A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal.

Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS.

PONV management in patients with QTc prolongation on the EKG.

Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.

Developing tool and Measuring Integration Characteristics of Basic Science Curriculum to Improve Curriculum Integration.

Background Integrated curriculum enhances students' learning and the retention of knowledge. At Patan Academy of Health Sciences, integrated organ system based curriculum is used with Problem Based Learning as the principle teaching learning method to foster students' learning. In addition, other approaches of integration were under taken such as integrated assessment; logical arrangement teaching learning methods (lectures and practicals); joint effort of faculty in curriculum planning and delivery; conducive environment to foster hidden curriculum. This study describes the perception of faculty and students on integration characteristics of Basic Science curriculum. Objective To measure the integration characteristics of Basic Science Curriculum. Method Tool was developed to measure integration characteristics of Basic Science Curriculum and ensure whether such planned integration has been achieved. Mixed method was used to measure the perception of the integration characteristics i) quantitatively by questionnaire survey to faculty and students ii) qualitatively by in-depth interview of students. Result Both faculty and students perceived that all the blocks in Basic Science was well integrated in the quantitative questionnaire survey. But, in the in-depth interview, students perceived integration of curriculum in organ system blocks were better integrated compared to Principle of Human Biology blocks where fundamentals of basic science disciplines were delivered. Students reflected that Problem Based Learning not only integrated Basic Science disciplines but also with clinical sciences and the social context. But, students perceived that Community Health Sciences curriculum was not so well integrated with Basic Science subjects. Conclusion Overall, this study showed that planned integration in Basic Science curriculum was successfully executed during curriculum implementation.

Knowledge, Attitude and Practice Regarding Pharmacovigilance and Consumer Pharmacovigilance among Consumers at Lalitpur District, Nepal.

BACKGROUND: Adverse drug reactions (ADRs) can be a big threat to the health of people in Nepal as a variety of medicines are consumed in the country. Involving consumers in pharmacovigilance can strengthen ADR reporting. The study aims to find out knowledge, attitude and practice regarding pharmacovigilance and consumer pharmacovigilance among consumers at Lalitpur district, Nepal Methods: It was carried out in outpatients visiting in KIST Medical College and Teaching Hospital, Lalitpur, Nepal. Participant's knowledge, attitude and practice were measured by noting their agreement with a set of 21 statements along with multiple choice and open ended questions. RESULTS: A total of 157 outpatients were surveyed. The knowledge scores for males (12) was better compared to the females (11), but the scores for attitude and practice were same for both groups. The maximum score for knowledge was 29, attitude was 6 and practice was 10. The overall KAP scores was 45. The total scores for knowledge, attitude and practice for males (24) were better compared to female (22) respondents. Seventy-one patients (68%) who participated in this study favoured establishing a consumer centre for obtaining information about ADRs. CONCLUSIONS: Knowledge scores among consumers regarding pharmacovigilance is low and require advocacy and improvement.

Admitting Deserving Medical Students from Rural and Disadvantaged: Patan Academy of Health Sciences' Approach.

BACKGROUND: Patan Academy of Health Sciences (PAHS) aims to produce physicians who would be able and willing to serve in the rural areas. Recognizing the critical importance of student selection strategy, among others, in achieving the program goals, it has adopted an innovative scheme for selecting medical students. This paper describes PAHS medical student selection scheme that favors enrollment of deserving applicants from rural and disadvantaged groups so as to help improve distribution of physicians in rural Nepal. METHODS: A student admission committee comprising a group of medical educators finalized a three-step student selection scheme linked with scholarships after reviewing relevant literatures and consultative meetings with experts within and outside Nepal. The committee did local validation of Personal Quality Assessment (PQA) that tested cognitive ability and personality traits, Admission OSPE (Objective Structured Performance Examination) that assessed non-cognitive attributes of applicants. It also provided preferential credits to applicants' socio-economic characteristics to favor the enrollment of deserving applicants from rural and disadvantaged groups through Social Inclusion Matrix (SIM). Three different categories of scholarship schemes namely Partial, Collaborative and Full were devised with Partial providing 50% and other two categories each providing 100% coverage of tuition fee. RESULTS: PAHS student selection scheme succeeded in enrolling more than half of its students from rural areas of Nepal, including about 10% of the students from that of the most backward region of the country. About one third of students were female and about the same were from public and community school. Sixty percent of students receive different categories of scholarships. CONCLUSIONS: Limited findings indicate the success of the selection scheme in enrolling high proportion of applicants from rural and disadvantageous groups and enable them to pursue study by providing scholarships.

Salivary biomarker levels and oral health status of children with autistic spectrum disorders: a comparative study.

AIM: To evaluate the oral health status, salivary flow rate, pH and buffering capacity in children with autistic spectrum disorders (ASD) in comparison to their healthy siblings. METHODS: A total of 30 subjects with ASD and 30 normal healthy siblings between the ages of 6-12 years of both genders attending various special schools and hospitals of Mangalore, India were recruited. Estimation of salivary pH, flow rate and buffering capacity were performed and oral health status was assessed using the WHO oral assessment form for children (World Health Organization in Oral health surveys: basic methods, World Health Organization, Geneva, 2013). The oral hygiene of the subjects was assessed using the oral hygiene index-simplified. Dental erosive lesions, presence of mucosal lesions and dental trauma were recorded for both the study and the control groups. RESULTS: It was observed that salivary pH and buffering capacity were lower in children with ASD than their healthy siblings, the dental caries incidence was higher in ASD children when compared to their healthy siblings and oral hygiene was fair with gingival bleeding in children with ASD. CONCLUSIONS: This study clearly indicates a need for better home care measures, parent, caregiver and institutional education on the importance of oral well-being among children with ASD.

Development of Community Based Learning and Education system within Undergraduate Medical Curriculum of Patan Academy of Health Sciences.

BACKGROUND: In response to continuing health disparities between rural and urban population, Patan Academy of Health Sciences (PAHS) was established in 2008. It aimed to produce physicians who would be able and willing to serve in the rural areas. In order to empower them with understanding and tools to address health issues of rural population, an innovative curriculum was developed. This paper aims to describe the community based learning and education (CBLE) system within the overall framework of PAHS undergraduate medical curriculum. METHODS: A Medical School Steering Committee (MSSC) comprising of a group of committed medical educators led the curriculum development process. The committee reviewed different medical curricula, relevant literatures, and held a series of consultative meetings with the stakeholders and experts within and outside Nepal. This process resulted in defining the desirable attributes, terminal competencies of the graduates, and then the actual development of the entire curriculum including CBLE. RESULTS: Given the critical importance of population health, 25% of the curricular weightage was allocated to the Community Health Sciences (CHS). CBLE system was developed as the primary means of delivering CHS curriculum. The details of CBLE system was finalized for implementation with the first cohort of medical students commencing their studies from June 2010. CONCLUSIONS: The CBLE, a key educational strategy of PAHS curriculum, is envisaged to improve retention and performance of PAHS graduates and, thereby, health status of rural population. However, whether or not that goal will be achieved needs to be verified after the graduates join the health system.

Synthesis and characterization of Cu/Ag nanoparticle loaded mullite nanocomposite system: A potential candidate for antimicrobial and therapeutic applications.

BACKGROUND: Microbial resistance to antibiotics has triggered the development of nanoscale materials as an alternative strategy. To stabilize these particles an inert support is needed. METHOD: Porous nanomullite developed by sol-gel route is loaded with copper and silver nanoparticle by simple adsorption method. These nanocomposites are characterized using XRD, FTIR, TEM, SEM, EDAX and UV-visible spectrophotometer. Antibacterial activity of these nanocomposites against Gram positive and Gram negative bacteria are performed by bactericidal kinetics, flow cytometry and MTT assay. The underlying mechanisms behind the antimicrobial property and cell death are also investigated by EPR spectroscopy, intracellular ROS measurement and ß-galactosidase assay. The cytocompatibility of the nanocomposites is investigated by cell viability (MTT), proliferation (Alamar blue) and wound healing assay of mammalian fibroblast cell line. RESULTS: Nanocomposites show a fairly uniform distribution of metal nanoparticle within mullite matrix. They show excellent antibacterial activity. Metal ions/nanoparticle is found to be released from the materials (CM and SM). Treated cells manifested high intracellular oxidative stress and ß-galactosidase activity in the growth medium. The effect of nanocomposites on mammalian cell line depends on exposure time and concentration. The scratch assay shows normal cell migration with respect to control. CONCLUSION: The fabricated nanoparticles possess diverse antimicrobial mechanism and exhibit good cytocompatibility along with wound healing characteristics in mouse fibroblast cell line (L929). GENERAL SIGNIFICANCE: The newly synthesized materials are promising candidates for the development of antimicrobial ceramic coatings for biomedical devices and therapeutic applications.

The dipole moment of the spin density as a local indicator for phase transitions.

The intra-atomic magnetic dipole moment - frequently called ⟨Tz⟩ term - plays an important role in the determination of spin magnetic moments by x-ray absorption spectroscopy for systems with nonspherical spin density distributions. In this work, we present the dipole moment as a sensitive monitor to changes in the electronic structure in the vicinity of a phase transiton. In particular, we studied the dipole moment at the Fe(2+) and Fe(3+) sites of magnetite as an indicator for the Verwey transition by a combination of x-ray magnetic circular dichroism and density functional theory. Our experimental results prove that there exists a local change in the electronic structure at temperatures above the Verwey transition correlated to the known spin reorientation. Furthermore, it is shown that measurement of the dipole moment is a powerful tool to observe this transition in small magnetite nanoparticles for which it is usually screened by blocking effects in classical magnetometry.

Prevalence of intestinal parasitic infections among public school children in a rural village of Kathmandu Valley.

Intestinal parasitic infections (IPI) are one of the most prevalent infections in humans residing in developing countries and its burden is high among school aged children. This cross-sectional study was conducted to determine the prevalence of intestinal parasitic infection and types of intestinal parasites in rural public school children of Nepal. It included students from Nursery to Class X of a rural public school located in the northeast part of the Kathmandu Valley, Nepal. Among the 194 participating children, prevalence of intestinal parasitic infection was found as 23.7%; (28.2% for boys; 20.2% for girls). Amongst the infected children, single and mixed parasitic infection was detected in 43 (93.5%) and 3 (6.5%) children respectively. Among protozoan parasites, Giardia lamblia was the most common (58.6%) whereas Hymenolepis nana was the most common (21.7%) among the helminths. Statistically different prevalence of intestinal parasitic infection was observed among children aged above 10 years and children aged below 6 years as well as 6 to 10 years. Gender-wise, there was no statistical difference in prevalence of intestinal parasitic infection. This study suggests the need of health education program in schools along with regular screening of intestinal parasites and treatment for effective management of the intestinal parasites among school children in Nepal.

Knowledge of care providers regarding the oral health care of visually impaired children.

OBJECTIVE: To assess the awareness of care providers of visually impaired children regarding their oral hygiene. METHOD: A simple pre-structured questionnaire was given to the care providers and the awareness regarding their oral health was assessed. RESULTS: There was a general lack of awareness among the care providers of these children regarding dental diseases and its prevention. Furthermore, the importance of oral hygiene was found to be very low. CONCLUSION: The results obtained showed that most of the caretakers were unaware of the difficulties faced by these children in the maintenance of their oral health.

Decision support system for diabetic retinopathy using discrete wavelet transform.

Prolonged duration of the diabetes may affect the tiny blood vessels of the retina causing diabetic retinopathy. Routine eye screening of patients with diabetes helps to detect diabetic retinopathy at the early stage. It is very laborious and time-consuming for the doctors to go through many fundus images continuously. Therefore, decision support system for diabetic retinopathy detection can reduce the burden of the ophthalmologists. In this work, we have used discrete wavelet transform and support vector machine classifier for automated detection of normal and diabetic retinopathy classes. The wavelet-based decomposition was performed up to the second level, and eight energy features were extracted. Two energy features from the approximation coefficients of two levels and six energy values from the details in three orientations (horizontal, vertical and diagonal) were evaluated. These features were fed to the support vector machine classifier with various kernel functions (linear, radial basis function, polynomial of orders 2 and 3) to evaluate the highest classification accuracy. We obtained the highest average classification accuracy, sensitivity and specificity of more than 99% with support vector machine classifier (polynomial kernel of order 3) using three discrete wavelet transform features. We have also proposed an integrated index called Diabetic Retinopathy Risk Index using clinically significant wavelet energy features to identify normal and diabetic retinopathy classes using just one number. We believe that this (Diabetic Retinopathy Risk Index) can be used as an adjunct tool by the doctors during the eye screening to cross-check their diagnosis.

Pattern of head and neck malignancies in eastern part of Nepal.

The term head and neck refers to the upper aerodigestive tract, the salivary glands, the thyroid, parathyroid glands, the sino-nasal tract and the skin of the head and neck region. Malignancies at these sites are important due to the divergence in their behaviors and prognosis. A retrospective, cross sectional, series of cases were studied to determine the pattern of head and neck malignancies in our department from January, 2005 to July, 2006. A total of 90 cases of head and neck malignancies proven on histopathology were studied. Pharynx 25 (27.78%) was the commonest site involved by cancer. In the pharynx, malignancies at the nasopharyngeal region contributed to the bulk of the tumor constituting 12 (48.00%). Histopathologically, squamous cell carcinoma was seen in 61, (67.77%) subjects. Most of the patients presented in IIIrd or IVth stage of disease. The commonest treatment strategy adopted was surgery with post operative radiotherapy. Nasopharyngeal carcinoma is a major concern in this part of the region.

Improved gas sensing activity in structurally defected bilayer graphene.

Graphene is a two-dimensional material with a capability of gas sensing, which is here shown to be drastically improved by inducing gentle disorder in the lattice. We report that by using a focused ion beam technique, controlled disorder can be introduced into the graphene structure through Ga(+) ion irradiation. This disorder leads to an increase in the electrical response of graphene to NO(2) gas molecules by a factor of three in an ambient environment (air). Ab initio density functional calculations indicate that NO(2) molecules bind strongly to Stone-Wales defects, where they modify electronic states close to the Fermi level, which in turn influence the transport properties. The demonstrated gas sensor, utilizing structurally defected graphene, shows faster response, higher conductivity changes and thus higher sensitivity to NO(2) as compared to pristine graphene.

Epistaxis in visceral leishmaniasis with hematological correlation.

Objective. To study the prevalence of epistaxis in visceral leismaniasis and its correlation with hematological profile. Methods. Out of 80 diagnosed cases of visceral leishmaniasis, 19 patients with epistaxis were included in the study. Diagnosis was made by Rk-39 from peripheral smear and LD bodies from bone marrow. Before starting anti-kala-azar treatment, nasal examination findings and hematological profile were noted. Study Design. Prospective cross-sectional hospital-based study. Results. Epistaxis was found in the age group of 7-66 years. Epistaxis was observed in 19 (23.8%) cases. One patient died because of epistaxis and neck hematoma. Conclusion. Epistaxis is a common ENT finding in endemic area of visceral leishmaniasis like our case.

Association of hypertension with microalbuminuria and lipid profile in the local population of Patan.

There is increasing prevalence of hypertension worldwide. Hypertension is an important risk factor for cardiovascular disease and renal disease which are the leading cause of death in the world. It is, therefore, very important to prevent progression of hypertension into these fatal diseases through appropriate treatment and monitoring. Microalbuminuria and dyslipidemia has been regarded as a predictor for cardiovascular and renal dysfunction in hypertension. In this study, we have included 130 hypertensive and 100 normotensive individuals of age > or = 25 years. Patients with a history of urinary tract infection, hematuria, renal failure, women with menstruation at the time of sample collection were excluded from this study. Measurements of anthropometric parameters; blood parameters like lipid profile, fasting blood sugar (FBS), creatinine after 8 hrs fasting and urine parameters like microalbumin and creatinine were done. The prevalence of microalbuminuria and macroalbuminuria is 17.7% and 3.1% respectively in hypertensive patients. Also, there was 9% prevalence of microalbuminuria in normotensive people. There was a significant association of hypertension with microalbuminuria and dyslipidemia, triglyceride, low density lipoprotein, high density lipoprotein, microalbumin creatinine ratio (MCR), body mass index (BMI), waist circumference (WC) and waist hip ratio (WHR) were significantly higher in hypertensive than in normotensive persons. These higher lipid levels, WC and MCR in hypertensive patient are established risk factors for progressing into diabetes and cardiovascular diseases. Hence, monitoring of these parameters would be beneficial for hypertensive patients in preventing the disease progression in this population.

Penetrating neck injury by an arrow: a paradigm of age old assault.

Penetrating neck injuries by traditional weapons are rare entity in the modern era of sophisticated weapons. We report an unusual case of penetrating neck injury by a metallic arrow entering anterior neck in zone II and its tip coming out of neck posteriorly causing difficulty for patient to lie down as well as posing challenge to intubate. Arrows are low velocity projectile and from a close proximity they can cause penetrating trauma similar to a low powered handgun. Management of the case was discussed.

Successful emergent reintubation using the Aintree intubation catheter and a laryngeal mask airway.

Tracheal extubation can be potentially catastrophic, especially in patients with difficult airways. This article describes a case where planned extubation in a patient with a large tongue lesion led to complete airway obstruction and subsequent cardiac arrest. Reintubation was facilitated using a laryngeal mask airway and an Aintree intubation catheter.

On-line capacity-building program on "analysis of data" for medical educators in the South Asia region: a qualitative exploration of our experience.

BACKGROUND AND OBJECTIVE: In medical education, using the World Wide Web is a new approach for building the capacity of faculty. However, there is little information available on medical education researchers' needs and their collective learning outcomes in such on-line environments. Hence, the present study attempted: 1)to identify needs for capacity-building of fellows in a faculty development program on the topic of data analysis; and 2) to describe, analyze and understand the collective learning outcomes of the fellows during this need-based on-line session. MATERIALS AND METHODS: The present research is based on quantitative (on-line survey for needs assessment) and qualitative (contents of e-mails exchanged in listserv discussion) data which were generated during the October 2009 Mentoring and Learning (M-L) Web discussion on the topic of data analysis. The data sources were shared e-mail responses during the process of planning and executing the M-L Web discussion. Content analysis was undertaken and the categories of discussion were presented as a simple non-hierarchical typology which represents the collective learning of the project fellows. RESULTS: We identified the types of learning needs on the topic 'Analysis of Data' to be addressed for faculty development in the field of education research. This need-based M-L Web discussion could then facilitate collective learning on such topics as 'basic concepts in statistics', tests of significance, Likert scale analysis, bivariate correlation, and simple regression analysis and content analysis of qualitative data. CONCLUSIONS: Steps like identifying the learning needs for an on-line M-L Web discussion, addressing the immediate needs of learners and creating a flexible reflective learning environment on the M-L Web facilitated the collective learning of the fellows on the topic of data analysis. Our outcomes can be useful in the design of on-line pedagogical strategies for supporting research in medical education.