Surgical Service Utilization and In-Patient Satisfaction in Surgical Service.

BACKGROUND: The patient satisfaction study is an important and commonly used valid indicator for service quality improvement in healthcare institutions. The aim of this study was to assess the service utilization and patient satisfaction in patients admitted under surgical service in Bir Hospital. METHODS: A prospective cross sectional analytical study was conducted in Bir Hospital, National Academy of Medical Sciences from February 2021 till June 2023. The patient satisfaction data was collected using the SAPS scale after obtaining ethical clearance from the Institutional Review Board. Data were entered and analyzed in Statistical Package for the Social Sciences version 20.0. RESULTS: There were 152 patients included in the study categorized into conservative treatment group, elective surgery group and emergency surgery group. 32.9%(50) patients were "very satisfied", 62.5%(95) patients were "satisfied", 2.6%(4) were "neither satisfied nor dissatisfied" and 2%(3) were "dissatisfied" with the effect of their treatment/care. The mean satisfaction score in conservative treatment group was 22.13 ±2.53 as compared to the mean satisfaction in elective surgery group which was 21.11± 2.55 (P=0.036) and the mean satisfaction score in emergency surgery group which was 21.66 ±2.68 (P=0.64). CONCLUSIONS: The mean score and proportion of patient satisfaction regarding service utilization in patients admitted under surgical service were high with satisfaction score higher in emergency surgery group among the operative groups in Bir Hospital, National Academy of Medical Sciences.

Effects of a dietary intervention on cardiometabolic risk and food consumption in a workplace.

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

Phytochemistry, Biological, and Toxicity Study on Aqueous and Methanol Extracts of Chromolaena odorata.

The medicinal plant Chromolaena odorata is traditionally used by people living in different communities of Nepal and the globe against diabetes, soft tissue wounds, skin infections, diarrhea, malaria, and several other infectious diseases. The present study focuses on the qualitative and quantitative phytochemical analyses and antioxidant, antidiabetic, antibacterial, and toxicity of the plant for assessing its pharmacological potential. The extracts of flowers, leaves, and stems were prepared using methanol and distilled water as the extracting solvents. Total phenolic content (TPC) and total flavonoid content (TFC) were estimated by using the Folin-Ciocalteu phenol reagent method and the aluminum chloride colorimetric method. Antioxidant and antidiabetic activities were assessed using the DPPH assay and α-glucosidase inhibition assay. A brine shrimp assay was performed to study the toxicity, and the antibacterial activity test was performed by the agar well diffusion method. Phytochemical analysis revealed the presence of phenols, flavonoids, quinones, terpenoids, and coumarins as secondary metabolites. The methanol extract of leaves and flowers displayed the highest phenolic and flavonoid content with 182.26 ± 1.99 mg GAE/g, 128.57 ± 7.62 mg QE/g and 172.65 ± 0.48 mg GAE/g, 121.74 ± 7.06 mg QE/g, respectively. The crude extracts showed the highest DPPH free radical scavenging activity with half maximal inhibitory concentration (IC50) of 32.81 ± 5.26 µg/mL and 41.00 ± 1.10 µg/mL, respectively. The methanol extract of the leaves was found to be effective against bacterial strains such as K. pneumoniae (ZOI = 9.67 ± 0.32 mm), B. subtilis (ZOI = 15.00 ± 0 mm), and E. coli (7.3 ± 0.32 mm). The methanol extract of the flowers showed the most α-glucosidase inhibitory activity (IC50 227.63 ± 11.38 µg/mL), followed by the methanol extract of leaves (IC50 249.50 ± 0.97 µg/mL). The aqueous extract of the flowers showed the toxic effect with LC50 107.31 ± 49.04 µg/mL against the brine shrimp nauplii. In conclusion, C. odorata was found to be a rich source of plant secondary metabolites such as phenolics and flavonoids with potential effects against bacterial infection, diabetes, and oxidative stress in humans. The toxicity study showed that the aqueous extract of flowers possesses pharmacological activities. This study supports the traditional use of the plant against infectious diseases and diabetes and provides some scientific validation.

How We Do It: Whole Lung Lavage.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by the accumulation of surfactant in the alveolar spaces resulting in hypoxemic respiratory failure. Whole lung lavage (WLL), the preferred treatment for PAP, physically removes the lipoproteinaceous material from the alveolar spaces. Since its initial description in 1963, the WLL procedure has undergone various modifications. However, the procedure has not been standardized yet. After securing a double lumen endotracheal tube, we perform WLL under general anesthesia. One lung is ventilated, while the other is lavaged using one-liter aliquots of pre-warmed saline. We use gravity-assisted drainage of the lavaged lung after each cycle till the milky white and opaque fluid becomes clear (usually 15-20 cycles). Herein, we describe the step-by-step procedure, precautions, and monitoring of WLL. We also provide videos demonstrating one-lung ventilation and bronchoscopic confirmation of lung isolation.

Autoimmune pulmonary alveolar proteinosis and sarcoidosis in the same patient: Case report and systematic review.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder characterized by surfactant accumulation in the alveolar spaces while sarcoidosis is a multisystem granulomatous disease of unknown etiology. The occurrence of PAP and sarcoidosis in the same patient is rare. A 37-year-old woman presented with cough and breathlessness and was diagnosed to have autoimmune PAP. She responded well to subcutaneous injections of recombinant granulocyte macrophage colony stimulating factor. Three years later, she developed fever, chest pain, cough, and facial palsy. The evaluation revealed a diagnosis of sarcoidosis that responded to immunosuppressive treatment. We discuss the link between PAP and sarcoidosis and review the literature on this association.

Extensive-disease small cell lung cancer, multiple relapses, five lines of therapy and more than 10-year survival.

Small cell lung cancer (SCLC) accounts for nearly 18% of lung cancer cases. Most of the patients of SCLC are not surgical candidates, due to advanced stage at presentation hence only viable options are chemotherapy and radiotherapy. Long-term survival in SCLC is extremely rare due to relapses and comorbidities. Ten-year survival has never been reported in cases with extensive disease at presentation and history of relapses. Here we are describing a case of extensive disease SCLC who has survived multiple relapses and has received five lines of systemic therapy apart from radiation and palliative care. This case emphasises on the need of active and strict disease surveillance at each follow-up.

Factors Affecting Psychological Burden on the Informal Caregiver of Patients With Cirrhosis: Looking Beyond the Patient.

BACKGROUND AND AIMS: Cirrhosis leads to considerable morbidity and mortality, compromises quality of life, and often necessitates assistance in activities of daily living. An informal caregiver bears the psychological burden of coping with the needs of the patient and the knowledge of morbid prognosis of a loved one. This aspect is rarely recognized and almost never addressed in a clinical practice. METHODS: This cross-sectional study assessed the factors influencing psychological burden of cirrhosis on the caregivers in a predominantly lower-middle socioeconomic class Indian population. Patients underwent psychometric tests [Psychometric Hepatic Encephalopathy Score (PHES)], and questionnaires for quantifying caregiver burden [Perceived Caregiver Burden (PCB) and Zarit Burden Interview (ZBI)] and assessing depression [Beck Depression Inventory (BDI)] and anxiety [Beck Anxiety Inventory (BAI)] were administered. RESULTS: One hundred patients with cirrhosis [70% male, 27% with past hepatic encephalopathy (HE), and 53% with minimal HE] and their caregivers (66% women, 81% spouse, 26.51 years of mean relationship) were evaluated. Caregiver burden scores were higher in patients with previous overt HE than in those without previous overt HE [PCB (74.63 vs. 66.15, P = 0.001), ZBI (27.93 vs. 21.11, P = 0.023), BDI (11.63 vs. 8.96, P = 0.082), and BAI (11.37 vs. 8.12, P = 0.027)]. Similarly, caregivers of patients with minimal HE had higher caregiver burden that those of patients who did not have minimal HE [PCB (70.74 vs. 65.85, P = 0.027), ZBI (26 vs. 19.51, P = 0.015)]. Burden scores correlated well with each other and with liver disease severity scores and negatively correlated with socioeconomic status. Repeated hospital admissions, alcohol as etiology, and lower socioeconomic status were the independent predictors of caregiver burden. CONCLUSION: Higher perceived burden is common in caregivers of patients with cirrhosis. Repeated hospital admissions, alcoholism, and lower socioeconomic status influence caregiver burden.

Seed germination ecology of Ageratum houstonianum: A major invasive weed in Nepal.

In recent years, spread of invasive alien plant species (IAPS) has been a major concern in Nepal. One such IAPS is Ageratum houstonianum, an Asteraceae, that is a prolific seed producer and difficult-to-control in farmland and various ecological regions causing crop yield and biodiversity losses. However, very little information is available on the germination biology and ecology of this species. Therefore, experiments were conducted to assess the effect of water stress, pH level, and light requirement on seed germination, and the effect of seed burial depth on seedling emergence. Water stress was simulated by polyethylene glycol solutions ranging from 0-5.56 MPa and pH solutions ranging from 4 to 9 were prepared using hydrochloric acid and sodium hydroxide. Germination tests were conducted in petri dishes lined with filter paper and placed in a controlled environment chamber set at 20° C. Light requirement comparisons were made by having petri dishes wrapped with aluminum foil or left unwrapped. Seedling emergence was evaluated by placing seeds at depths ranging from 0 to 20 mm in the soil. Results indicated that this species was moderately drought-tolerant because germination ceased beyond 0.51 MPa. Greater germination occurred at neutral to acidic than at alkaline pH levels. The seeds were positively photoblastic because no germination occurred under dark condition. No seedlings emerged from seeds placed more than 2 mm deep in the soil, indicating that this is a primarily surface germinating species. These findings will help predict future invasions and in development of management strategies for this IAPS.

IMFT of the sigmoid colon: a case report.

Inflammatory myofibroblastic tumor (IMFT) of the colon is a very rare entity, characterized by proliferation of myofibroblast cells admixed with inflammatory infiltrates. The entity was first described in the late 1990s, and since then less than 30 cases have been described. It frequently mimics other neoplasm of the colon, such as adenocarcinoma, lymphoma and stromal tumor, and is very difficult to clinch the diagnosis preoperatively based on the clinical and radiological findings. Here, we discuss an uncommon case of sigmoid IMFT in a 35-year old male, presenting with bleeding per rectum and managed successfully by colectomy.

Implantation cutaneous tuberculosis after ultrasound-guided fine needle aspiration cytology.

A 45-year-old female presented with recurrent biliary pain, fever, anorexia and weight loss of 3 months duration. She was on highly active antiretroviral therapy for underlying human immunodeficiency virus infection for the past 5 months. Clinical examination revealed a 3-cm firm hepatomegaly. Investigations suggested mild anaemia, elevated erythrocyte sedimentation rate, deranged liver function tests, Mantoux test of 25 mm and CD4 count of 417 cells µl-1. Ultrasonography revealed mild central intrahepatic biliary radical dilatation with a dilated common bile duct and multiple periportal and peripancreatic lymph nodes. Ultrasound-guided fine needle aspiration cytology (FNAC) from the periportal lymph node was performed twice. Both were reported as only bloody aspirate. The patient developed an erythematous tender skin nodule at the site of insertion of the FNAC needle 15 days after the second FNAC procedure. An excision biopsy of the nodule showed ill-formed epithelioid cell granulomas with acid-fast bacilli, indicating tuberculosis. The patient was started on antitubercular therapy with complete response.

Down-regulation of replication factor C-40 (RFC40) causes chromosomal missegregation in neonatal and hypertrophic adult rat cardiac myocytes.

BACKGROUND: Adult mammalian cardiac myocytes are generally assumed to be terminally differentiated; nonetheless, a small fraction of cardiac myocytes have been shown to replicate during ventricular remodeling. However, the expression of Replication Factor C (RFC; RFC140/40/38/37/36) and DNA polymerase δ (Pol δ) proteins, which are required for DNA synthesis and cell proliferation, in the adult normal and hypertrophied hearts has been rarely studied. METHODS: We performed qRT-PCR and Western blot analysis to determine the levels of RFC and Pol δ message and proteins in the adult normal cardiac myocytes and cardiac fibroblasts, as well as in adult normal and pulmonary arterial hypertension induced right ventricular hypertrophied hearts. Immunohistochemical analyses were performed to determine the localization of the re-expressed DNA replication and cell cycle proteins in adult normal (control) and hypertrophied right ventricle. We determined right ventricular cardiac myocyte polyploidy and chromosomal missegregation/aneuploidy using Fluorescent in situ hybridization (FISH) for rat chromosome 12. RESULTS: RFC40-mRNA and protein was undetectable, whereas Pol δ message was detectable in the cardiac myocytes isolated from control adult hearts. Although RFC40 and Pol δ message and protein significantly increased in hypertrophied hearts as compared to the control hearts; however, this increase was marginal as compared to the fetal hearts. Immunohistochemical analyses revealed that in addition to RFC40, proliferative and mitotic markers such as cyclin A, phospho-Aurora A/B/C kinase and phospho-histone 3 were also re-expressed/up-regulated simultaneously in the cardiac myocytes. Interestingly, FISH analyses demonstrated cardiac myocytes polyploidy and chromosomal missegregation/aneuploidy in these hearts. Knock-down of endogenous RFC40 caused chromosomal missegregation/aneuploidy and decrease in the rat neonatal cardiac myocyte numbers. CONCLUSION: Our novel findings suggest that transcription of RFC40 is suppressed in the normal adult cardiac myocytes and its insufficient re-expression may be responsible for causing chromosomal missegregation/aneuploidy and in cardiac myocytes during right ventricular hypertrophy.

Using focus groups to develop contingent valuation scenarios--a case study of women's groups in rural Nepal.

The construction of a contingent valuation (CV) scenario forms a critical component of willingness-to-pay (WTP) survey design, especially when working across diverse cultural and socio-economic settings. However, the methods used to develop CV scenarios have not been well reported in the health economics literature. This paper begins by describing how qualitative methods can be used to develop CV surveys. It then presents a case study illustrating how focus groups were used to develop a CV survey to value a women's group intervention in rural Nepal. A series of focus group discussions were conducted with three stakeholder groups. These were used to determine the most appropriate description of the good to be valued and the means by which payment would be elicited. These methods were very helpful in designing the survey tool and choosing the key attributes to describe the intervention. They also familiarised field workers with the concept of WTP. Further work of this kind will help to highlight additional advantages and limitations of qualitative approaches to survey design.