Knowledge, attitudes and practices regarding respirable silica exposure and personal protective equipment use among brick kiln workers in Nepal.

OBJECTIVES: Brick kiln workers in Nepal are a neglected population who are exposed to high respirable silica concentrations, and few use interventions to reduce exposure. We aimed to characterise the prevalence of respiratory personal protective equipment (PPE) use, understand knowledge and attitudes towards kiln dust and respiratory PPE and identify factors associated with respiratory PPE use. METHODS: We conducted a cross-sectional study in Bhaktapur, Nepal. We used simple random selection to identify 10 out of 64 total kilns and stratified random sampling of 30 households to enrol workers aged ≥14 years within selected kilns. Field workers surveyed participants using structured questionnaires. Our primary outcome was to characterise the prevalence of current respiratory PPE use and secondary outcomes were summaries of knowledge, attitudes and practice of PPE use. RESULTS: We surveyed 83 workers (mean age 30.8 years, 77.1% male). Of these, 28.9% reported current respiratory PPE use at work, 3.6% heard of silicosis prior to the survey and 24.1% correctly identified the best respiratory PPE (N95, compared with surgical masks and barrier face coverings) for reducing dust exposure. Respiratory PPE users had higher income (mean monthly household income US$206 vs US$145; p=0.04) and education levels (25% vs 5.1% completed more than primary school; p=0.02) compared with non-users. CONCLUSIONS: Respiratory PPE use was low. Workers had poor knowledge of kiln dust health effects and proper respiratory PPE. We highlight important barriers to PPE use, particularly knowledge gaps, which can guide future investigations to reduce the silicosis burden among brick kiln workers.

Triage practices for emergency care delivery: a qualitative study among febrile patients and healthcare workers in a tertiary care hospital in Nepal.

BACKGROUND: Improving screening and triage practices is essential for early severity assessments at the first point of contact and ensuring timely attention by healthcare workers (HCWs). The main objective of this study was to explore the triage process among febrile patients and HCWs in the emergency department (ED) of a tertiary care hospital in a resource-constrained setting. METHODS: This qualitative study was conducted from March to May 2023 at the ED of Tribhuvan University Teaching Hospital (TUTH), Nepal. The study included in-depth interviews with febrile patients (n = 15) and HCWs (n = 15). Additionally, direct observation notes (n = 20) were collected to document the triage process and patients' experiences in the ED. Data underwent thematic analysis using the Interpretative Phenomenological Analysis (IPA) approach. RESULTS: The ED of TUTH offered comprehensive triage services with clear delineation for the severity of febrile patients in line with the World Health Organization (WHO) guidelines. Nonetheless, challenges and constraints were identified. In the ED, evenings were generally the busiest period, and the triage process was not thorough during night shifts. Perception of triage was limited among patients and variable among HCWs. Digitalizing recordings of patient information including payment was deemed necessary for effective management of patients' waiting times at the triage station. High patient throughput added pressure on HCWs and had a potential influence on the delivery of services. Availability of medical equipment and space were also identified as challenges, with patients sometimes compelled to share beds. There were constraints related to waste disposal, hygiene, cleanliness, and the availability and maintenance of washrooms. Febrile patients experienced delays in receiving timely consultations and laboratory investigation reports, which affected their rapid diagnosis and discharge; nonetheless, patients were satisfied with the overall healthcare services received in the ED. CONCLUSIONS: Improving current triage management requires resource organization, including optimizing the waiting time of patients through a digitalized system. Urgent priorities involve upgrading visitor facilities, patient consultations, laboratory investigations, hygiene, and sanitation. HCWs' recommendations to resource the ED with more equipment, space, and beds and a dedicated triage officer to ensure 24-hour service, together with training and incentives, warrant further attention.

Chronic Obstructive Pulmonary Disease Self-Management in Three Low- and Middle-Income Countries: A Pilot Randomized Trial.

Objectives: Chronic obstructive pulmonary disease (COPD) disproportionately affects low- and middle-income countries. Health systems are ill prepared to manage the increase in COPD cases. Methods: We performed a pilot effectiveness-implementation randomized field trial of a community health worker (CHW)-supported, 1-year self-management intervention in individuals with COPD grades B-D. The study took place in low-resource settings of Nepal, Peru, and Uganda. The primary outcome was the St. George's Respiratory Questionnaire (SGRQ) score at 1 year. We evaluated differences in moderate to severe exacerbations, all-cause hospitalizations, and the EuroQol score (EQ-5D-3 L) at 12 months. Measurements and Main Results: We randomly assigned 239 participants (119 control arm, 120 intervention arm) with grades B-D COPD to a multicomponent, CHW-supported intervention or standard of care and COPD education. Twenty-five participants (21%) died or were lost to follow-up in the control arm compared with 11 (9%) in the intervention arm. At 12 months, there was no difference in mean total SGRQ score between the intervention and control arms (34.7 vs. 34.0 points; adjusted mean difference, 1.0; 95% confidence interval, -4.2, 6.1; P = 0.71). The intervention arm had a higher proportion of hospitalizations than the control arm (10% vs. 5.2%; adjusted odds ratio, 2.2; 95% confidence interval, 0.8, 7.5; P = 0.15) at 12 months. Conclusions: A CHW-based intervention to support self-management of acute exacerbations of COPD in three resource-poor settings did not result in differences in SGRQ scores at 1 year. Fidelity was high, and intervention engagement was moderate. Although these results cannot differentiate between a failed intervention or implementation, they nonetheless suggest that we need to revisit our strategy. Clinical trial registered with www.clinicaltrials.gov (NCT03359915).

Association of vaccination status with the clinicobiochemical profile, hospital stay, and mortality in COVID-19: A case-control study.

Background and Aims: The effectiveness of coronavirus disease 2019 (COVID-19) vaccines in reducing symptoms, disease advancement, complications, and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been well-established. This case-control study aimed to compare different blood parameters, and prognostic and survival outcomes of COVID-19 patients based on vaccination status. Methods: We performed a case-control study that included hospitalized patients with COVID-19 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Individuals who received vaccination were designated as cases and unvaccinated individuals as controls. Demographics, co-morbidity, clinical data, laboratory data, and disease outcomes were recorded for both groups. Multivariate, Cox, and linear regression were used for analysing blood parameters, hospital admission, survival, and hospital stay, respectively, between cases and controls. Results: Out of 100 participants enrolled, 46 were vaccinated, and 54 weren't. At admission, ferritin and erythrocyte sedimentation rate (ESR) were significantly lower in cases. At discharge, cases showed a higher monocyte than controls. Ferritin, ESR, and d-imer showed excellent performance in determining the severity of symptoms. Significant correlation and regression of ferritin and ESR with the length of hospital stay was observed. Length of hospital stay was significantly lower in cases than in controls. No significant differences between cases and controls were observed in mortality. Conclusion: COVID-19 vaccines effectively reduced hospitalization duration. Ferritin and ESR were significantly lower in vaccinated individuals and showed the best utility in monitoring the disease.

Prevalence and clinical impact of anemia in patients diagnosed with chronic obstructive pulmonary disease: A cross-sectional study.

Background and Aims: Unlike classically described polycythemia, anemia is found to be more prevalent in patients with chronic obstructive pulmonary disease (COPD). Anemia increases the cost of hospital stay and causes an increased risk of adverse outcomes including death in COPD patients. This study was done to find the prevalence of anemia in COPD patients, the factors associated, and the outcomes of anemic COPD. Methods: It was a quantitative, descriptive-analytical, and cross-sectional study conducted in Tribhuvan University Teaching Hospital's medical wards and the Emergency Room from September 2019 to September 2020. A simple random sampling method was used. Clinical information was obtained, and patients were followed up 3 months after discharge to document the number of exacerbations and deaths if present. Results: The patients in our study had a mean age of 70.80 ± 11.16 years. Most were female. Most (85.5%) had a history of exposure to firewood smoke. Twenty-three percent of the patients had anemia and these patients had significantly greater mortality 3 months postdischarge. Middle-old and old were more likely to have anemia with odds ratio (OR) of 2.55 (confidence interval [CI]: 0.48-13.5) and 13.6 (CI: 1.12-24.2), respectively. Current smokers had less likelihood of having anemia (OR: 0.05, CI: 0.006-0.49). Multivariate analysis showed that age, sex, and smoking status were significant determinants of anemia in COPD. There was no association between anemia and duration of hospital stay. However, mortality was higher at 3 months in COPD patients with anemia (p < 0.001). Conclusion: In COPD patients, anemia is prevalent comorbidity that is significantly linked to higher mortality but not to exacerbations. It is unknown, though, if treating anemia in COPD patients will affect the patient's outcome. Additional research in this area may be possible.

Accumulation of IL-12-activated antitumor effector cells into lymph nodes of tumor-bearing mice.

Simultaneous administration of high dose of IL-12 into tumor-inoculated mice resulted in a marked reduction of tumor growth in parallel with the augmented generation of cytotoxic T-cells, natural killer (NK) cells and IFN-gamma-producing Th cells. We found that these IL-12-activated antitumor effector cells preferentially accumulated in peripheral lymph nodes concomitantly with lymphadenopathy. However, IL-12 rather induced disappearance of antitumor effector cells including CD4+ T, CD8+ T and NK cells from spleen in spite of inducing splenomegaly. Lymph node cells obtained from IL-12-treated B16F0-bearing mice showed a marked IFN-gamma production in response to not only IL-2, IL-12, anti CD3 mAb but also B16F0 melanoma cells. Moreover, they could lyse B16F0 melanoma cells in a long-term cytotoxicity assay. It was also confirmed that IL-12-activated IFN-gamma producing Th1 cells were accumulated in tumor local site. Thus, IL-12 appeared to have a capability of stimulating selective migration of antitumor cells into lymph nodes and tumor local sites.

The role of phorbol ester-sensitive protein kinase C isoforms in lymphokine-activated killer cell-mediated cytotoxicity: dissociation between perforin-dependent and Fas-dependent cytotoxicity.

Treatment of lymphokine-activated killer (LAK) cells with phorbol ester (PMA) caused the downmodulation of LAK activity concomitantly with the inhibition of serine esterase (SE) release, which has been shown as a marker for perforin-dependent cell-mediated cytotoxicity. The reduction of perforin-dependent LAK activity by PMA-treatment appeared to be due to the disappearance of PMA-sensitive protein kinase C (PKC) isoforms such as PKC alpha, gamma, epsilon, theta. In contrast, Fas-mediated LAK activity was refractory against PMA-induced downregulation. Treatment of LAK cells with PMA caused a disappearance of cytotoxicity against Fas L5178Y tumor cells, while cytotoxicity against Fas+ transfectants was not affected by PMA treatment. Moreover, Fas-mediated LAK activity of perforin-knockout mice was not inhibited by PMA treatment. These results clearly demonstrated that Fas-mediated cytotoxicity could be dissociated from perforin-mediated cytotoxicity by their different requirement of PMA-sensitive PKC isoforms.

Involvement of IL-4-producing Vbeta8.2+ CD4+ CD62L- CD45RB- T cells in non-MHC gene-controlled predisposition toward skewing into T helper type-2 immunity in BALB/c mice.

It was found that freshly isolated BALB/c CD4+ T cells produced high levels of IL-4 and IL-10 in response to immobilized anti-CD3 mAb, while C57BL/6 CD4+ T cells produced low amounts of IL-4 and IL-10. The high IL-4-producing ability of BALB/c mice was demonstrated to be genetically dominant and it was controlled by non-MHC gene (or genes). The cells responsible for IL-4 production in BALB/c mice were defined as TCRVbeta8.2+ CD4+ CD62L- CD45RB- memory-type T cells, which were distinct from NK1.1+ CD4+ NKT cells. Although these memory-type T cells were also detected in C57BL/6 mouse spleen at the same frequency, they showed a functionally different property from BALB/c CD4+ CD62L- CD45RB- T cells in terms of IL-4 production. The fact that germfree BALB/c mouse spleen cells also produced high levels of IL-4 suggested that the IL-4 producer in BALB/c mice might be developed under the influence of unknown factors other than environmental Ags. The CD4+ CD62L- CD45RB- T cells obtained from BALB/c mice accelerated the development of IL-4-producing memory-type CD4+ T cells from CD4+ CD62L+ CD45RB+ naive T cells prepared from OVA-specific TCR-transgenic mice. Therefore, IL-4-producing CD4+ CD62L- CD45RB- T cells might play an important role in the preferential induction of Th2-dominant immunity in BALB/c mouse strain.

Manipulation of Th1/Th2 balance in vivo by adoptive transfer of antigen-specific Th1 or Th2 cells.

We have investigated the possibility that the Th1/Th2 balance in vivo may be modulated by adoptive transfer of Th1 or Th2 cells induced in vitro. Thl cells were induced from I-Ad-binding OVA323-339-specific T-cell receptor-transgenic (TCR-Tg) mouse spleen cells by culturing with OVA323-339 peptide and antigen presenting cells (APC) in the presence of IL-2, IL-12 and anti-IL-4 mAb. Th2 cells were induced from TCR-Tg mouse spleen cells by culturing with IL-2, IL-4 and anti-IL-12 mAb in addition to OVA323-339 plus APC. Immunomodulating activities of both Th1 and Th2 cells were determined by their effect on delayed type hypersensitivity (DTH) responses or cytokine production. No significant DTH responses (footpad swelling) were observed in untreated BALB/c mice following a single injection of OVA323-339-pulsed syngeneic spleen cells. However, adoptive transfer of Th1 cells into BALB/c mice induced strong dose dependent DTH responses in response to I-Ad-bound OVA323-339 but not unrelated peptide. In contrast, only slight DTH responses were detected in BALB/c mice transferred with Th2 cells. In parallel with the DTH responses, increased levels of serum IFN-gamma were demonstrated in mice adoptively transferred with Th1, while no significant increase was observed in Th2-transferred mice. In vitro analysis also demonstrated that both spleen cells and popliteal lymph node cells prepared from Th1-transferred mice showed Th1-type cytokine production, while cells obtained from Th2-transferred mice revealed Th2-dominant cytokine production. Such immune deviation induced by antigen-specific Th1 cells was demonstrated up to three months after cell transfer. Therefore, it may be possible to manipulate the Th1/Th2 balance in vivo by adoptive transfer of antigen-specific Th1 or Th2 cells.

Functional characterization of NK1.1 + Ly-6C+ cells.

It was found that NK1.1+ cells were subdivided by their different expression pattern of Ly-6C antigen. To characterize their functional significance in immunoregulation, we separated NK1.1 + Ly6C+ cells and NK1.1 + Ly-6C- cells from C57BL/6 mouse nylon-passed spleen cells by FACStar. Both NK1.1 + Ly-6C+ and NK1.1 + Ly-6C- cells responded to the stimulation with IL-2 plus IL-12 and showed strong cytotoxicity against YAC-1 cells. However, these cells revealed different ability in terms of IFN-gamma production. Only NK1.1 + Ly-6C+ cells, but not NK1.1 + Ly-6C- cells, cultured with IL-12 alone or IL-2 plus IL-12, produced high levels of IFN-gamma. Flow cytometric analysis demonstrated that NK1.1 + Ly-6C+ cells consisted of NK1.1 + CD3-Ly-6C+ NK cells and NK1.1 + CD3 + Ly-6C+ NKT cells. Therefore, we further separated these two populations from NK1.1 + Ly-6C+ cells to define their functions. Although, both NK1.1 + CD3-Ly-6C+ NK cells and NK1.1 + CD3+ NKT cells showed the same level of cytotoxicity. It was clearly demonstrated that NK1.1 + CD3+Ly-6C+ NKT cells were major immunoregulatory cells to produce IFN-gamma in respond to IL-12 alone or IL-2 plus IL-12.

Murine asialo GM1+CD8+ T cells as novel interleukin-12-responsive killer T cell precursors.

Freshly isolated CD8+ T cells, but not CD4+ T cells, contained 20-30% of asialo GM1+ (ASGM1+) T cells which were distinct from ASGM1+NK1.1+ natural killer cells. This novel ASGM1+CD8+ T cell subpopulation showed a strong proliferative response to interleukin-12 (IL-12) in the presence of IL-2. Culture of ASGM1+CD8+ T cells with IL-12 plus IL-2 allowed the generation of anomalous killer T cells concomitantly with the accumulation of cytolytic molecules. Moreover, ASGM1+CD8+ T cells produced high levels of interferon-gamma (IFN-gamma), but not IL-4, upon stimulation with IL-12 plus IL-2. Such immune responses were not observed in ASGM1-CD8+ T cell subpopulations constituting the majority of CD8+ T cells. These results demonstrated that ASGM1+CD8+ T cells are a novel subpopulation of IL-12-responsive and IFN-gamma-producing killer T cell precursors.