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Background: The causative agents of Acute Encephalitis Syndrome remain unknown in 68–75% of the cases. In Nepal, the cases are tested only for Japanese encephalitis, which constitutes only about 15% of the cases. However, there could be several organisms, including vaccine-preventable etiologies that cause acute encephalitis, when identified could direct public health efforts for prevention, including addressing gaps in vaccine coverage. Objectives: This study employs metagenomic next-generation-sequencing in the investigation of underlying causative etiologies contributing to acute encephalitis syndrome in Nepal. Methods: In this study, we investigated 90, Japanese-encephalitis-negative, banked cerebrospinal fluid samples that were collected as part of a national surveillance network in 2016 and 2017. Randomization was done to include three age groups (< 5-years; 5-14-years; >15-years). Only some metadata (age and gender) were available. The investigation was performed in two batches which included total nucleic-acid extraction, followed by individual library preparation (DNA and RNA) and sequencing on Illumina iSeq100. The genomic data were interpreted using Chan Zuckerberg-ID and confirmed with polymerase-chain-reaction. Results: Human-alphaherpes-virus 2 and Enterovirus-B were seen in two samples. These hits were confirmed by qPCR and semi-nested PCR respectively. Most of the other samples were marred by low abundance of pathogen, possible freeze-thaw cycles, lack of process controls and associated clinical metadata. Conclusion: From this study, two documented causative agents were revealed through metagenomic next-generation-sequencing. Insufficiency of clinical metadata, process controls, low pathogen abundance and absence of standard procedures to collect and store samples in nucleic-acid protectants could have impeded the study and incorporated ambiguity while correlating the identified hits to infection. Therefore, there is need of standardized procedures for sample collection, inclusion of process controls and clinical metadata. Despite challenging conditions, this study highlights the usefulness of mNGS to investigate diseases with unknown etiologies and guide development of adequate clinical-management-algorithms and outbreak investigations in Nepal. [ABSTRACT FROM AUTHOR]

Background: Worksite-based health programs have shown positive impacts on employee health and have led to significant improvements in cardiovascular risk factor profiles. We aimed to determine the effect of cafeteria intervention on cardio-metabolic risk factors diet in a worksite setting (Dhulikhel Hospital) in Nepal. Methods: In this one-arm pre-post intervention study, we recruited 277 non-pregnant hospital employees aged 18–60 with prediabetes or pre-hypertension. The study was registered in clinicaltrials.gov (NCT03447340; 2018/02/27). All four cafeterias in the hospital premises received cafeteria intervention encouraging healthy foods and discouraging unhealthy foods for six months. We measured blood pressure, fasting glucose level, glycated hemoglobin, cholesterol in the laboratory, and diet intake (in servings per week) using 24-hour recall before and six months after the intervention. The before and after measures were compared using paired-t tests. Results: After six months of cafeteria intervention, the median consumption of whole grains, mono/polyunsaturated fat, fruits, vegetable and nuts servings per week increased by 2.24(p<0.001), 2.88(p<0.001), 0.84(p<0.001) 2.25(p<0.001) and nuts 0.55 (p<0.001) servings per week respectively. The median consumption of refined grains decreased by 5.07 servings per week (p<0.001). Mean systolic and diastolic blood pressure decreased by 2 mmHg (SE = 0.6; p = 0.003) and 0.1 mmHg (SE = 0.6; p = 0.008), respectively. The low-density lipoprotein (LDL) was significantly reduced by 6 mg/dL (SE = 1.4; p<0.001). Conclusion: Overall, we found a decrease in consumption of refined grains and an increase in consumption of whole grains, unsaturated fats, fruits, and nuts observed a modest reduction in blood pressure and LDL cholesterol following a 6-month cafeteria-based worksite intervention incorporating access to healthy foods. [ABSTRACT FROM AUTHOR]

Background: Environmental surveillance, using detection of Salmonella Typhi DNA, has emerged as a potentially useful tool to identify typhoid-endemic settings; however, it is relatively costly and requires molecular diagnostic capacity. We sought to determine whether S. Typhi bacteriophages are abundant in water sources in a typhoid-endemic setting, using low-cost assays. Methodology: We collected drinking and surface water samples from urban, peri-urban and rural areas in 4 regions of Nepal. We performed a double agar overlay with S. Typhi to assess the presence of bacteriophages. We isolated and tested phages against multiple strains to assess their host range. We performed whole genome sequencing of isolated phages, and generated phylogenies using conserved genes. Findings: S. Typhi-specific bacteriophages were detected in 54.9% (198/361) of river and 6.3% (1/16) drinking water samples from the Kathmandu Valley and Kavrepalanchok. Water samples collected within or downstream of population-dense areas were more likely to be positive (72.6%, 193/266) than those collected upstream from population centers (5.3%, 5/95) (p=0.005). In urban Biratnagar and rural Dolakha, where typhoid incidence is low, only 6.7% (1/15, Biratnagar) and 0% (0/16, Dolakha) river water samples contained phages. All S. Typhi phages were unable to infect other Salmonella and non-Salmonella strains, nor a Vi-knockout S. Typhi strain. Representative strains from S. Typhi lineages were variably susceptible to the isolated phages. Phylogenetic analysis showed that S. Typhi phages belonged to the class Caudoviricetes and clustered in three distinct groups. Conclusions: S. Typhi bacteriophages were highly abundant in surface waters of typhoid-endemic communities but rarely detected in low typhoid burden communities. Bacteriophages recovered were specific for S. Typhi and required Vi polysaccharide for infection. Screening small volumes of water with simple, low-cost (~$2) plaque assays enables detection of S. Typhi phages and should be further evaluated as a scalable tool for typhoid environmental surveillance. Author summary: Typhoid fever is a major health issue in low- and middle-income countries, causing illness and death. The World Health Organization recommends the use of typhoid-conjugate vaccines to combat its spread. However, limited data on typhoid prevalence in these countries hinders effective vaccination programs. Environmental surveillance, which involves detecting Salmonella Typhi DNA in the environment, has emerged as a method to identify high-risk areas for typhoid transmission. Nevertheless, this approach is costly and requires infrastructure often unavailable in many communities. To address this, we conducted a study in Nepal to explore a low-cost and sustainable typhoid surveillance method. We examined typhoid bacteriophages in surface and drinking water across communities with varying population densities and typhoid burdens. Phages were easily detectable in communities with high typhoid burdens but less prevalent in areas with lower burdens. The isolated phages exhibited specificity for S. Typhi and were effective against different bacterial strains in Nepal. This study demonstrates that phage-based assays can be a simple and affordable tool for typhoid environmental surveillance. This method can help identify areas that require vaccination prioritization and interventions for clean water and sanitation. By utilizing phage-based assays, health authorities can better understand typhoid transmission and implement targeted control measures. [ABSTRACT FROM AUTHOR]

Introduction: Salmonella Typhi and Salmonella Paratyphi, fecal-oral transmitted bacterium, have temporally and geographically heterogeneous pathways of transmission. Previous work in Kathmandu, Nepal implicated stone waterspouts as a dominant transmission pathway after 77% of samples tested positive for Salmonella Typhi and 70% for Salmonella Paratyphi. Due to a falling water table, these spouts no longer provide drinking water, but typhoid fever persists, and the question of the disease's dominant pathway of transmission remains unanswered. Methods: We used environmental surveillance to detect Salmonella Typhi and Salmonella Paratyphi A DNA from potential sources of transmission. We collected 370, 1L drinking water samples from a population-based random sample of households in the Kathmandu and Kavre Districts of Nepal between February and October 2019. Between November 2019 and July 2021, we collected 380, 50mL river water samples from 19 sentinel sites on a monthly interval along the rivers leading through the Kathmandu and Kavre Districts. We processed drinking water samples using a single qPCR and processed river water samples using differential centrifugation and qPCR at 0 and after 16 hours of liquid culture enrichment. A 3-cycle threshold (Ct) decrease of Salmonella Typhi or Salmonella Paratyphi, pre- and post-enrichment, was used as evidence of growth. We also performed structured observations of human-environment interactions to understand pathways of potential exposure. Results: Among 370 drinking water samples, Salmonella Typhi was detected in 7 samples (1.8%) and Salmonella Paratyphi A was detected in 4 (1.0%) samples. Among 380 river water samples, Salmonella Typhi was detected in 171 (45%) and Salmonella Paratyphi A was detected in 152 (42%) samples. Samples located upstream of the Kathmandu city center were positive for Salmonella Typhi 12% of the time while samples from locations in and downstream were positive 58% and 67% of the time respectively. Individuals were observed bathing, washing clothes, and washing vegetables in the rivers. Implications: These results suggest that drinking water was not the dominant pathway of transmission of Salmonella Typhi and Salmonella Paratyphi A in the Kathmandu Valley in 2019. The high degree of river water contamination and its use for washing vegetables raises the possibility that river systems represent an important source of typhoid exposure in Kathmandu. Author summary: Understanding the dominant route of transmission of a pathogen is important for designing and implementing effective control strategies. Salmonella Typhi and Paratyphi A, which cause enteric fever, infect approximately 10 million people and cause over 100,000 deaths annually. In the Kathmandu Valley, prior work suggested ancient stone spouts used for drinking water were often contaminated and driving transmission of the diseases. However, many of these spouts no longer function, and people are still getting sick, suggesting other possible dominant pathways for enteric fever transmission. We tested drinking water from households in this area as well as local river water and found that only 7 drinking water samples were positive for Salmonella Typhi and 4 were positive for Salmonella Paratyphi A. We also tested river water and found many samples (>40%) tested positive for these bacteria. River water samples were not often positive upstream of Kathmandu city center (12% positive for Salmonella Typhi) but were often positive within the city center (58% positive for Salmonella Typhi) and in rural areas up to 10 km downstream of the city (67% positive for Salmonella Typhi). During sample collection, individuals were observed interacting with rivers by walking in them, washing clothes and washing vegetables for sale in markets. This study shows that drinking water may not be a primary driver of enteric fever transmission in the Kathmandu Valley, but that sewage contaminated river water may be a way disease transmits into the wider population. [ABSTRACT FROM AUTHOR]

Background: Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy. Method: This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale. Results: Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5. Conclusion: Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery. [ABSTRACT FROM AUTHOR]

Background: Frontline nurses dealing with the coronavirus disease‐2019 (COVID‐19) pandemic face various mental health challenges ranging from excessive stress and anxiety to severe depression. Aims: To study the comparative prevalence of anxiety and depression, and their contributing factors, between nurses working in intensive care units (ICU) with COVID‐19 patients (COVID ICU) and nurses working in ICU with patients admitted for other reasons (non‐COVID ICU). Design: Quantitative comparative cross‐sectional study. Methods: All frontline nurses working in COVID and non‐COVID ICUs at a tertiary care university hospital in Nepal were included. The data were collected using Google Forms. The groups were evaluated and compared in terms of various relevant variables with self‐designed socio‐demographic questionnaire, the validated Nepali version of the Hospital Anxiety and Depression Scale (HADS), and the General Health Questionnaire 12 (GHQ‐12). Results: The response rate was 100%. Of the 99 nurses who met the inclusion criteria, three were excluded. Out of the 96 nurses included, psychiatric caseness was present in 82 (85.4%). There was no statistically significant difference in the prevalence of psychiatric caseness, anxiety, and depression between the COVID ICU and non‐COVID ICU nurses (caseness of 90.4% vs 79.5%, P =.134; anxiety of 36.5% vs 27.3%, P =.587; and depression of 21.2% vs 9.1%, P =.214, respectively). Among the factors that could potentially lead to psychiatric caseness, anxiety, and depression, statistically significant differences were observed only in relation to sleep disturbances, confidence in caring for patients with COVID‐19 and intentions to discontinue current job, all being significantly higher in COVID ICU nurses. Conclusion: Anxiety and depression are common in nurses working in both the COVID and non‐COVID ICUs, although the difference is not statistically significant. Relevance to clinical practice: Early assessment of anxiety and depression in nurses working in all ICUs and their active medical and behavioural interventions are important in protecting this vital work force dealing with the pandemic. [ABSTRACT FROM AUTHOR]

Diabetes mellitus (DM) is a chronic metabolic disorder leading toward elevation of the blood glucose level due to insulin insufficiency (Type I) or insulin resistance of responsible tissues (Type II). Aside from allopathic medicine, herbal therapy using crude and extracted forms is drawing the interest of many researchers for its hypoglycemic effect. Therefore, this study was designed by selecting eight local medicinal plants – Azadirachta indica, Gymnema Sylvestre, Swertia chiraita, Cinnamomum tamala, Psidium guajava, Aegle marmelos, Urtica dioica and Momordica charantia – which have a long history of being utilized for glucose-lowering property to provide the experimental and scientific evidence of their antidiabetic efficacy. Among the four formulations prepared, tetra-herbal formulations F3 and F4 were found to have the highest total phenolic content (TPC) of 223.38 ± 0.25 μg GAE/mg plant extract and 220.24 ± 0.89 μg GAE/mg plant extract, respectively. At the same time, the total flavonoid content (TFC) study also revealed that F3 and F4 have the highest TFC of 282.29 ± 0.54 and 255.24 ± 0.37 μg QE/mg extract, respectively. Furthermore, antioxidant activity study showed that F3 and F4 showed potent DPPH free-radical scavenging effect with IC50 values of 12.22 and 15.24 μg/mL, respectively. Continuing the experiment, it was established that the results of quantitative phytochemical screening and antioxidant activity study coincide with the in vivo and in vitro antihyperglycemic activity assay. Formulation F3 showed the potent alpha-amylase inhibition with an IC50 value of 43.75 mg/mL, and the in vivo glucose-lowering efficacy of F3 showed its ability of markedly reducing the blood glucose level up to 130.2 ± 2.03 mg/dL within 21 days. With these findings, the present study provides evidence-based experimental and scientific basis for using these selected medicinal plants as high hypoglycemic activity agents. [ABSTRACT FROM AUTHOR]

Background: Stakeholder engagement is important from the management point of view to capture knowledge, increase ownership, reduce conflict, encourage partnership, as well as to develop an ethical perspective that facilitates inclusive decision making and promotes equity. However, there is dearth of literature in the process of stakeholder engagement. The purpose of this paper is to describe the process of increasing stakeholder engagement and highlight the lessons learnt on stakeholder engagement while designing, implementing, and monitoring a study on diabetes and hypertension prevention in workplace settings in Nepal. Methodology: We identified the stakeholders based on the 7P framework: Patients and public (clients), providers, payers, policy makers, product makers, principal investigators, and purchasers. The identified stakeholders were engaged in prioritization of the research questions, planning data collection, designing, implementing, and monitoring the intervention. Stakeholders were engaged through focus group discussions, in-depth interviews, participatory workshops, individual consultation, information sessions and representation in study team and implementation committees. Results: The views of the stakeholders were synthesized in each step of the research process, from designing to interpreting the results. Stakeholder engagement helped to shape the methods and plan, and process for participant's recruitment and data collection. In addition, it enhanced adherence to intervention, mutual learning, and smooth intervention adoption. The major challenges were the time-consuming nature of the process, language barriers, and the differences in health and food beliefs between researchers and stakeholders. Conclusion: It was possible to engage and benefit from stakeholder's engagement on the design, implementation and monitoring of a workplace-based hypertension and diabetes management research program in Nepal. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine is a method of using a variety of telecommunication techniques to evaluate patients. This research was carried out to study the clinical and demographic characteristics of the patients who sought neurological care via telemedicine during the first and second waves of the coronavirus disease 2019 pandemic. Methods and Materials: It is a retrospective study based on patients' records. Patients were consulted via Viber, WhatsApp, Facebook Messenger and telehealth facility of Danphe Care. The data were entered into and analyzed by using the Statistical Package for the Social Sciences version 26. Results: A total of 197 patients were examined. Viber was the most common tool used (n=109, 55.3%). One hundred and twenty-two patients (61.9%) were from outside the Kathmandu Valley. Majority of the patients (n=155, 78.7%) did not come across any technical disturbances during the consultation. Cerebrovascular diseases were the most common diseases evaluated followed by headache disorders and seizures. One hundred and thirty-seven patients (69.5%) did not require further investigations, 179 (90.9%) did not require in-person evaluations and 142 (72.1%) did not require referral to other specialists for further evaluation. Majority (54.3%) of the patients became better at follow-up. All patients who became better had at least one follow-up compared to 82.2% of the combined who remained static or had unknown status of their health in follow up (p = <0.001). Conclusion: Telemedicine is a useful tool to evaluate various neurological disorders. Even though most of the patients did not require investigations, referrals and in-person visits, majority of the patients improved. Patients who have at least one follow-up became better compared to patients who did not have any follow-ups. [ABSTRACT FROM AUTHOR]

Background: Brown rice consumption reduces the risk of diabetes. The prevalence of diabetes is increasing in Nepal; however, dietary preference remains for white rice. This study aimed to understand the perception, enablers, barriers, and facilitators of acceptance brown rice at a worksite cafeteria. Methods: We conducted a mixed‐method qualitative research among 42 employees of a hospital in central Nepal. The participants tasted and rated the qualities of five different combinations of brown and white rice on a hedonic scale. We conducted eight focus group discussions (FGDs)—four before and four after tasting rice combinations. FGDs were recorded, transcribed, and coded verbatim and analyzed manually using inductive–deductive thematic method. Results: Before tasting, the participants perceived brown rice as poor in quality. After tasting, the participants found that brown rice had better quality and were willing to switch gradually starting with a 25B ratio. Eighty‐three percent of participants liked a combination of 25B. Major barriers were poor perception of its quality, tradition, unavailability, lack of awareness of health benefits, and high price. Major facilitators were availability, self and family awareness about the health benefits, knowledge, the brown rice cooking process, serving with side dishes, prior tasting, and gradual substitution of brown rice. Conclusion: We found that brown rice should be promoted stepwise, first as a mixture with white rice and gradually increasing the proportion of brown rice. Brown rice acceptance can be increased by improved knowledge of its nutrition and health benefits, increasing availability, and affordability. [ABSTRACT FROM AUTHOR]

Introduction: Magnesium has been shown to have bronchodilator properties in asthma and chronic obstructive pulmonary disease (COPD). Therapeutic benefits of nebulized magnesium in asthma has been seen. The purpose of this study was to compare therapeutic benefits of nebulised magnesium sulphate as an adjuvant with normal saline in patients with COPD exacerbation. Methods: It was a randomized single blind interventional study of 172 cases of acute exacerbation of COPD presenting (AECOPD) with a peak expiratory flow rate (PEFR) <300 L/min measured 20 min after initial management. Patients received 5 mg salbutamol mixed with 3 ml isotonic magnesium sulphate or 3 ml normal saline on three occasions at 30 min intervals via nebulizer. The primary outcome measured was PEFR at 90 min and hospital admission, noninvasive or invasive ventilation and mortality were taken as secondary outcomes. Results: The mean PEFR were 86.3±11.9 l/min, 97.6±19.1 l/min and 99.6±15.2 l/min after nebulization with magnesium sulphate and 79.17±14.11 l/min, 90.17±18.27 l/min and 93.17±20.63 l/min at 30, 60 and 90 minutes respectively in normal saline group which were statistically significant differences. Total 91.9% were admitted in ward and 8.1% got admitted in Medical and intermediate intensive care units from magnesium group and 81.7% were admitted in ward and 18.3% required ICU admissions in saline group. Differences in ventilation and mortality were insignificant. Conclusion: Nebulized magnesium sulphate as an adjuvant to salbutamol treatment in the setting of AECOPD has therapeutic benefit on PEFR but no effect in terms of hospital admission, requirement of invasive or non-invasive ventilation and mortality. [ABSTRACT FROM AUTHOR]

Background: The liver is the second most injured organ following blunt abdominal trauma (BAT) after the spleen. Although the computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT, it may not readily available in all the hospitals. This study was performed to evaluate the role of aspartate transaminase (AST) and alanine transaminase (ALT) in patients with BAT and its significance in predicting the diagnosis and severity of the liver injury. Method: The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. It was a prospective observational study. All the patients with BAT were received by on-duty surgical residents in the emergency department. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT. Results: Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The median length of the intensive care unit (ICU) stay of patients with liver injury was higher than without liver injury. There was a significant difference in the median level of AST and ALT (< 0.001) between patients with liver injury and no liver injury. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86–0.98) and of ALT was 0.92 (95% confidence interval 0.83–0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury and also the severity of liver enzymes. The cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Based on these values, AST ≥ 106 U/l had a sensitivity of 71.7%, a specificity of 90%, a positive predictive value of 86.8%, and a negative predictive value of 77.6%. The corresponding values for ALT ≥ 80 U/l were 77.8%, 94.1%, 92.1%, and 82.8%, respectively. Conclusion: In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. The elevated level of AST and ALT might assist the emergency physicians and surgeons to timely refer the suspected patients with the liver injury to a tertiary center. [ABSTRACT FROM AUTHOR]

Background: Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Methods: We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data. Results: A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants' knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, p< 0.001, n=85) and self-confidence (0.6, 0.3, 1.3 increases out of 4.0, p< 0.01, n=111). The participants were highly satisfied with the program (4.2, 4.1, and 4.0 out of 5.0, n=162). Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance. Conclusion: The program was successful in improving participant's knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study is to analyze the pattern of semen abnormality in male partner of infertile couple in Nepal. Methods: A retrospective study of semen sample of male partner of infertile couple analyzed in Department of pathology, Dhulikhel Hospital from January 2014 to December 2018. All semen samples were processed and analyzed according to methods and standards outlined by World Health Organization laboratory manual for the examination and processing of human semen 2010. Results: A total of 520 semen samples were analyzed. Our study shows 221 (44%) abnormal for different semen parameters and asthenozoospermia (39.3%) is the most common abnormality followed by azoospermia (28.8 %), Oligoasthenozoospermia (17.9 %), Oligozoospermia (8.7 %), Oligoasthenoteratozoospermia (3.5 %) and teratozoospermia (1.8 %). Conclusions: Abnormal semen parameters remain significant causes in overall infertility in our set up with asthenozoospermia and azoospermia were common abnormalities in male partner. Semen analysis is an inevitable tool for evaluation of infertility in male partner. Further study is required to find out the possible etiologies of male infertility for holistic management of infertility. [ABSTRACT FROM AUTHOR]

Background Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear. Methods We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence. Results Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities. Conclusions In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever. [ABSTRACT FROM AUTHOR]

Background Enteric fever, a bacterial infection caused by Salmonella enterica serotypes Typhi and Paratyphi A, frequently presents as a nonlocalizing febrile illness that is difficult to distinguish from other infectious causes of fever. Blood culture is not widely available in endemic settings and, even when available, results can take up to 5 days. We evaluated the diagnostic performance of clinical features, including both reported symptoms and clinical signs, of enteric fever among patients participating in the Surveillance for Enteric Fever in Asia Project (SEAP), a 3-year surveillance study in Bangladesh, Nepal, and Pakistan. Methods Outpatients presenting with ≥3 consecutive days of reported fever and inpatients with clinically suspected enteric fever from all 6 SEAP study hospitals were eligible to participate. We evaluated the diagnostic performance of select clinical features against blood culture results among outpatients using mixed-effect regression models with a random effect for study site hospital. We also compared the clinical features of S. Typhi to S. Paratyphi A among both outpatients and inpatients. Results We enrolled 20 899 outpatients, of whom 2116 (10.1%) had positive blood cultures for S. Typhi and 297 (1.4%) had positive cultures for S. Paratyphi A. The sensitivity of absence of cough was the highest among all evaluated features, at 65.5% (95% confidence interval [CI], 55.0–74.7), followed by measured fever at presentation at 59.0% (95% CI, 51.6–65.9) and being unable to complete normal activities for 3 or more days at 51.0% (95% CI, 23.8–77.6). A combined case definition of 3 or more consecutive days of reported fever and 1 or more of the following (a) either the absence of cough, (b) fever at presentation, or (c) 3 or more consecutive days of being unable to conduct usual activity--yielded a sensitivity of 94.6% (95% CI, 93.4–95.5) and specificity of 13.6% (95% CI, 9.8–17.5). Conclusions Clinical features do not accurately distinguish blood culture–confirmed enteric fever from other febrile syndromes. Rapid, affordable, and accurate diagnostics are urgently needed, particularly in settings with limited or no blood culture capacity. [ABSTRACT FROM AUTHOR]

Background Enteric fever is endemic in Nepal and its economic burden is unknown. The objective of this study was to estimate the cost of illness due to enteric fever (typhoid and paratyphoid) at selected sites in Nepal. Methods We implemented a study at 2 hospitals in Nepal to estimate the cost per case of enteric fever from the perspectives of patients, caregivers, and healthcare providers. We collected direct medical, nonmedical, and indirect costs per blood culture–confirmed case incurred by patients and their caregivers from illness onset until after enrollment and 6 weeks later. We estimated healthcare provider direct medical economic costs based on quantities and prices of resources used to diagnose and treat enteric fever, and procedure frequencies received at these facilities by enrolled patients. We collected costs in Nepalese rupees and converted them into 2018 US dollars. Results We collected patient and caregiver cost of illness information for 395 patients, with a median cost of illness per case of $59.99 (IQR, $24.04–$151.23). Median direct medical and nonmedical costs per case represented ~3.5% of annual individual labor income. From the healthcare provider perspective, the average direct medical economic cost per case was $79.80 (range, $71.54 [hospital B], $93.43 [hospital A]). Conclusions Enteric fever can impose a considerable economic burden on patients, caregivers, and health facilities in Nepal. These new estimates of enteric fever cost of illness can improve evaluation and modeling of the costs and benefits of enteric fever–prevention measures. [ABSTRACT FROM AUTHOR]

Background Antibiotic use prior to seeking care at a hospital may reduce the sensitivity of blood culture for enteric fever, with implications for both clinical care and surveillance. The Surveillance for Enteric Fever in Asia Project (SEAP) is a prospective study of enteric fever incidence in Nepal, Bangladesh, and Pakistan. Nested within SEAP, we evaluated the accuracy of self-reported antibiotic use and investigated the association between antibiotic use and blood culture positivity. Methods Between November 2016 and April 2019, we collected urine samples among a subset of SEAP participants to test for antibiotic use prior to the hospital visit using an antibacterial activity assay. All participants were asked about recent antibiotic use and had a blood culture performed. We used mixed-effect logit models to evaluate the effect of antimicrobial use on blood culture positivity, adjusted for markers of disease severity. Results We enrolled 2939 patients with suspected enteric fever. Antibiotics were detected in 39% (1145/2939) of urine samples. The correlation between measured and reported antibiotic use was modest (κ = 0.72). After adjusting for disease severity, patients with antibiotics in their urine were slightly more likely to be blood culture positive for enteric fever; however, the effect was not statistically significant (prevalence ratio, 1.22 [95% confidence interval,.99–1.50]). Conclusions The reliability of self-reported prior antibiotic use was modest among individuals presenting with fever to tertiary hospitals. While antibiotics are likely to reduce the sensitivity of blood culture, our findings indicate that there is still considerable value in performing blood culture for individuals reporting antibiotic use. [ABSTRACT FROM AUTHOR]

Background Blood culture is the current standard for diagnosing bacteremic illnesses, yet it is not clear how physicians in many low- and middle-income countries utilize blood culture for diagnostic purposes and to inform treatment decisions. Methods We screened suspected enteric fever cases from 6 hospitals in Bangladesh, Nepal, and Pakistan, and enrolled patients if blood culture was prescribed by the treating physician. We used generalized additive regression models to analyze the probability of receiving blood culture by age, and linear regression models to analyze changes by month to the proportion of febrile cases prescribed a blood culture compared with the burden of febrile illness, stratified by hospital. We used logistic regression to analyze predictors for receiving antibiotics empirically. We descriptively reviewed changes in antibiotic therapy by susceptibility patterns and coverage, stratified by country. Results We screened 30 809 outpatients resulting in 1819 enteric fever cases; 1935 additional cases were enrolled from other hospital locations. Younger outpatients were less likely to receive a blood culture. The association between the number of febrile outpatients and the proportion prescribed blood culture varied by hospital. Antibiotics prescribed empirically were associated with severity and provisional diagnoses, but 31% (1147/3754) of enteric fever cases were not covered by initial therapy; this was highest in Pakistan (50%) as many isolates were resistant to cephalosporins, which were commonly prescribed empirically. Conclusions Understanding hospital-level communication between laboratories and physicians may improve patient care and timeliness of appropriate antibiotics, which is important considering the rise of antimicrobial resistance. [ABSTRACT FROM AUTHOR]

Background Characterizing healthcare-seeking patterns for acute febrile illness is critical for generating population-based enteric fever incidence estimates from facility-based surveillance data. Methods We used a hybrid model in the Surveillance for Enteric Fever in Asia Project (SEAP) to assess incidence of enteric fever at 6 study hospitals in 3 countries. We recruited individuals presenting to the hospitals and obtained blood cultures to evaluate for enteric fever. For this analysis, we undertook cluster random household surveys in Dhaka, Bangladesh (2 sites); Karachi, Pakistan; Kathmandu, Nepal; and Kavrepalanchok, Nepal between January 2017 and February 2019, to ascertain care-seeking behavior for individuals with 1) fever for ≥3 consecutive days within the past 8 weeks; or 2) fever resulting in hospitalization within the past year. We also collected data about disease severity and household demographics and assets. We used mixed-effect multivariable logistic regression models to identify determinants of healthcare seeking at study hospitals and determinants of culture-confirmed enteric fever. Results We enrolled 31 841 households (53 926 children) in Bangladesh, 25 510 households (84 196 children and adults) in Nepal, and 21 310 households (108 031 children and adults) in Pakistan. Children <5 years were most likely to be taken to the study hospitals for febrile illness at all sites. Household wealth was positively correlated with healthcare seeking in 4 of 5 study sites, and at least one marker of disease severity was positively associated with healthcare seeking in 3 of 5 catchment areas. Wealth and disease severity were variably predictive of blood culture-confirmed enteric fever. Conclusions Age, household wealth, and disease severity are important determinants of healthcare seeking for acute febrile illness and enteric fever risk in these communities, and should be incorporated into estimation models for enteric fever incidence. [ABSTRACT FROM AUTHOR]

Background Implementation of population-based surveys is resource intensive and logistically demanding, especially in areas with rapidly changing demographics and incomplete or no enumeration of the underlying population and their residences. To remove the need for pre-enumeration and to simplify field logistics for the population healthcare utilization survey used for the Surveillance for Enteric Fever in Asia Project in Nepal, we incorporated a geographic information system–based geosurvey and field mapping system into a single-stage cluster sampling approach. Methods A survey was administered to ascertain healthcare-seeking behavior in individuals with recent suspected enteric fever. Catchment areas were based on residential addresses of enteric fever patients using study facilities; clusters were randomly selected from digitally created grids using available satellite images and all households within clusters were offered enrollment. A tablet-compatible geosurvey and mapping system that allowed for data-syncing and use in areas without cellular data was created using the ArcGIS suite of software. Results Between January 2017 and November 2018, we surveyed 25 521 households in Nepal (16 769 in urban Kathmandu and 8752 in periurban Kavrepalanchok), representing 84 202 individuals. Overall, the survey participation rate was 90.9%, with geographic heterogeneity in participation rates within each catchment area. Areas with higher average household wealth had lower participation rates. Conclusion A geographic information system–based geosurvey and field mapping system allowed creation of a virtual household map at the same time as survey administration, enabling a single-stage cluster sampling method to assess healthcare utilization in Nepal for the Surveillance for Enteric Fever in Asia Project. This system removed the need for pre-enumeration of households in sampling areas, simplified logistics and could be replicated in future community surveys. [ABSTRACT FROM AUTHOR]

Background: Several studies have shown increase in prevalence of cardiovascular risk factors in the individuals residing in high altitude in various parts of the world. Aims and Objective: This study was conducted with an aim to estimate the prevalence and determinants of hypertension among the high-altitude population of Jomsom district of Nepal. Materials and Methods: We carried out a prospective camp based survey in Jomsom area on 4th and 5th June of 2017 where we measured the blood pressure, recorded anthropometric measurements like weight, height, BMI, Waist, Hip, Waist/hip ratio and maintained the thorough recorded after verbal consent of the participants. Results: A total of 617 local residents of Jomsom were screened. The mean age was 44.4±17. 6 years with predominant female subjects (53.5% female vs. 46.5% male). Hypertension was present in 142(23.0%) which was significantly lower than in the general population of Nepal as compared to other large scale studies. In addition, alcohol consumption in 29.3%, cigarette smoking in 15.9% and tobacco consumption in 8.3% was present. Higher BMI and waist/hip ratio was significantly associated with male sex and hypertension. Conclusion: The overall prevalence of hypertension is lower among the individuals residing in higher altitude compared to the general population although the other determinants are comparable. [ABSTRACT FROM AUTHOR]

Background: HIV-related stigma among people living with HIV/AIDS (PLWHA) is the foremost barrier to HIV prevention, treatment, care, and support. The aim of this study was to identify the perceived stigma level of PLWHA and its relation with selected demographic and situational factors in Pokhara, Nepal. Methods: Cross-sectional descriptive study was conducted among 282 PLWHA after probability sampling from antiretroviral treatment center of Western Regional Hospital, Pokhara, Nepal. Face-to-face interview was taken by using Bunn standard HSS tool. Stigma was measured in terms of felt stigma (public attitude concern [PAC], disclosure concern [DC], negative self-image [NSI]), enacted stigma [ES], as well as overall stigma. Result: The mean score of PAC, DC, NSI, ES, and overall stigma was 3.09, 3.02, 2.79, 1.66, and 2.52, respectively, where mean score of all domains of felt stigma (PAC, DC, and NSI) was >2.5, thus reflecting a higher level of felt stigma. ANOVA and t-test revealed higher level of overall stigma among younger age group (P<0.001), highly educated group (P=0.007), unmarried group (P<0.001), and recently HIV-diagnosed group (P=0.003). Conclusion: The study suggests high level of felt stigma, which has devastating effects on PLWHA as well as leads to nondisclosure of sero-positive status. So considering the significant impact of felt stigma on control of HIV epidemic, it is important to have a broader comprehension of this phenomenon and its repercussions on PLWHA via timely intervention like better educational intervention and counseling to PLWHA, wide-scale societal awareness campaigns, and more focused local interventions. [ABSTRACT FROM AUTHOR]

Introduction: Typhoid fever (TF) continues to cause considerable morbidity and mortality in Nepal, but only limited epidemiologic data is available about TF outside Kathmandu. Methods: As part of an interventional trial, we performed a prospective cohort study of bacteremic TF patients in Dhulikhel Hospital between October 2012 and October 2014. Demographic, epidemiological, clinical, and microbiologic data were recorded. Results: 116 bacteremic typhoid patients were included in the study. Most were young, healthy, adults (mean age 27.9±12 years), 41.4% of whom were female. More than 70% of patients were employed in non-manual services or were university students. Salmonella Typhi accounted for 64/115 (55.7%) of all isolates, while Salmonella Paratyphi accounted for 51/115 (44.3%), of which 42 were Paratyphi A and 9 Paratyphi B. A significant proportion of TF cases occurred also during the dry season (48/116, 41.6%). The clinical presentation of Salmonella Typhi and Paratyphi infections was similar, except for a greater proportion of arthralgia in patients with Salmonella Typhi. Most Salmonella Typhi and Paratyphi isolates were resistant to nalidixic acid and susceptible to older antibiotics. One Salmonella Paratyphi isolate was resistant to ceftriaxone. Conclusions: TF remains common in the Dhulikhel area, even among those with a high level of education. Public health measures aimed at reducing the incidence of TF in the Dhulikhel area are warranted. The relative burden of TF caused by Salmonella Paratyphi is rising; a vaccine with activity against Salmonella Paratyphi is needed. Since Salmonella Paratyphi B was more prevalent in this cohort than in large cohorts of patients from Kathmandu, it is likely that there are significant regional variations in the epidemiology of TF outside Kathmandu. [ABSTRACT FROM AUTHOR]

In the present study, ethanol extracts of 90 wild mushroom samples from Nepal, and the pure compound hispidin, were screened for their ability to inhibit β-hexosaminidase release (BHR) from rat basophilic leukemia-2H3 cells. Simultaneously, the toxicity of the extracts toward the cells was also determined, using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Samples belonging to the groups Hymenochaetales and Polyporales showed promising anti-allergic activity, with Phellinus adamantinus and Ganoderma lingzhi 3 allowing a mere 19.4% and 16.7% BHR, respectively, without any cell cytotoxicity. Moreover, the 50% inhibitory concentration (IC50) values for Inonotus clemensiae and P. adamantinus were determined to be 51.24 and 50.65 μg/mL, respectively; whereas hispidin, the major bioactive compound in I. clemensiae showed an IC50 value of 82.47 μg/mL. These findings are crucial in underscoring the medicinal value of the wild mushrooms of Nepal, as a source of strong antiallergic agents. [ABSTRACT FROM AUTHOR]

Background: In resource-limited nations like Nepal, congenital defects, including neural tube defects (NTDs), have great public health impact. NTDs and a few other congenital defects can be prevented by micronutrient supplementation. Without proper research regarding such defects, it is difficult to assess the damage made to health and productivity. This study aims to investigate different congenital defects among children in Nepal.Methods: Household surveys and health camps were conducted from 2011 to 2012. Physical examination of women of reproductive age (15 to 49 years) was done in selected Village Development Committees of nine districts in three ecological regions of Nepal. Congenital defects, including NTDs, were examined in children (age 0 to 5 years) who were alive at the time of the survey. Data entry and analysis was performed by using SPSS version 11.5.Results: 21,111 women were interviewed and 27,201 children born to them were assessed. The prevalence of congenital defects was 52.0 (95% CI: 44.0-61.0) per 10,000 children. The prevalence of selected NTDs was 4.0 (95% CI: 2.0-7.0) per 10,000 children. Among the neural tube defects, encephalocele, myelomeningocele and dermal sinus were the major ones, having almost the same prevalence in the Hill and Terai regions. The majority of children with genital abnormalities (17.0 per 10,000 children; 95% CI: 10.0-28.0) and limb deformities (14.0 per 10,000 children; 95% CI: 8.0-24.0) were found in the Terai. The rate of congenital birth defects was higher in the regions where women were in poor health.Conclusion: There is high prevalence of congenital defects in Nepal. Since such defects add a burden to families and society, it is imperative that health policies addressing programs like supplementation, fortification and dietary diversification be implemented. [ABSTRACT FROM AUTHOR]

Aims: Global family planning programs have been in existence in the developing world. Modern techniques of temporary contraceptives have been proved to be useful tool for limiting births. This study is intended to identify the use pattern, associated factors with the choice, shift and continuity of temporary methods of contraception. Methods: This is descriptive cross-sectional study, incorporating qualitative aspects. Out of sixteen districts six were selected proportionately by using simple random methods from each ecological zone of the Western Development Regions, Nepal. Focus group discussion was accomplished among the different level family planning service providers. Results: User of Depo-Provera and pills were seen more in comparison to other temporary contraceptive. There are different reasons behind choosing of temporary contraceptive method such as Pills make regularity in menstruation, Norplant is useful for prolonged period, Depo-Provera is useful for three months and confidently used for a long time without any risk, motivation by friends/relatives. Reasons in changing the contraceptives includes associated side effects, lack of availability, irregularity in menstruation, choosing the another best method, excessive bleeding, difficult to use, pressure from family and husband to give birth, misunderstanding and stress in the family, traditional belief and lack of education. Conclusions: For proper choice of modern contraceptive methods promotion, education and knowledge about associated factors related to use of these method is needed. Continuous information on contraceptives focusing particularly on the side effects and trained health care providers are essential. [ABSTRACT FROM AUTHOR]

Background. The government of Nepal aims to reach millennium development goals 4 and 5 by focusing on the provision of skilled birth attendants (SBAs). This is undertaken by providing two months’ additional training on complicated childbirth to physicians, certified nurses, auxiliary nurse-midwives and degree-trained nurses. However, SBAs are under-utilised, as only 36% of all births are supported by SBAs, while 72% of births take place at home. For the women in Nepal that do access main hospitals with the highest level of maternity care, there are limited descriptions of their experiences of being cared for during birth. Aim. To explore mothers’ experiences of the care received while giving birth in hospital settings in Nepal. Method. An interview study with 10 first-time mothers voluntarily recruited from maternity units in two tertiary-level hospitals was conducted over a four-month period. Ethical approval was obtained from the Nepal Health Research Council. Data were analysed using content analysis. Results. The main category ‘trust in care providers, both relatives and professionals, was fundamental for mothers to feel cared for’ captured the essence of the two categories ‘accountable caring’ and ‘the act of communication’ with, in total, nine sub-categories. Conclusion. For women to experience ‘being cared for’ in birth, they need to be accompanied by relatives and they need to trust those relatives and healthcare providers. This study concludes by arguing that relatives are a valued addition to healthcare providers’ provision of clinical care during birth. Delivery of preparation for birth sessions for both mother and relatives are recommended. Mothers highlighted that more information and some preparation for birth might have reduced their fear. [ABSTRACT FROM AUTHOR]

Introduction: Maternal mortality remains a global public health problem. Despite the call to improve access to maternal health care services and reduce maternal mortality, maternal health-seeking behavior in Nepal has remained poor. This study, therefore, aims to assess the awareness regarding pregnancy and health seeking behavior of pregnant women in Nepal. Methods: House-hold Survey and health camps were conducted from 2011 to 2012 by using structured questionnaires and physical examination of reproductive age women (15 to 49 years) in selected Village Development Committees of nine districts of Nepal. Data entry and analysis was performed by using SPSS version 11.5. Results: Among the pregnant women, 19.6% (n=235) did not go for Antenatal check (ANC). More than a half of the women having ANC visited Auxiliary Nurse Mid-wife. 15.8% (n=200) of the pregnant women did not receive tetanus toxoid (T.T) vaccine and 16.3% (n=195) did not take iron/folic acid. In comparison to younger age, the odds of having antenatal check-up was increased by two times in the women 25 to 34 years of age (p<0.001, OR=2.166). Women having formal education were more likely to go for ANC than other women were (p-0.002, OR-1.703). Involvement of pregnant women in the community organizations motivated them for ANC visit (p<0.001, OR=2.106). ANC visit had significantly increased T.T vaccination (p<0.001) and consumption of iron/folic acid (p<0.001). Conclusion: Lack of proper knowledge regarding complications of pregnancy and delivery remains the major challenge in health seeking behaviors. Therefore, raising awareness about its importance can improve maternal and child health. [ABSTRACT FROM AUTHOR]

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Background. Respectful maternity care is the universal right of childbearing women, but in Nepal there are no midwives to deliver this care and it is provided by skilled birth attendants (SBAs), who may be physicians, certified nurses, auxiliary nursemidwives or degree-trained nurses. Aim. To explore how this concept of respectful maternity care was perceived by SBAs in practice. Design. Focus group discussions were used and the setting was two tertiary level maternity hospitals in Nepal. Ethical approval for the study was obtained from the Nepal Health Research Council. A total of 24 SBAs were recruited voluntarily from the maternity units. Data were analysed using a phenomenographic approach and interpretation was verified by the focus group facilitator and note-taker. Findings. Five categories, divided into16 sub-categories, present the SBAs' collective description of respectful care. Conclusions. SBAs understood that respectful care at birth was important, but argued that 'safety comes before comfort'. To achieve safe maternity care, the contribution of relatives is essential, in addition to the provision of medical care. Implications. Family members need to accompany the woman and her newborn from admission to discharge to provide basic care and this needs to be reviewed. Professional midwives need to be trained, recruited, and deployed in areas where they are most needed and the government needs to regulate the profession and make it legal. [ABSTRACT FROM AUTHOR]

Not only the high mountainous regions but also the southern hilly regions of Nepal frequently suffer from landslides and debris flows. An interesting toppled structure with sliding was distinguished on an excavated slope facing the major highway in one such region, the Siwalik Hills. These hills are mostly composed of alternating beds of sandstones and mudstones of the Siwalik Group. A distinct contrast in the direction of dip of the strata was recognized on the excavated slope; the strata in the upper portion of the slope dipped southward, whereas those of the foot slope dipped northward. This indicated that toppling of strata had occurred. The northward direction of toppling and the angle and axis of rotation of the block were determined by examining the distribution of the attitudes of the strata.Steeply dipping strata influenced by southward thrusting along the major tectonic line, contrasting rigidity between sandstone and mudstone, and rapid dissection by a river were the major causes of the toppling. The bottom surface of the toppled part dipped gently not only northward but also partially westward, showing that the toppled block slid westward after toppling. Evidence for tension cracking and scarplets on the top slope indicated that the block was still actively sliding.Because steeply dipping sandstone and mudstone strata are widely distributed in the Siwalik Hills, similar structures are inferred to exist in many places. Therefore, the investigation of such slope structures is important, and their instability must be evaluated before road construction and excavation projects are carried out in Nepal. [Copyright &y& Elsevier]

Interconnection between river water and groundwater plays an important role in maintaining water quantity and quality in hydrological systems. Furthermore, the exact interconnection is often difficult to observe and measure. This study attempts to explain river and shallow groundwater interconnection in urbanized areas of the Kathmandu Valley, Nepal. Isotopic (δD and δ18O) and chemical analyses were performed on river and groundwater samples, and the results were analyzed using statistical methods to identify areas of interconnection between river water and groundwater. Higher concentrations and positive strong correlations of Na+ with K+, NH4+-N, Cl−, HCO3−, and PO4−-P, and a change of water type from Ca-HCO3 during the wet season to Na-K-HCO3 during the dry season indicate higher contamination in river water during the dry season. Hierarchical cluster analysis was used in grouping water samples into clusters on the basis of isotopic and chemical (Na+ and Cl−) composition. Grouping of river and groundwater samples in one–one clusters from wet and dry seasons shows the presence of interconnection, indicating the contribution of river water in recharging shallow groundwater. These results imply that shallow groundwater found near rivers is chemically contaminated by polluted river water through bank infiltration, in both wet and dry seasons. [ABSTRACT FROM AUTHOR]

Background: One of the leading cause of maternal mortality and morbidity is unsafe abortion. Globally 55.7million of abortions occurred each year between 2010 and 2014. In lower resource countries 24.3 million abortions were unsafe which is significantly higher. Nepal is one of the lower resource countries among others. Comprehensive abortion care (CAC) service can reduce this burden among women.Methods: A retrospective review of CAC service register at Tribhuvan University Teaching Hospital (TUTH) was conducted to collect data from 2006 to2015 with approval from the Nursing Department to identify the trends of CAC service delivery, client characteristics, category of service providers, and reason for seeking CAC services, its effectiveness and complications. The data was entered in SPSS software and descriptive analysis was performed.Results: A total of 2367 women received CAC in ten years period showing similar trend as 272-275 cases per year. Women's mean age was 28.4 years, 34% attained secondary level education and 98.9% were married. 70% were house wives and 84% multi gravid. The gestational period varied from 5 to 12 weeks. 85.6% had Manual Vacuum Aspiration (MVA) and 14.4% had Medical Abortion (MA). Only 37.6% women used any method of post abortion contraception. Unwanted pregnancy was the commonest reason for CAC. A majority of service providers were doctors (62.4%). The nurses were equally competent to provide CAC service as doctors.Conclusions: The number of women receiving CAC was relatively constant over the ten-year period. Nurses should be promoted for providing CAC services to cover a larger population in need. [ABSTRACT FROM AUTHOR]

Background: To increase cardiovascular disease prevention efforts, worksite interventions can promote healthy food choices, facilitate health education, increase physical activity and provide social support. This pioneer study will measure the effectiveness of a cafeteria and a behavioral intervention on cardio-metabolic risk in a worksite in Nepal.Methods: The Nepal Pioneer Worksite Intervention Study is a two-step intervention study conducted in Dhulikhel Hospital in eastern Nepal. In the first step, we will assess the effectiveness of a 6-month cafeteria intervention on cardio-metabolic risk using a pre-post design. In the second step, we will conduct a 6-month, open-masked, two-arm randomized trial by allocating half of the participants to an individual behavioral intervention based on the 'diabetes prevention program' for the prevention of cardio-metabolic risk. We will recruit 366 full time employees with elevated blood pressure, fasting blood sugar, or glycosylated haemoglobin (HbA1c). At baseline, we will measure their demographic variables, lifestyle factors, anthropometry, fasting blood sugar, HbA1c,and lipid profiles. We will measure cardio-metabolic outcomes at 6 months, 12 months, and 18 months. At 12 months, we will compare the proportion of participants who have attained two or more cardio-metabolic risk factor reduction goals (HbA1c decrease ≥0.5%; systolic blood pressure decrease ≥5 mmHg; or triglycerides decrease ≥10 mg/dL) during the cafeteria intervention period and the control period using generalized estimating equations. At 18 months, we will compare the proportion from the 'cafeteria only arm' to the 'cafeteria and behavior arm' for the same outcome using a chi-square test.Discussion: This pioneer study will estimate the effect of environmental-level changes on lowering cardio-metabolic risks; and added benefit of an individual-level dietary intervention. If the study demonstrates a significant effect, a scaled up approach could produce an important reduction in cardiovascular disease burden through environmental and individual level prevention programs in Nepal and similar worksites worldwide.Trial Registration: The trial was retrospectively registered on clincaltrials.gov (Identification Member: NCT03447340 ; Date of Registration: February 27, 2018). [ABSTRACT FROM AUTHOR]

Objective: To evaluate obstetric hemorrhage outcomes and present data specific to adoption of pneumatic circumferential abdominopelvic compression devices.Methods: Two resource-limited locations added low-cost pneumatic compression devices to their standard protocols for obstetric hemorrhage between 2010 and 2019. Providers in rural Nepal and Papua New Guinea used devices that incorporated a bicycle tube or soccer ball ("Ball and Binder") to provide abdominopelvic pressure after all available routine treatments had failed. Data were collected during the entire period as part of ongoing obstetric quality improvement. Data presented include obstetric event, etiology of bleeding, need for surgery, transfusion, transport, length of transports, maternal survival, and complications.Results: Circumferential abdominopelvic compression was used 106 times. The devices were used primarily after vaginal birth with atony, but also for obstetrical lacerations, miscarriages, and post-abortion bleeding. In all cases the bleeding stopped "promptly." All women survived, none required hysterectomy, and no complications were reported resulting from device use. Only 15 (14%) patients were transported to a referral hospital.Conclusion: In this quality improvement project, obstetric hemorrhage was controlled when circumferential pressure was applied after usual care had failed. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding a small outbreak of cholera in Eastern Nepal during the winter season.

Aims: Nepal cannot afford renal replacement therapy (RRT) for ESRD due to lack of resources. Early diagnosis of CKD and its risk factors may reduce the need of RRT. Materials and Methods: In this first community-based screening program in Nepal, 3218 people iÝ 20 years were assessed by door-to-door survey in Dharan. Health status, lifestyle habit, physical examination and blood pressure were evaluated. Spot urine was examined for proteins and glucose by dipstick. Fasting blood glucose and serum creatinine were measured in a subset of 1000 people and the prevalence of CKD was evaluated. A cardiovascular risk factor score was also determined. Results: Overweight, obesity, hypertension, diabetes and proteinuria were found in 20%, 5.0%, 38.6%, 7.5%, and 5.1% respectively. 47% hypertensives were newly detected during the screening. In the subset of 1000 subjects, CKD was detected in 10.6%. Multivariate logistic regression analysis showed that age (P <0.0001) and presence of diabetes (P = 0.027) were statistically significant predictors for CKD. Two or more cardiovascular risk factors were present in 47.3%. 848 patients entered the management phase of the program with lifestyle modification and pharmacologic intervention. 15% drop out during follow-up. Five patients died (2 on RRT). Glycemic (fasting glucose < 120 mg/dL) and blood pressure control (< 140/90 mmHg) was achieved in 60% and 72%, respectively. Regression or stabilization of proteinuria was reported in 52% of patients. Conclusion: Burden of CKD and cardiovascular risk factors are high at community level in Dharan. Reasonable control of blood sugar, hypertension and proteinuria was achieved in this program. These findings indicate the need of activating a large prevention and intervention program to tackle CKD and CVD in Nepal. [ABSTRACT FROM AUTHOR]

Introduction: As mental health systems are still developing in many Asian countries, knowledge of the pathways to mental health care (MHC) in this region would be very important. Aims: To clarify the pathways to MHC in 5 Asian countries. Method: A total of 50 new subjects attending each institution were interviewed. Pathway diagrams, the patterns and duration of care seeking, and the previous treatment were compared. Results: Four major pathways were direct access, referrals from private practitioners, referrals from general hospitals, and referrals from native or religious healers. General practitioners did not play a pivotal role in any of the areas, whereas native or religious healers had an important place in all areas except for Yokohama, Japan. Family members had a significant impact on the decision to seek MHC. Conclusions: Studies of pathways to MHC in Asian countries are feasible and can provide data of interest in the organization of care. [ABSTRACT FROM PUBLISHER]

Adverse pregnancy outcomes (APOs) include stillbirth, preterm birth, and low birthweight (LBW). Studies exploring the impact of weather factors and air pollution on APOs are scarce in Nepal. We examined the impacts of prenatal exposure to temperature, precipitation, and air pollution (PM 2.5) on APOs among women living in Kavre, Nepal. We conducted a hospital and rural health centers-based historical cohort study that included health facility birth records (n = 1716) from the Nepali fiscal year 2017/18 through 2019/20. We linked health records to temperature, precipitation, and PM 2.5 data for Kavre for the six months preceding each birth. A random intercept model was used to analyze birthweight, while a composite APO variable, was analyzed using multivariable logistic regression in relation to environmental exposures. The proportion of LBW (<2500 gm), preterm birth (babies born alive before 37 weeks of gestation), and stillbirth was 13%, 4.3%, and 1.5%, respectively, in this study. Overall, around 16% of the study participants had one or more APOs. Total precipitation (β: 0.17, 95% CI 0.01 to 0.33, p = 0.03) had a positive effect on birthweight in the wetter season. Negative effects for mean maximum (β: 33.37, 95% CI -56.68 to −10.06, p = 0.005), mean (β: 32.35, 95% CI -54.44 to −10.27, p = 0.004), and mean minimum temperature (β: 29.28, 95% CI -49.58 to −8.98, p = 0.005) on birthweight was also observed in the wetter season. A positive effect of temperature (mean maximum, mean, and mean minimum) and total precipitation on birthweight was found in the wetter season. This study emphasizes the need for future research using larger cohorts to elucidate these complex relationships in Nepal. • Temperature, precipitation, and PM 2.5 were statistically non-significant in terms of birthweight in the pooled analysis. • Total precipitation had a positive effect on birthweight in the wetter season. • Mean maximum, mean and mean minimum temperature negatively affected birthweight in the wetter season. [ABSTRACT FROM AUTHOR]

Background: Typhoid fever is an endemic disease in many low-income and middle-income countries. The 2018 WHO position paper recommends that countries should consider typhoid vaccination in high-risk groups and for outbreak control. To address the typhoid vaccine supply and demand gap, a typhoid Vi polysaccharide-diphtheria toxoid (Vi-DT) conjugate vaccine development effort was undertaken to achieve WHO prequalification and contribute to the global supply of typhoid conjugate vaccine. The main aim of this study was to show immune non-inferiority of the Vi-DT vaccine compared with the WHO prequalified Vi polysaccharide-tetanus toxoid (Vi-TT) conjugate vaccine (Typbar TCV; Bharat Biotech India, Hyderabad, India) in participants of various ages from an endemic country.Methods: We did an observer-blind, active-controlled, randomised, non-inferiority, phase 3 trial at four hospitals in Kathmandu, Dhulikhel, Dharan, and Nepalgunj in Nepal. Eligible participants were healthy individuals aged 6 months to 45 years for whom informed consent was obtained, were willing to follow the study procedures and were available for the duration of the study. Patients with an acute or chronic illness that could interfere with interpretation of the study endpoints, or who were involved in any other clinical trial were excluded. Participants were randomly assigned (1:1:1:1) by block randomisation (block size of four and eight), stratified by age (6 months to <2 years, 2 years to <18 years, and 18 years to 45 years), into one of four groups (A-D). Participants in groups A-C received a single dose (25 μg; 0·5 mL) of Vi-DT test vaccine via intramuscular injection from one of three good manufacturing practice lots (group A received lot 1, group B received lot 2, and group C received lot 3), and those in group D received a single dose (25 μg; 0·5 mL) of the Vi-TT vaccine via intramuscular injection. All participants, site staff (except for those who administered the study vaccines), and those assessing the outcomes were masked to group assignment. The co-primary endpoints were: (1) non-inferiority of immunogenicity of the Vi-DT vaccine (pooled groups A-C) versus the Vi-TT vaccine (group D), measured by the anti-Vi IgG seroconversion rate at 4 weeks after vaccination; and (2) the lot-to-lot consistency of the Vi-DT vaccine, measured by immune equivalence of the anti-Vi IgG geometric mean titre (GMT) at 4 weeks after receipt of the three Vi-DT vaccine lots (lot 1 vs lot 2, lot 1 vs lot 3, and lot 2 vs lot 3). Non-inferiority of the Vi-DT vaccine compared with the Vi-TT vaccine was shown if the lower limit of the 97·5% CI for the difference between the seroconversion rates in Vi-DT vaccine groups A-C combined versus Vi-TT vaccine group D was above the predefined non-inferiority margin of -10%. Lot-to-lot immune equivalence was shown if the upper and lower bounds of the two-sided 99·17% CI around the GMT ratio for each pairwise lot-to-lot comparison was between 0·67 and 1·50, which is the predefined equivalence margin recommended by WHO. The co-primary immunogenicity endpoints were assessed in all randomised participants who had received their assigned vaccine and had completed at least one post-baseline immunogenicity assessment. Safety was descriptively summarised by group and age strata, and was assessed in all participants who had received one dose of the investigational vaccine. The trial is registered with ClinicalTrials.gov, NCT03933098.Findings: Between Nov 20, 2019, and March 10, 2020, 1854 individuals were screened, of whom 1800 were enrolled and randomly assigned to groups A-D (450 participants in each group). 1786 (99·2%; 443 in group A, 450 in group B, 447 in group C, and 446 in group D) were included in the immunogenicity assessments at 4 weeks post vaccination, and all 1800 participants were included in the safety analysis. In the immunogenicity analysis, the anti-Vi-IgG seroconversion rate in all age strata was 99·33% (97·5% CI 98·61 to 99·68; 1331 of 1340 participants) in Vi-DT vaccine groups A-C and 98·88% (97·10 to 99·57; 441 of 446) in Vi-TT vaccine group D. The difference in seroconversion rates between Vi-DT vaccine groups A-C combined versus Vi-TT group D was 0·47% (97·5% CI -0·68 to 1·61), indicating non-inferiority of the Vi-DT vaccine. Anti-Vi-IgG GMT ratios at 4 weeks post-vaccination were 1·02 (99·17% CI 0·85 to 1·22) for lot 1 versus lot 2, 1·02 (0·85 to 1·23) for lot 1 versus lot 3, and 1·01 (0·84 to 1·21) for lot 2 versus lot 3, indicating lot-to-lot equivalence according to the predefined, WHO-recommended equivalence margin. The proportion of participants reporting adverse events was similar between Vi-DT vaccine groups A-C and Vi-TT vaccine group D; 260 (19·3%) of 1350 participants in Vi-DT vaccine groups A-C and 115 (25·6%) of 450 in Vi-TT vaccine group D reported solicited adverse events within 7 days after vaccination, and 208 (15·4%) in Vi-DT vaccine groups A-C and 76 (16·9%) in Vi-TT vaccine group D reported unsolicited adverse events within 4 weeks after vaccination. Seven serious adverse events (four [0·3%] participants in Vi-DT vaccine groups A-C and three [0·7%] in Vi-TT vaccine group D), including one death in the Vi-TT vaccine group, were reported during the 24-week follow-up period, none of which were considered related to the investigational product.Interpretation: When administered as a single dose, the Vi-DT test vaccine was safe, immunogenic, and non-inferior to the Vi-TT vaccine at 4 weeks post vaccination. Equivalent immunogenicity of the three lots of Vi-DT vaccine was also shown, supporting the manufacturing process of this vaccine. Once prequalified by WHO, this vaccine could be an option for purchase by UN agencies.Funding: The Bill & Melinda Gates Foundation.Translation: For the Nepali translation of the abstract see Supplementary Materials section. [ABSTRACT FROM AUTHOR]

Uncontrolled open-air burning of waste vehicle tyres causing environmental pollution has become a popular practice in Nepal despite official ban considering the environment and public health hazards. In this study, an experimental model was set up in a laboratory scale in an attempt to understand the potential emission of hazardous gases such as CO, SO2 and NO2 due to such activities in Kathmandu Valley and their possible impacts on the environment. For this purpose, four types of tyre were collected representing two from passenger car and two from motorbike category. The emission level of CO in the tyre smoke was measured with a CO gas detector tube while SO2 and NO2 were determined by UV–visible spectrophotometer. Among the three types of the gases analyzed, SO2 was emitted in significantly high levels by all the representative tyre samples. The emission levels of CO, SO2 and NO2 ranged from 21to 49, 102to 820 and 3to 9μgg−1, respectively. Results revealed that the emission levels also varied with the tyre types and qualities. The potential emission of the hazardous gases per representative scrap tyre mass was also estimated. Results indicate that the gaseous pollutants due to the tyre fires could make a significant contribution for deterioration of the environmental condition of the Valley or elsewhere. [Copyright &y& Elsevier]

Introduction: Free Newborn Care (FNC) service has been implemented to address the financial barriers to access sick newborn care in Nepal. This study was designed to evaluate the effectiveness of FNC package in terms of its adequacy to support a facility financially and the factors to be considered for reimbursement schemes in the FNC guideline. Methods: This is a cross sectional retrospective study where 2907 newborns who received FNC service from 2019 Mar 15 to 2021 Jan 14 over 20 months were included. Descriptive statistics using frequency and percentages were used to describe the package received. Pearson's Chi squared test was used to determine if the various factors receiving different newborn packages were statistically significant or not. Results: Amount reimbursed by FNC package for 20 months fell short by NRs 1355541. Majority of preterm (58%), LBW (52.3%) and MAS (55.3%) received package C. Babies who received package C with single morbidity was 576 (37.3%) with two to three morbidities was 380 (48.7%) and with more than three morbidities was 301 (70.2%). Those newborns who stayed for four to seven days, majority 654 (53.4%) received package B, whereas those who stayed for eight to 14 days, 15 - 21 days and > 21 days, the majority 490 (38.4%), 66 (5.2%), 32 (2.5%) received package C respectively. There was an association between receiving package C mortality among cases (P < 0.001). Conclusions: Inpatient quality newborn care can save lives of many vulnerable newborns. FNC service has provided opportune context in care of sick newborns with promising results. However, revising the reimbursing schemes by focusing on length of stay, mortality and disease severity can better strengthen sick newborn care. [ABSTRACT FROM AUTHOR]

Objective: This study was aimed to determine prevalence and resistance pattern like multidrug resistant (MDR) or ESBL nature of E. coli and Klebsiella spp. from various sewage drain samples with an idea to deliver baseline information that could be utilized for defining guidelines for the treatment of hospital sewages., Results: Of 10 sewage samples analyzed, 7 (70%) contained E. coli while 6 (60%) contained Klebsiella. Except one sample, all positive samples contained both E. coli and Klebsiella spp. E. coli isolates were resistant to ampicillin, amoxicillin, cefoxitin, cefuroxime, and cefpodoxime; while 85.7% were resistant to amoxicillin/clavulanate, ceftazidime, cefotaxime and ceftriaxone. 71.4%, 57.1%, 42.9%, and 28.6% were resistant to aztreonam, trimethoprim/sulfamethoxazole, nitrofurantoin, and gentamicin. Most were sensitive to chloramphenicol, ofloxacin, ciprofloxacin, and azithromycin. 85.7% and 57.1% of E. coli were MDR and ESBL isolates, respectively. Klebsiella were resistant to ampicillin, amoxicillin, and amoxicillin/clavulanate. 83.4% of Klebsiella were resistant to cefoxitin. 66.7% of strains were resistant to cefuroxime, ceftazidime, cefotaxime, ceftriaxone, and cefpodoxime. Klebsiella showed 50% resistant to aztreonam and trimethoprim/sulfamethoxazole, while 33.3% were resistant to chloramphenicol, nitrofurantoin, ofloxacin, and ciprofloxacin. Klebsiella were sensitive to azithromycin and gentamicin. 66.7% and 33.3% of Klebsiella were MDR and ESBL isolates, respectively.