcers are wounds or open sores, often chronic in nature (long-lasting and non-healing), which cause damage to the skin. Appropriate management of chronic venous leg ulcers is essential to prevent further deterioration of the wound, improve patients' quality of life and reduce any healthcare costs associated with treating complications of such ulcers, including infection. However, management of leg ulcers can be challenging, particularly in patients who do not adhere to treatment regimens, cannot tolerate compression therapy, or have increased pain and infection. This article aims to identify best practice in the management of venous leg ulcers.

Breech presentation among nullipara at term: an indication for caesarean section.

BACKGROUND: Breech is the commonest malpresentation. Vaginal breech delivery in a nulliparous lady carries higher risk than in multiparous ladies. Poor neonatal outcome following vaginal delivery has made the mode of delivery a matter of controversy. OBJECTIVE: To evaluate the outcome of planned caesarean section among nullipara ladies with breech presentation. METHOD: This is a prospective, analytical study conducted in Dhulikhel Hospital Kathmandu University Hospital from January 2008 to June 2012 among 102 nullipara ladies at term gestation with breech presentation. All cases underwent caesarean section either elective or emergency. During section cause of breech presentation was searched for. Neonatal condition was evaluated using APGAR Score, need for resuscitation and admission in NICU. Post partum status was also recorded for evaluation of maternal morbidity and mortality. RESULTS: These Nullipara ladies often had some reason for breech presentation, the most common being cord around the neck. Perinatal outcome was uneventful in 97(95%) neonates, there were two (2%) still birth and three (3%) needed NICU care. APGAR was good in 92 neonates, average in eight and poor in two. Total 16(15.6%) ladies stayed hospital for more than eight days. Among them 11(10.7%) developed wound infection and five stayed in hospital waiting for baby. CONCLUSION: Nullipara ladies with breech presentation should have elective caesarean section as a preferred route of delivery.

Safety and efficacy of the supracostal access for percutaneous nephrolithotomy: our initial experience.

The aim of this study was to evaluate the safety and efficacy of the supracostal access for percutaneous nephrolithotomy (PCNL). Between July 2007 and June 2010, 122 patients underwent PCNL, of whom 28 (23%) had supracostal access. All procedures were performed in a single sitting under general anesthesia. The data were analysed for indications, stone clearance rates and the complications associated with supracostal puncture. The indications for a supracostal access were staghorn stones (50%), pelvis stones (28.5%), calyceal stones in high-lying kidney (18%) and upper ureter/ureteric stones (3.5%). All tracts were made in the 11th intercostal space. Single tract access was used in 22 cases (78%), but 6 (22%) required a second tract. Additional punctures were required mainly for staghorn stones (4 out of 14). Overall, 82% of the patients were rendered stone free or had clinically insignificant residual stones with PCNL monotherapy, and this increased to 96% with secondary procedures. In patients with staghorn stones, they were completely cleared in 78%. Overall complication rate was 28% and included hydrothorax in 3 (10%) patients, which required insertion of a chest tube. One (3.5%) patient developed haemothorax secondary to injury of the intercostal artery, pelvic perforation in 1 (3.5%), perinephric collection in 1 (3.5%), infection/sepsis in 2 (7%). Except those patients who had complication, all other patient recovered uneventfully. Postoperative hospital stay ranged from 2 to 9 days. In conclusion, supracostal access gives high clearance rate with acceptable complications and should not be avoided for fear of chest complications.

Fulminant hepatic failure due to dengue.

Dengue Fever (DF) is only rarely considered as a cause of acute liver failure even globally and only a few case reports of acute hepatic failure and encephalopathy occurring in DF in adults are available. We report a case of Acute Liver Failure due to Dengue during a major outbreak in 2010 in Chitwan. A 20 year old previously healthy female presented to the emergency department of Chitwan Medical College with fever, jaundice and altered sensorium. She was tested positive for Dengue IgM. Her biochemical and clinical parameters were suggestive of acute liver failure with total billirubin of 10.1 mg/dL, direct billirubin of 5.2 mg/dL, ALT 5760 IU, AST 14100 IU, alkaline phosphatase of 1250 IU, PT INR of 1.76 and platelet count of 30,000/mm3. Other causes for acute hepatic failure like acute viral hepatitis, leptospirosis, malaria, Reyes syndrome were ruled out. The patient was admitted and managed in the ICU with supportive care and platelet transfusion. With treatment she made a significant clinical and biochemical improvement with AST of 105 IU, ALT of 120 IU and platelet count of 150,000/mm3. She was discharged after 11 days of hospital stay.

Bora phosphorylation substitutes in trans for T-loop phosphorylation in Aurora A to promote mitotic entry.

Polo-like kinase 1 (Plk1) is instrumental for mitotic entry and progression. Plk1 is activated by phosphorylation on a conserved residue Thr210 in its activation segment by the Aurora A kinase (AURKA), a reaction that critically requires the co-factor Bora phosphorylated by a CyclinA/B-Cdk1 kinase. Here we show that phospho-Bora is a direct activator of AURKA kinase activity. We localize the key determinants of phospho-Bora function to a 100 amino acid region encompassing two short Tpx2-like motifs and a phosphoSerine-Proline motif at Serine 112, through which Bora binds AURKA. The latter substitutes in trans for the Thr288 phospho-regulatory site of AURKA, which is essential for an active conformation of the kinase domain. We demonstrate the importance of these determinants for Bora function in mitotic entry both in Xenopus egg extracts and in human cells. Our findings unveil the activation mechanism of AURKA that is critical for mitotic entry.

64-slice CT scan in Kathmandu Medical College Teaching Hospital.

64-slice CT scan is a versatile newly introduced imaging technology, which is capable of diagnosing various diseases from head to toe. The 64-slice CT coronary angiography has a negative predictive value of 100%. Virtual images of bronchi, stomach and colon can provide definite diagnosis. Coronary artery calcification score which predicts coronary artery disease can be calculated by 64-slice CT scan.

Lubricin/Proteoglycan 4 binds to and regulates the activity of Toll-Like Receptors In Vitro.

Proteoglycan 4 (PRG4/lubricin) is secreted by cells that reside in articular cartilage and line the synovial joint. Lubricin may play a role in modulating inflammatory responses through interaction with CD44. This led us to examine if lubricin could be playing a larger role in the modulation of inflammation/immunity through interaction with Toll-like receptors (TLRs). Human Embryonic Kidney (HEK) cells overexpressing TLRs 2, 4 or 5 and surface plasmon resonance were employed to determine if full length recombinant human lubricin was able to bind to and activate TLRs. Primary human synovial fibroblasts were also examined using flow cytometry and Luminex multiplex ELISA. A rat destabilization model of osteoarthritis (OA) was used to determine if lubricin injections were able to regulate pain and/or inflammation in vivo. Lubricin can bind to and regulate the activity of TLRs, leading to downstream changes in inflammatory signalling independent of HA. We confirmed these findings in vivo through intra-articular injections of lubricin in a rat OA model where the inhibition of systemic inflammatory signaling and reduction in pain were observed. Lubricin plays an important role in regulating the inflammatory environment under both homeostatic and tissue injury states.

Prevalence of rheumatic and congenital heart disease in schoolchildren of Kathmandu valley in Nepal.

BACKGROUND: Rheumatic heart disease remains a major public health problem in developing countries with its very high prevalence. Rheumatic and congenital heart disease are significant causes of morbidity and mortality among Nepalese schoolchildren. The aim of our study was to determine the prevalence of rheumatic and congenital heart disease among schoolchildren of the Kathmandu valley in Nepal. METHODS AND RESULTS: The study included 9420 students, of whom 4466 were male and 4954 were female, with ages ranging from 5 to 18 years. A clinical survey was conducted by the examining team in selected schools, and involved answering standard questionnaires. A total of 83 children were suspected of having heart disease. Out of these 83 children, 23 were confirmed to have heart disease; 11 had rheumatic heart disease, and 12 congenital heart disease, giving a prevalence of 1.2/1000 and 1.3/1000, respectively. The commonest cardiac lesions were mitral regurgitation in the rheumatic heart disease group, and atrial septal defect in the congenital heart disease group. A higher prevalence of congenital heart disease was detected in females. CONCLUSIONS: The prevalence of rheumatic heart disease and congenital heart disease among schoolchildren of Kathmandu is 1.2/1000 and 1.3/1000, respectively, with mitral regurgitation and atrial septal defect being the commonest lesions.

A first estimate of ground water ages for the deep aquifer of the Kathmandu Basin, Nepal, using the radioisotope chlorine-36.

The Kathmandu Basin in Nepal contains up to 550 m of Pliocene-Quaternary fluvio-lacustrine sediments which have formed a dual aquifer system. The unconfined sand and gravel aquifer is separated by a clay aquitard, up to 200 m thick, from the deeper, confined aquifer, comprised of Pliocene sand and gravel beds, intercalated with clay, peat, and lignite. The confined aquifer currently provides an important water supply to the central urban area but there are increasing concerns about its sustainability due to overexploitation. A limited number of determinations of the radioisotope 36Cl have been made on bore waters in the basin, allowing us to postulate on the age of ground water in the deeper, confined aquifer. Ground water evolution scenarios based on radioisotope decay, gradual dissolution of formational salts as the ground waters move downgradient, and flow velocity estimations produce comparable ground water ages for the deep waters, ranging from 200,000 to 400,000 years. From these ages, we deduce a mean ground water flow velocity of only 45 mm/year from recharge in the northeast to the main extraction region 15 km to the southwest. We thus estimate current recharge at about 5 to 15 mm/year, contributing 40,000 to 1.2 million m3/year to the ground water system. Current ground water extraction is estimated to be 20 times this amount. The low specific discharge confirms that the resource is being mined, and, based on current projections, reserves will be used up within 100 years.

Prevalence of Conventional Risk Factors in ST Segment Elevation Myocardial Infarction Patients in Shahid Gangalal National Heart Centre, Nepal.

INTRODUCTION: Smoking, diabetes mellitus, hypertension, and dyslipidemia are labelled as conventional risk factors for coronary artery disease. Prevalence of these risk factors varies across populations. This study aimed to assess the prevalence of these conventional risk factors in patients, who were discharged from our hospital, with the diagnosis of ST elevation myocardial infarction. METHODS: Medical records of 495 ST elevation myocardial infarction patients discharged from our centre in between January 2012 to December 2012 were retrospectively reviewed to evaluate the prevalence of conventional risk factors. RESULTS: Clear dominance (75%) of male patients was seen. Inferior wall myocardial infarction (29.9%) was the most common diagnosis followed by anterior wall myocardial infarction (25.1%). Hypertension (65%), smoking (57.8%) and dyslipidemia (45.5%) were the most common risk factors. Diabetes (31.1%) was the least common. Prevalence of hypertension, dyslipidemia was similar among male and female. Smoking was statistically common in male (76.8%vs 49.5%),though diabetes was common in female (36.5%vs.29.3%) not statistically significant. CONCLUSIONS: Conventional risk factors are common among ST elevation myocardial infarction patients. Early detection and treatment of these risk factors play a vital role for the prevention of coronary artery disease. Much more focus should be stressed on preventive programs throughout the country.

Cancer with pregnancy in a cancer hospital.

BACKGROUND: Cancer during pregnancy is rare, occurring one in every 1,000 pregnancies. Cancer itself rarely harms the baby and some cancer treatments are safe during pregnancy. However, treatment dilemmas often occur. METHODS: Descriptive study was conducted at B. P. Koirala memorial cancer hospital. Case records of women with cancer and pregnancy from January 2001 to February 2012 were analyzed regarding their clinical details, treatment, follow-up and feto-maternal outcome. RESULTS: Nineteen women, of 17 to 40 years had cancer with pregnancy. Observed cancers with pregnancy were: leukemia (4), head and neck (3), ovary (3), cervix (2), rectum (2), breast (1), Non-Hodgkin's lymphoma (1), osteosarcoma (1), spinal cord (1) and vulva (1). Seven women (36%) presented in the second trimester and six women (32%) presented in the first and third trimester each. Seven (36%) women opted for termination of pregnancy for definitive treatment, five (26%) deferred treatment until delivery. Among the seven (36%) that accepted definitive treatment along with pregnancy, fetal demise occurred in three and delivery of healthy baby occurred in four. Nine babies born to mothers with cancer during pregnancy till date have normal growth and development. Total 10 (52%) of the mothers are in remission, six (32%) have died from disease. CONCLUSIONS: Cancers during pregnancy, more common in younger women, posed treatment challenges. Definitive cancer treatment could have greater fetal risk during the first trimester but could be offered with more acceptable risk in the second and third trimesters.