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Background: In response to the COVID-19 pandemic, incoming travelers were quarantined at specific centers in Nepal and major checkpoints in Nepal-India border. Nepal adopted a generic public health approaches to control and quarantine returnee migrants, with little attention towards the quality of quarantine facilities and its aftermath, such as the poor mental health of the returnee migrants. The main objective of this study was to explore the status of anxiety and depression, and factors affecting them among returnee migrants living in institutional quarantine centers of western Nepal. Methods: A mixed method approach in this study included a quantitative survey and in-depth interviews (IDIs) among respondents in quarantine centers of Karnali province between 21st April and 15th May 2020. Survey questionnaire utilized Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) tools, which were administered among 441 quarantined returnee migrants. IDIs were conducted among 12 participants which included a mix of six quarantined migrants and healthcare workers each from the quarantine centres. Descriptive and inferential analyses were conducted on quantitative data; and thematic analysis was utilized for qualitative data. Results: Mild depression (9.1%; 40/441) and anxiety (16.1%; 71/441) was common among respondents followed by moderate depression and anxiety {depression (3.4%; 15/441), anxiety (4.1%; 18/441)} and severe depression and anxiety {depression (1.1%; 5/441), anxiety (0.7%; 3/441)}. Anxiety and depression were independent of their socio-demographic characteristics. Perceived fear of contracting COVID-19, severity and death were prominent among the respondents. Respondents experienced stigma and discrimination in addition to being at the risk of disease and possible loss of employment and financial responsibilities. In addition, poor (quality and access to) health services, and poor living condition at the quarantine centres adversely affected respondents' mental health. Conclusion: Depression and anxiety were high among quarantined population and warrants more research. Institutional quarantine centers of Karnali province of Nepal were in poor conditions which adversely impacted mental health of the respondents. Poor resource allocation for health, hygiene and living conditions can be counterproductive to the population quarantined. [ABSTRACT FROM AUTHOR]

The use of antimicrobials in animals for growth promotion and infection prevention significantly contributes to the development of antimicrobial resistance (AMR), a growing public health threat. While the World Health Organization (WHO), the United Nations (UN) and the European Union (EU) have taken steps towards reducing and restricting the use of antimicrobials in animals, initiatives are insufficient in developing countries where the demands for food animals continue to rise over the years. The inter-sectoral acknowledgment of inextricable link between animal health, human health and the environment (One Health approach) is critical. Concerted and collaborative efforts among all the stakeholders are essential to deal with this complex problem of resistance. [ABSTRACT FROM AUTHOR]

Background In the absence of proper guidelines and algorithms, available rapid diagnostic tests (RDTs) for common acute undifferentiated febrile illnesses are often used inappropriately. Methods Using prevalence data of 5 common febrile illnesses from India and Cambodia, and performance characteristics (sensitivity and specificity) of relevant pathogen-specific RDTs, we used a mathematical model to predict the probability of correct identification of each disease when diagnostic testing occurs either simultaneously or sequentially in various algorithms. We developed a web-based application of the model so as to visualize and compare output diagnostic algorithms when different disease prevalence and test performance characteristics are introduced. Results Diagnostic algorithms with appropriate sequential testing predicted correct identification of etiology in 74% and 89% of patients in India and Cambodia, respectively, compared with 46% and 49% with simultaneous testing. The optimally performing sequential diagnostic algorithms differed in India and Cambodia due to varying disease prevalence. Conclusions Simultaneous testing is not appropriate for the diagnosis of acute undifferentiated febrile illnesses with presently available tests, which should deter the unsupervised use of multiplex diagnostic tests. The implementation of adaptive algorithms can predict better diagnosis and add value to the available RDTs. The web application of the model can serve as a tool to identify the optimal diagnostic algorithm in different epidemiological settings, while taking into account the local epidemiological variables and accuracy of available tests. [ABSTRACT FROM AUTHOR]

Background: Outbreaks of acute undifferentiated febrile illness (AUFI) are common in Nepal, but the exact etiology or risk factors for them often go unrecognized. Diseases like influenza, enteric fever and rickettsial fevers account for majority of such outbreaks. Optimal diagnostic tests to inform treatment decisions are not available at the point-of-care. A proper epidemiological and clinical characterization of such outbreaks is important for appropriate treatment and control efforts.Methods: An investigation was initiated as a response to increased presentation of patients at Patan Hospital from Chalnakhel locality in Dakchinkali municipality, Kathmandu with AUFI from June 10 to July 1, 2016. Focused group discussion with local inhabitants and the epidemiological curve of febrile patients at local primary health care centre confirmed the outbreak. The household-survey was conducted in the area with questionnaire administered on patients to characterize their illnesses and their medical records were reviewed. A different set of questionnaire was administered on the patients and controls to investigate the association with common risk factors. Water samples were collected and analyzed microbiologically.Results: Eighty one patients from 137 households suffered from febrile illness within 6 weeks window before the investigation. All the 67 sampled patients with acute fever had a generalized illness without a discernible focus of infection. Only 38% of the patients had received a clinical diagnosis while the rest were treated empirically without a diagnosis. Three patients had blood culture confirmed enteric fever. Forty-two (63%) patients had been administered antibiotics, most commonly, ofloxacin, cefixime or azithromycin with a mean fever clearance time of 4 days. There was no definite association between several risk factors and fever. Fecal contamination was noted in tap water samples.Conclusion: Based on the pattern of illness, this outbreak was most likely a mixture of self-limiting viral infections and enteric fever. This study shows that even in the absence of a confirmed diagnosis, a detailed characterization of the illness at presentation and the recovery course can suggest the diagnosis and help in formulating appropriate recommendation for treatment and control. [ABSTRACT FROM AUTHOR]

Background: Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI.Methods/design: This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients.Discussion: Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever.Trial Registration: ClinicalTrials.gov, ID: NCT02773407 . Registered on 5 May 2016. [ABSTRACT FROM AUTHOR]

Self-diffusion coefficients along with the mutual diffusion coefficients of nitric oxide (NO) and SPC/E water (H2O) as solute and solvent of the mixture, have been studied within the framework of classical molecular dynamics level of calculations using GROMACS package. The radial distribution function (RDF) of the constituent compounds are calculated to study solute-solute, solute-solvent and solvent-solvent molecular interactions as a function of temperature. A dilute solution of five NO molecules (mole fraction 0.018) and 280 H2O molecules (mole fraction 0.982) has been taken as the sample. The self-diffusion coefficient of the solvent is calculated by using mean square displacement (MSD) where as that for solute (NO) is calculated by using MSD and velocity auto-correlation function (VACF). The results are then compared with the available experimental values. The results from the present work for water come in good agreement, very precise at low temperatures, with the experimental values. The diffusion coefficients of NO, on the other hands, agree well with the available theoretical studies, and also with experiment at low temperatures (up to 310 K). The results at the higher temperatures (up to 333 K), however, deviate significantly with the experimental observations. Also, the mutual diffusion coefficients of NO in water have been calculated by using Darken's relation. The temperature dependence of the calculated diffusion coefficients follow the Arrhenius behavior. [ABSTRACT FROM AUTHOR]

Patient: Female, 72 Final Diagnosis: Granulomatosis with polyangiitis Symptoms: Finger pain • gangrene Medication: -- Clinical Procedure: -- Specialty: Rheumatology Objective: Unusual clinical course Background: This is a very interesting case of Granulomatosis with Polyangiitis (GPA) presenting with hand ischemia which rapidly evolved into dry gangrene from the involvement of digital arteries. GPA usually affects the small and medium sized blood vessels. GPA affecting muscular artery causing limb ischemia is a rare manifestation. Case Report: A 72 years old Caucasian female was sent to our hospital for the evaluation of left hand pain and bluish discoloration, which she noticed for few days. Physical examination was notable for bluish discoloration of left 2nd to 5th fingers, which later evolved, into dry gangrene at the tips. Angiogram revealed ischemia with no evidence of thrombosis. Administration of intra-arterial nitroglycerin resulted in improved blood flow through the radial artery. Labs revealed ESR of 142 mm/hr. C-ANCA titer was 5120, (normal <20) and antiproteinase 3 was 1117 (normal <20) consistent with GPA. Conclusions: GPA usually affects the small and medium sized blood vessels. This case highlights an unusual presentation of GPA manifesting as critical limb ischemia. Given the rarity of this circumstance, a high index of suspicion is necessary in order to initiate proper treatment and limb salvaging intervention. [ABSTRACT FROM AUTHOR]

Background: Inferior vena cava filter complications can range from dislodgement to perforation. Patients who present with concomitant bacteremia have rarely been reported. Persistent bacteremia usually results from direct bacterial seeding from a source other than perforation of surrounding viscus. It is unclear if the risk of perforation is higher in patients who are bacteremic due to other causes. Case Presentation: We report an interesting case of a 67-year-old white woman who presented with fever, chills, and right upper quadrant abdominal pain. Her blood cultures were positive for methicillin-sensitive Staphylococcus aureus with no obvious source. Upon further investigation, she was found to have an inferior vena cava filter perforating her duodenum. The cause of her abdominal pain was explained by the inferior vena cava filter penetrating the duodenum; however, the source of bacteremia could not be ascertained. The inferior vena cava filter was removed successfully, and she was discharged on an intravenous antibiotic. Her symptoms resolved soon after the filter was removed. Conclusions: The use of inferior vena cava filters has increased significantly in recent years. This is likely due to their wider availability and safer placement techniques. With increasing use, the complications arising from these filters have been on the rise as well. It is very important for clinicians to be aware of these complications to avoid delays in diagnosis and patient care. [ABSTRACT FROM AUTHOR]

Background. Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods. We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results. From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions. Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. [ABSTRACT FROM AUTHOR]

Aim: To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner's toolkit for insulin motivation in the management of diabetes mellitus (DM). Background: Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization. Review Results: After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy. Conclusions: In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To assess the prevalence and predictors of post-transplant diabetes mellitus (PTDM) in Chinese renal recipients and describe their long-term evolution of glucose metabolism. Methods: 887 non-diabetic Chinese adult renal recipients were studied retrospectively, with a median follow-up of 7 years. PTDM patients were categorized into transient PTDM and permanent PTDM. The cumulative incidence and risk factors of PTDM were estimated by Kaplan–Meier and Cox regression. Results: The cumulative incidence of PTDM at 3 months, 1, 3, 5, 10, 15 and 20 years post-transplant was 10.4%, 11.4%, 13.4%, 15.2%, 22.7%, 27.9% and 38.3%, respectively. 61.9% of PTDM cases were diagnosed within the first three months and 61.6% of them developed persistent diabetes in the future. Risk factors for all PTDM included older age, body mass index (BMI)≥25kg/m2, triglycerides≥1.5mmol/L, rejection, the use of tacrolimus and diltiazem. The predictors of permanent PTDM included age >50 years (RR=2.322, 95% CI 1.255–4.296, P =0.007), BMI≥25kg/m2 (RR=1.699, 95% CI 1.014–2.846, P =0.044) and the use of tacrolimus (RR=1.835, 95% CI 1.181–2.851, P =0.007). Conclusions: Patients were most susceptible to PTDM within the first three months post-transplant and more than half of them developed persistent diabetes in the future. Age >50 years, overweight and tacrolimus application were risk factors for both PTDM and permanent PTDM. [Copyright &y& Elsevier]