Monitoring Iodine Deficiency in a District Hospital, Nepal.

Background Iodine deficiency possesses serious threat to pregnant women and infants. During pregnancy, iodine deficiency can result in stillbirth while in infants it can lead to impaired brain development. Objective This study was conducted to assess the status of iodine deficiency among pregnant women and infants. Method Ninety seven pregnant women seeking antenatal check-up (ANC) from Chautara Hospital Sindhupalchowk were included to analyze urine iodine. Thirty one mothers and their children were followed-up for their clinical status. Additionally, the infants were assessed for their urine iodine excretion and the mothers were assessed for their awareness about iodine and iodine deficiency disorder (IDD). Result Urinary iodine excretion revealed 25.2% of pregnant women and 20% children below one year of age had insufficient iodine intake while 42.9% of pregnant women and 24% children had iodine level above normal. Almost all households were found using iodized salt, 80% respondents had heard about iodized salt, 13% mothers were aware of benefits of iodized salt, 41.9% had knowledge of iodine deficiency diseases and 38.4% cognized the source of iodine. Conclusion Though awareness about iodine and iodine deficiency disorder was satisfactory, pregnant women and children were at risk of iodine deficiency and excessive iodine disorder. Therefore, to improve health of pregnant women and newborn, their nutrition must be prioritized which ultimately will help reduce morbidity and mortality.

Implementation of Active Case Detection of Visceral Leishmaniasis along with Leprosy through Female Community Health Volunteers in Sarlahi District, Nepal.

Background Visceral leishmaniasis (VL) and leprosy are important public health problem in Nepal. Female Community Health Volunteers (FCHVs) play pivotal role to promote community based health services. Therefore, we designed an implementation research to assess the effectiveness of active case detection (ACD) and information education and communication (IEC) campaign of Visceral leishmaniasis cases along with leprosy cases through Female Community Health Volunteers in Visceral leishmaniasis endemic 10 Village Development Committees of both Visceral leishmaniasis and leprosy prevalent Sarlahi district of Nepal. Objective To determine the effectiveness of active case search strategy of visceral leishmaniasis along with leprosy through Female Community Health Volunteers in Sarlahi district. Method One hundred fifty one Female Community Health Volunteers of twelve Village Development Committees were oriented on detection, identification and referral of Visceral leishmaniasis and leprosy patients. They were oriented on referring the patients to district hospital for confirmatory diagnosis and treatment. The intervention was continued up to ten months after training of Female Community Health Volunteers. Data on number of Visceral leishmaniasis and leprosy patients detected and referred by Female Community Health Volunteers and detected through passively at district hospital were collected and indicators was calculated. Result Altogether 151 Female Community Health Volunteers were trained from 12 (Village Development Committees) VDCs of Sarlahi district. Their knowledge on leprosy and Visceral leishmaniasis related information subsequently increased after training. None of the Visceral leishmaniasis or leprosy cases were detected actively through Female Community Health Volunteers. However, two leprosy cases were detected through household screening. Conclusion Female Community Health Volunteers should be provided sufficient knowledge to use them in community based active case detection of Visceral leishmaniasis and leprosy.

Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance.

BACKGROUND AND PURPOSE: Inadvertent intrafacet injection can occur during interlaminar epidural steroid injection, resulting in a false-positive loss of resistance and nontarget injection of medication. The purpose of this investigation was to compare the observed rates of this phenomenon during lumbar interlaminar epidural steroid injection performed by using conventional fluoroscopic and CT fluoroscopic guidance. MATERIALS AND METHODS: We retrospectively reviewed 349 lumbar interlaminar epidural steroid injections performed by using conventional fluoroscopy or CT fluoroscopic guidance to determine the observed rates of inadvertent intrafacet injection with each technique. Cases of inadvertent intrafacet injection were classified as either recognized or unrecognized by the proceduralist at the time of the procedure. Multivariate logistic regression was used to determine the independent effect of imaging guidance technique, age, and sex. RESULTS: The rate of inadvertent intrafacet injection was observed to be 7.5% in the CT fluoroscopic group and 0.75% in the conventional fluoroscopy group. All 16 cases identified from CT fluoroscopic procedures were recognized during the procedure; the single case identified from conventional fluoroscopy procedures was not recognized prospectively. The type of imaging guidance showed a statistically significant effect on the detection of the phenomenon (OR for conventional fluoroscopy versus CT fluoroscopy = 0.10, P = .03) that was independent of differences in age or sex. CONCLUSIONS: Inadvertent intrafacet injection is identified during CT fluoroscopic-guided interlaminar epidural steroid injection at a rate that is 10-fold greater than the same procedure performed under conventional fluoroscopy guidance.

The Indian and Nepalese programmes of indoor residual spraying for the elimination of visceral leishmaniasis: performance and effectiveness.

Although, when applied under controlled conditions in India and Nepal, indoor residual spraying (IRS) has been found to reduce sandfly densities significantly, it is not known if IRS will be as effective when applied generally in these countries, via the national programmes for the elimination of visceral leishmaniasis. The potential benefits and limitations of national IRS programmes for the control of sandflies were therefore evaluated in the districts of Vaishali (in the Indian state of Bihar), Sarlahi (in Nepal) and Sunsari (also in Nepal). The use of technical guidelines, levels of knowledge and skills related to spraying operations, insecticide bio-availability on the sprayed surfaces, concentrations of the insecticide on the walls of sprayed houses, insecticide resistance, and the effectiveness of spraying, in terms of reducing sandfly densities within sprayed houses (compared with those found in unsprayed sentinel houses or control villages) were all explored. It was observed that IRS programme managers, at district and subdistrict levels in India and Nepal, used the relevant technical guidelines and were familiar with the procedures for IRS operation. The performance of the spraying activities, however, showed important deficiencies. The results of bio-assays and the chemical analysis of samples from sprayed walls indicated substandard spraying and suboptimal concentrations of insecticide on sprayed surfaces. This was particularly obvious at one of the Nepali study sites (Sunsari district), where no significant vector reduction was achieved. Sandfly resistance to the insecticide used in India (DDT) was widespread but the potential vectors in Nepal remained very susceptible towards a pyrethroid similar to the one used there. The overall short-term effectiveness of IRS was found to be satisfactory in two of the three study sites (in terms of reduction in the densities of the sandfly vectors). Unfortunately, the medium-term evaluation, conducted 5 months after spraying, was probably made invalid by flooding or lime plastering in the study areas. Preparation for, and the monitoring of, the IRS operations against sandfly populations in India and Nepal need to be improved.

Iodine supplementation in pregnancy and its effects on perinatal outcome.

Iodine is an important micronutrient for mental growth and development. Limited information is available on the role of iodine supplementation in pregnancy and its effect on perinatal outcome. We designed intervention study to assess the effect of iodine supplementation during second half pregnancy and its effect on perinatal outcomes (maternal and neonatal health). Among 60 intervened with oral iodine tablet in pregnancy and 60 control pregnant women in Sindhupalchowk District Hospital Chautara, we assessed maternal and neonatal health after the delivery. The significant differences were found among duration of pregnancy, weight of pregnant mother before and after intervention of at least three months duration (56.1 kg vs. 59.6 kg, p < 0.001), weight of neonate (3.3 kg in intervention vs. 3.0 kg in control, p < 0.001), and thyroxin hormone (1.1 ng in intervention vs. 1.2 ng in control, p < 0.001) of women between intervened and control subjects. Therefore, regular supplementation of iodine in oral form for more than three months during pregnancy preferably during early stage will bring significant positive changes in perinatal outcomes.

Attenuation of carbon tetrachloride-induced hepatotoxicity by cow urine distillate in rats.

OBJECTIVE: To study the carbon tetrachloride-induced hepatoprotective activity in cow urine. METHODS: Effect of cow urine distillate on liver function was studied in vivo in rats intoxicated with carbon tetrachloride (CCl4). Hepatotoxicity was induced by a 1:1 (v/v) mixture of CCl4 in olive oil (5 mL/kg i.p). Protective effect of cow urine distillate (in three dose levels) and standard drug Silymarin (100 mg/kg, p.o) on liver function were studied in intoxicated rats. Parameters in the study included liver function tests and histological observations. RESULTS: The cow urine distillate decreased the levels of SGOT, SGPT, ALP, GGT, and total bilirubin in a dose-dependent manner (P < 0.05) as sylimarin. CONCLUSION: The observed protective effects of cow urine distillate on liver function might be due to the presence of antioxidants in cow urine.

Characteristics and risk factors of Plasmodium falciparum malaria in Eastern and Central Nepal.

BACKGROUND: Very limited information is available on epidemiology of falciparum malaria in Nepal. Such information is very important for malaria control programmes. It is believed that malaria in Eastern region is imported from border districts of India and local transmission follows whereas it is indigenous in Central region. Therefore, the characteristics and risk factors of malaria are believed to be different in Eastern and Central Nepal. OBJECTIVE: The objective of the study is to describe and compare the characteristics and risk factors of falciparum malaria in Eastern and Central Nepal. MATERIALS AND METHODS: This cross-sectional study was conducted in falciparum malaria endemic districts of Eastern and Central Nepal, during the period 2007 to 2008. We identified and collected information from 106 patients (62 from Eastern and 44 from Central region). Patient examination, clinical and laboratory assessment were done and patients were interviewed using structured questionnaire for malaria related characteristics, risk factors and behaviours. RESULTS: There were significant differences in risk factors and characteristics of falciparum malaria in the Central than the Eastern region. In the Central region, male, illiteracy and thatched roof hut were significant risk factors of falciparum malaria patients as compared to the Eastern region. Visits outside within three months, previous malaria within three months, taking antimalarial before confirmatory diagnosis were significantly higher in patients of the Eastern region as compared to the Central region. CONCLUSION: Falciparum malaria in Nepal should not be seen as similar entity, and different strategies for prevention and control is needed for its diverse characteristics and endemicity.

Malaria related knowledge, practices and behaviour of people in Nepal.

BACKGROUND & OBJECTIVES: The information on malaria related knowledge, practices and behaviour of the people of Nepal living in malaria endemic areas are essential to develop behavioural change communication messages and for producing policy to prevent and control malaria in the country. The objective of this study was to assess knowledge, practices and behaviour of the people living in malaria endemic districts and relate with malaria control policy in Nepal. METHODS: The paper utilizes data from a cross-sectional study of 1330 households conducted during December 2004 to April 2005 in rural areas of Jhapa, Kailali and Kanchanpur districts. The method used includes structured questionnaire and focus group discussions. RESULTS: The results revealed that 40% respondents were illiterates. Eighty-six percent respondents have heard about malaria but only 50% responded fever with chills as the sign and symptom of malaria. Seventy-three percent responded that mosquito bite causes malaria transmission and 74% respondents considered that malaria is the fatal disease but very few have knowledge that the treatment of malaria in time can save life. More than 50% did not have information on availability of free treatment of malaria in Nepal. Still 16% were found consulting traditional healers for the treatment. The outside sleeping habit was found in almost one fourth of the population mainly in summer season indicating no knowledge about prevention of malaria. Although bednet use practice was higher, only 4% had knowledge on insecticide impregnated bednets and 23% of them practicing it. Issues regarding the proper and regular use of bednets, the quality of the bednet and use of free treatment provided by the government, since these districts are reporting high incidence of malaria. INTERPRETATION & CONCLUSION: Health education must be taken into account for communities in malaria endemic areas to produce desired outcomes in malaria control.

Hepatoprotective activity of the Leucas lavandulaefolia on D(+)galactosamine-induced hepatic injury in rats.

The chloroform extract of Leucas lavandulaefolia at an oral dose of 200 mg/kg and 400 mg/kg exhibited a significant protection on D(+)galactosamine induced liver damage in rats. Silymarin (25 mg/kg), a known hepatoprotective drug used as a standard also exhibited a significant activity.

Unintentional injuries among school adolescents in Kathmandu, Nepal: a descriptive study.

OBJECTIVE: To describe detailed mechanisms and activities at the time of unintentional injuries among adolescents in Kathmandu, Nepal. METHODS: A school-based study was conducted on 1557 students in grades 6-8 across 14 schools, using a self-administered questionnaire during August-September 2003. Mechanisms and activities were coded using the Nordic Medico Statistical Committee's classification. FINDINGS: Falls (65%) and cuts (63%) were the most common injuries, followed by transport-related injuries (36%) and burns (22%). In urban areas, falls (59%) were the most common injuries, followed by transport-related injuries (50%); in semi-urban areas, falls (66%) and cuts (65%) were the most common injuries, followed by transport-related injuries (34%). At the time of falls, boys were generally engaged in sports while girls were engaged in walking on streets or on stairs in houses, in both areas. Falls from trees among boys and falls from roofs among girls were also common in semi-urban areas. Cut injuries while processing food were common among boys and girls in both areas, whereas agricultural work was also a source of injury in semi-urban areas. Pedestrian injuries were common during transport among boys and girls in both areas; boys in semi-urban areas were almost equally likely to be injured during cycling. Burn injuries while cooking and serving food were more common among girls in semi-urban areas. CONCLUSION: Falls, cuts, transport-related injuries, and burn injuries were quite prevalent among adolescents in Kathmandu. The reported injury mechanisms and activities posing injury risks have implications for future interventions.

Elimination of visceral leishmaniasis in Nepal: pipe-dreams and possibilities.

INTRODUCTION: Visceral Leishmaniasis (VL) re-emerged in the Indian subcontinent in the mid-1970s after an almost complete absence in the previous fifteen or so years. The disease was first noted in Nepal in 1978 and, since 1980, it has been reported regularly in increasing numbers. Elimination of visceral leishmaniasis by 2015 has been identified as regional priority program in the level of high political commitment. OBJECTIVE: The objectives of this study are the comprehensive assessment of information related to VL on the basis of past research studies conducted in Nepal, and an assessment of the prospects of control measures. MATERIALS AND METHODS: This was time line comprehensive VL epidemiological assessment study based on the research conducted by main author during the past ten years. During the period the studies were conducted using cross sectional, case control and exploratory study design. The statistical analysis was done using qualitative and quantitative methods. RESULTS: In our study in the visceral leishmaniasis endemic district, Siraha, in the population of 112,029, a total of 996 clinically suspected cases were reported (with fever of long duration and splenomegaly, with no malaria) during 1998-2002. In all, 283 subjects were found positive for visceral leishmaniasis by rK39 and 284 had positive bone marrow. There was no detectable difference in the density of Phlebotomus argentipes between high, and moderate incidence village development committees (VDC: the smallest administrative unit), but collections in the low incidence areas (in winter) were negative. P. argentipes was never numerous (maximum 4.4 females collected per man-hour), and was much less common than P. papatasi. Peaks of abundance were recorded in the March and September collections. We have found that the numbers of reported cases of visceral leishmaniasis in Nepalese villages was unaffected by indoor residual spray (IRS) indicated by parallel trends in case numbers by time series analysis in treated and untreated villages. A series of maps through ten years clearly showed that the infection can move rapidly between villages, and it is impossible to predict where transmission will occur from year to year. CONCLUSION: If maximum benefit in relation to cost is the goal, it may be preferable to put all possible efforts into active case detection (ACD) with free treatment. ACD should involve the network of Village Health Workers or Female Community Health Volunteers and the rK39 dipstick test at health centre level. Surveillance of disease and vector, communication for behavioural impacts and insecticide spraying should be important component of elimination program. If IRS is to be a part of the intervention, it is essential that it is carried out effectively, both in areas where the disease has been reported and in neighbouring areas. Integrated vector management need to be monitored for its application and effectiveness for VL elimination.

Phytochemical observation of whole plant of phyllanthus debilis klein .ex.willd.

Phytochemical studies of whole plant of Phyllanthus debilis Klein.ex.willd (Euphorbiaceae) reveals the presence of phytosterols, lignans, glycosides and absence of saponin, triterpenoids, tannins and alkaloids have been reported in this plant for the first time.

Willingness to pay for cataract surgery in Kathmandu valley.

AIM: A cross sectional study was carried out on 78 screened cataract patients of two screening camps in Kathmandu valley, Nepal, to assess the willingness to pay for cataract surgery. METHODS: A non-probability sampling technique with open ended and close ended questionnaires was used. RESULTS: The average age of patients was 68.8 years. The ratio of men and women was 0.9:1. 42.3% (33) of patients were willing to pay for cataract surgery. Among them 48.5% (16) of people were willing to pay less than dollars 13 and 51.5% (17) were willing to pay more than dollars 13. The mean was dollars 2.3 (SD dollars 15.5) per case. Patients with bilateral cataract were more willing to pay than unilateral cases. Poverty (44.4%, 20) was the main barrier for unwillingness to pay for cataract surgery. Other reasons were the lack of family support (28.9%, 13), lack of knowledge of surgery and belief that it was an unnecessary procedure (15.6%, seven), and waiting for a free surgical service (11.1%, five). CONCLUSION: This study clearly indicates that although there was awareness of the availability of treatment and services provided within the reach, people are not willing to pay for the surgery and use the facility primarily because of poverty. Hence, to change patients' attitudes, a more holistic approach is needed, keeping in view the cultural, social, and economic background of the society.

Long-term results of cemented, posterior cruciate ligament-retaining total knee arthroplasty in osteoarthritis.

Two hundred fifty-four total knee arthroplasties (TKAs) in 223 patients (82 men and 141 women) with osteoarthritis were reviewed. Average patient age at surgery was 68 years (range: 37-90 years). No patient was lost to follow-up. Average follow-up was 16.8 years (range: 15.2-23.2 years). Preoperatively, 175 (69%) knees had a varus deformity. The posterior cruciate ligament (PCL) was retained in all 254 knees, and all prostheses were cemented. Clinically, 91% of knees were rated as excellent; however, functionally, only 23% of knees were rated as excellent. There were 13 (5%) complications. Revision was performed in 10 (4%) knees. Survivorship analysis showed average implant survival for all revisions was 96.3% (range: 91.9%-98.3%) at 15 years and 82% (range: 60%-92.6%) at 23 years. Long-term results of cemented, PCL-retaining TKA for osteoarthritis are excellent in terms of improved clinical function and pain relief.

Preformulation studies on the S-isomer of oxybutynin hydrochloride, an Improved Chemical Entity (ICE).

(S)-Oxybutynin HCl (S-OXY) is a white crystalline solid powder with an acicular particle morphology. Differential scanning calorimetry (DSC) thermograms revealed one characteristic endotherm at 116.2 degrees C. On rescanning a sample heated to 120 degrees C, no thermal events were distinguished in the temperature range 25 degrees C to 150 degrees C. Weight loss curves determined by thermogravimetric analysis showed a continuous, gradual weight loss of about 0.15% over the temperature range 30 degrees C to 110 degrees C, followed by a change in slope and more rapid weight loss beginning at 150 degrees C. Observation by hot-stage microscopy confirmed the melting endotherm observed by DSC. Equilibrium moisture uptake studies indicated low water vapor uptake at low relative humidities (<52.8%). At relative humidities of 75.3% and 84.3%, S-OXY first deliquesced and then converted to a lower melting point crystal form. X-ray powder diffraction (XRPD) data supported the DSC findings. S-OXY underwent degradation by ester hydrolysis at alkaline pHs. The kinetics of this reaction were studied at 25 degrees C in carbonate-bicarbonate buffers. Observed rate constants of 0.008 h(-1) and 0.0552 h(-1) were determined at pH 9.69 and 10.25, respectively. The pKa of S-OXY was 7.75. The aqueous solubility of S-OXY was described as a function of pH and the free-base solubility. The mean partition coefficient log P was 3.33 using 1-octanol. The surface tensions of aqueous solutions of S-OXY decreased with increasing concentration, but no concentration-independent region was observed, indicating that S-OXY does notform micelles in aqueous solution. The dissolution rate of S-OXY from a compressed disk in 0.1 N HCl was rapid, whereas it was considerably slower at pH 7.4. Addition of 1% hexadecyltrimethylammonium bromide (CTAB) at pH 7.4 significantly improved the dissolution rate. S-OXY displayed very poor flow properties when compared to standard pharmaceutical excipients. XRPD results indicated that S-OXY exhibited a loss in crystallinity following ball milling. Hiestand tableting indices indicated that S-OXY has good bonding properties andforms strong compacts, but is likely to be susceptible to capping on ejection from the die. This indicated the needfor a plastically deformable excipient such as Avicel PH-101 in tablet formulations.

Long-term results of Kinematic Condylar knee replacement. An analysis of 404 knees.

We present the long-term results of the Kinematic Condylar Knee Arthroplasty followed in a prospective fashion. Between October 1982 and March 1988, 404 consecutive replacement arthroplasties were carried out on 335 patients. Of these, 354 knees had osteoarthritis, 45 rheumatoid arthritis and five other diagnoses. At the time of final follow-up 158 patients (188 knees) had died. No patient was lost to follow-up. The minimum follow-up for all living patients was ten years (10 to 17). The mean age at surgery was 68 years (30 to 92). There were seven complications (1.7%). Sixteen knees (3.9%) were revised, four because of infection. Survivorship was 99.4% (CI 97.9 to 99.8) at five years, 98.2% (CI 96.1 to 99.2) at ten years and 92.6% (CI 87.6 to 95.6) at 17 years.

Long-term results of retention of the posterior cruciate ligament in total knee replacement in rheumatoid arthritis.

We analysed the long-term results with a mean follow-up of 10.2 years, of 66 total knee replacements in 42 patients with rheumatoid arthritis. In all cases the posterior cruciate ligament was retained. There were only three complications (4.5%). Revision surgery was necessary in five knees (7.6%), including one (1.5%) with infection. At the final follow-up, 75.8% of knees were rated excellent clinically. Only 15% had an excellent function score. The survival rate of the implant was 90.7% at 19 years. The clinical, radiological and survivorship analysis shows that the posterior-cruciate-retaining knee arthroplasty performs well in rheumatoid arthritis.

The degradation pathways of glucagon in acidic solutions.

OBJECTIVE: Glucagon is a 29 amino acid peptide hormone that exhibits degradation via both chemical and physical pathways. The objective of the studies reported herein was to identify the degradation products and scheme for glucagon hydrolysis in acidic solutions. METHODS: Solutions of glucagon in 0.01 N HCl (pH 2.5) were degraded at 60 degrees C for 70 h. One isocratic and two gradient RP-HPLC methods were developed to separate the degradation products. Structure elucidation of the separated peaks was achieved using amino acid sequencing, amino acid analysis, and mass spectrometry. Degradation was carried out in the pH range 1.5-5 to check for changes in degradation scheme with pH. Authentic samples of degradation products were degraded under similar acidic conditions to confirm precursor successor relationships in the degradation scheme. RESULTS: Sixteen major degradation products were isolated and identified. The major pathways of degradation were found to be aspartic acid cleavage at positions 9, 15, and 21 and glutaminyl deamidation at positions 3, 20, and 24. Cleavage occurred on both sides of Asp-15 but only on the C-terminal side of Asp-9 and Asp-21. Deamidation of the Asn residue at position 28 was not detected.

Use of the recombinant K39 dipstick test and the direct agglutination test in a setting endemic for visceral leishmaniasis in Nepal.

We evaluated the field use of two serologic tests for visceral leishmaniasis (VL), the direct agglutination test (DAT) and rK39 dipstick test, in the context of a case-control study. Most VL cases in Nepal are currently diagnosed on clinical grounds and with relatively non-specific tests such as the formol-gel test. Among 14 newly diagnosed VL patients with bone-marrow slides confirmed positive in two independent laboratories, the sensitivity of both tests was 100%. Among 113 controls with no personal or household history of VL, the specificity of the rK39 was 100% while that of the DAT was 93%. The rK39 was less expensive than DAT, and has the advantages of ease of use and obtaining results within minutes. The wider use of the rK39 dipstick test could improve the specificity of VL diagnosis in Nepal.