Maternal and Perinatal Outcome of Urinary Tract Infection in Pregnancy at Dhulikhel Hospital, Kathmandu University Hospital.

Background Urinary tract infection (UTI) is common in pregnancy and poses a great challenge because it has several adverse outcomes in both the mother and her unborn foetus. Objective This study aims to determine the incidence of culture positive urinary tract infection, culture and sensitivity of the common causative organisms and find out the maternal and perinatal outcomes in culture positive urinary tract infection. Method This prospective study was carried out in the Department of Obstetrics and Gynaecology at Dhulikhel Hospital over a period of one year. Urine routine and microscopy was done as a preliminary screening test for urinary tract infection and those with abnormal results were subjected to urine culture and sensitivity and ultrasonological evaluation. Result A total of 162 pregnant women were included in the study. Incidence of culture positive urinary tract infection was 25.9%, highest in age group 15-20 years (47.8%), more in primigravida (30.1%) and common at second trimester (40.4%). Escherichia coli (90.4%) was the commonest organism isolated and ceftriaxone was the most sensitive antibiotic. Patients with culture positive urinary tract infection had higher incidence of anaemia, preterm labour, need of surgical intervention. Such patients also had increased chances of preterm delivery, low birth weight babies and newborn intensive care unit (NICU) admission. Conclusion We conclude that urinary tract infection in pregnancy leads to adverse maternal and fetal outcomes. And we recommend urine culture and sensitivity at each trimester so that urinary tract infection can be diagnosed and treated on time.

Comparative Efficacy and Safety of Diacerein in Patients with Knee Osteoarthritis: A Pilot Study.

Background Osteoarthritis (OA) is the most common chronic rheumatic disease. The prevalence of OA is skyrocketing with time. Providing a proper treatment regimen for OA is also growing as a major public health challenge. Conventional pharmacological treatments are mainly for alleviating pain and have some severe adverse effects. Diacerein is a new oral anti-inflammatory drug especially developed for the management of OA having only mild to moderate adverse effects. However, the evidence of efficacy and safety of Diacerein in OA is not well documented and yet to be explored. Objective To compare the efficacy and safety of Diacerein in knee OA with conventional nonsteroidal anti-inflammatory drugs (NSAIDs). Method A comparative study was conducted among knee OA patients attending OutPatient Orthopedic department in Dhulikhel Hospital, Nepal from December 2019 to September 2020, using self-structured and standard questionnaire. The patients were randomized to receive either a conventional standard treatment (Treatment Group I: NSAIDs) or alternative treatment regimen (Treatment Group II: NSAIDS+ Diacerein). Patients were followed-up after two months and data were analyzed using SPSS 21.0. Result Among 72 patients enrolled in this study, majority (44.44%) were between 51-60 years of age in which 81.94% of the patients were female. Post treatment data was collected from 15 participants. The mean KOOS-PS score of the participants in Treatment Group I decreased from 35.56 ± 14.33 to 35.14 ± 12.65 while that of the Treatment Group II participants reduced from 63.31 ± 12.08 to 49.99 ± 13.10 in two months. Similarly, the mean WOMAC score decreased from 46.87 ± 17.80 to 34.37 ± 16.83 in Treatment Group I and from 54.23 ± 14.66 to 46.22 ± 12.16 in Treatment Group II. The mean Lysholm score in Treatment Group I increased from 55.57 ± 8.16 to 60.86 ± 15.01 and in Treatment Group II, it increased from 46.62 ± 13.01 to 60.25 ± 17.598. Conclusion Diacerein treatment group had better functional outcome compared to the patients in the treatment group with conventionally used drugs. Also, the adverse effects faced by the patients were minor. The current study are suggestive of better efficacy and safety of Diacerein compared to other drugs.

A Rare Case of Large Left Lateral Wall Vaginal Myoma.

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

Adherence to Iron, Folic Acid and Calcium Supplement and Factors Affecting it among the Antenatal Care Attending Women in a Tertiary Care Hospital: A Cross Sectional Study.

Background Pregnancy or gestation is the time during which a single or more children grows and develops inside a woman. Antenatal care improves the pregnancy outcomes under which a group of medication i.e. iron, folic acid and calcium are supplemented. Despite the effectiveness of such supplements, poor clinical outcomes are often encountered because of poor-adherence to the regimen. Objective To determine the adherence pattern and factors affecting adherence in antenatal care patients under iron, folic acid, and calcium therapy. Method A cross-sectional study was conducted in Dhulikhel Hospital, Kathmandu University Hospital. Pregnant women attending antenatal care under iron, folic acid, and calcium therapy fulfilling the inclusion criteria were enrolled in this study. After obtaining the informed consent from the patients, structured questionnaire was used to interview the patients. Statistical analysis was performed by using SPSS 23.0. P-value < 0.05 was considered as statistically significant. Result Among 191 patients enrolled in this study majority (39.3%) of them belonged to age group 26-30 years. More than half (61.3%) of the patients were illiterate. Of the total 191, 64.40% were non-adherent to the medication. Forgetfulness was the main reason for missing the dose in majority (52.06%) of the non-adherent subjects while adverse effects (55.40%) was the most prominent cause for discontinuing the medication among non-adherent participants. Significant association was found between patients' adherence and busy work schedule, visiting doctor for follow up. Conclusion More than half of the patients had not adhered to the medication under antenatal care. Forgetfulness was the most common factor for missing the dose in nonadherent patients. Illiteracy was associated with poor adherence. Patient-provider relationship, Socio-economic factors were determined as major barrier to medication adherence.

Control of Pelvic Blood Flow Using a Novel Pneumatic Abdominal Binder.

Background Obstetrical hemorrhage continues to be the leading cause of maternal death; additional means of treatment are needed to reach women who are currently not being saved. We developed the "Ball and Binder", an inexpensive and innovative pneumatic abdominal-pelvic compression device made with a cloth binder and soccer ball. Objective To measure the change in distal aortic blood flow before and after placement of the device. Method A comparative study was done on nine healthy volunteers measuring the flow in the distal aorta before and after placement of a pneumatic abdominal binder. Result Distal aortic flow decreased by over half when the device was inflated. Conclusion An inexpensive pneumatic external abdominal compression "Ball and Binder" device was able to decrease flow to the pelvis by over half. This provides an additional tool for rapid treatment of postpartum hemorrhage unresponsive to routine initial measures.

First Reported Death of a Postpartum Woman Due to Coronavirus Disease 2019 in Nepal: A Lesson Learnt.

The first case of coronavirus disease 2019 was reported on December 31, 2019 in Wuhan, China where the average case fatality rate was 6.1 ± 2.9%. There are 453 deaths as of September 24, 2020 in Nepal. We report the first death of a 29-years-old postpartum woman due to COVID-19 in Nepal who was referred from a rural health center to Dhulikhel Hospital. On arrival, she was taken to the acute respiratory zone of the emergency department to provide immediate lifesaving procedures. Despite the repeated resuscitative measures, return of spontaneous circulation could not be achieved. The real time polymerase chain reaction test was positive. Our case report highlights the importance of early clinical suspicion, importance of "safety first" in healthcare settings, and the chain of management in such patients. We consider the fact that a postpartum woman registered as the first case of COVID-19 related death in Nepal to be an area of further study.

Minimal Invasive Gynaecological Surgeries in Dhulikhel Hospital: One and Half Decade Long Experience.

Background One of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. Dhulikhel Hospital is one of the very few institutions in Nepal where minimal invasive gynaecological surgeries are being regularly performed since early years of its establishment. There are very few publications related to experiences of minimal invasive gynaecological surgeries published in Nepal. Objective To review the varieties of minimal invasive gynaecological surgeries and find out the different milestones those were crossed in this field. Method This is retrospective study of minimal invasive gynaecological surgeries performed from January 1, 2004 to June 30, 2018. Result A total of 1849 cases were performed by mid 2018. Almost half of the cases were of Brahmin/Chhetri caste (49.9%). Mean age of the patients who underwent gynaecological minimal invasive surgeries in DH was 36.70±10.60 years (with range 12-81 years). More than half of the patients were from Kavre (58.2%). Abnormal uterine bleeding, ovarian lesions and chronic pelvic pain were the most common indications for these procedures. Among these procedures, hysteroscopy (769 cases), diagnostic laparoscopy with or without chromotubation (385 cases), operative laparoscopy (419 cases) and LAVH/TLH (242 cases) were performed. In this study, 34 minimal invasive surgeries cases (1.8%) were converted to laparotomy for certain reasons. Of them eight cases were of laparoscopic hysterectomies. Only very few major and minor complications were experienced during this period. Conclusion Varieties of minimal invasive surgeries for various gynaecological problems were performed with minimal complications. We scaled up these minimal invasive surgeries over the period.

Persistence analysis of poliovirus on three different types of fomites.

AIMS: The goal of this study was to explore various models for describing viral persistence (infectivity) on fomites and identify the best fit models. METHODS AND RESULTS: The persistence of poliovirus over time was studied on three different fomite materials: steel, cotton and plastic. Known concentrations of poliovirus type 1 were applied to the surface coupons in an indoor environment for various lengths of time. Viruses were recovered from the surfaces by vortexing in phosphate buffer. Seven different mathematical models of relative persistence over time were fit to the data, and the preferred model for each surface was selected based on the Bayesian information criterion. CONCLUSIONS: While the preferred model varied by fomite type, the virus showed a rapid initial decay on all of the fomite types, followed by a transition to a more gradual decay after about 4-8 days. Estimates of the time for 99% reduction ranged from 81 h for plastic to 143 h for cotton. A 6 log reduction of recoverable infectivity of poliovirus did not occur during the 3-week duration of the experiment for any of the fomites. SIGNIFICANCE AND IMPACT OF THE STUDY: In protected indoor environments poliovirus can remain infective for weeks. The models identified by this study can be used in risk assessments to identify appropriate strategies for managing this risk.

Dysmenorrhea and Stress among the Nepalese Medical Students.

Background Dysmenorrhea is the most common gynecological disorder in women of reproductive age with implications as reduced quality of life and school absenteeism. Mental stress is possibly the most important known predisposing factor for primary dysmenorrhea. Objective This study aims to assess the relationship between stress and dysmenorrhea amongst the Nepalese medical students. Method This is cross-sectional descriptive study, conducted from 1st Dec. 2012 to 31st Jan. 2013. The study was conducted in Kathmandu University School of Medical Sciences. A total of 184 participants consented for this study and each one was given a questionnaire to complete. This study included only unmarried nulliparous, healthy (all through first to final years) female medical students, in age group of 16 to 24 years. Result The mean age of the participants was 19.43(±3.9) years. Among them, 67% of the participants experienced dysmenorrhea. Of them, 85% experienced increase in frequency and severity of dysmenorrhea after joining medical college. Similarly, 65% of participants considered medical education to be stressful. Of participants experiencing dysmenorrhea, 29.45% missed classes and 17.39% participants had positive family history of dysmenorrhea in first and second degree relatives. Conclusion The present study indicated a positive relationship between psychological stress and dysmenorrhea. Dysmenorrhea is the leading cause of recurrent short-term school absence in young ladies; this issue certainly needs to be addressed.

Imaging in Infertile Female Patients Who Underwent Hysterosalpingography Investigation at Dhulikhel Hospital.

Background Fallopian tube and uterine abnormalities are the most common cause of female infertility, accounting for 30% of cases. Hysterosalpingography is the safe, minimal invasive radiographic technique for evaluation of uterine cavity and fallopian tubes defects. The purpose of the study was to assess the various uterine and tubal abnormalities leading to infertility Objective To assess the abnormalities in uterus and fallopian tubes detected on Hysterosalpingography (as causative factors of infertility in a tertiary care centre for proper decision making in treatment. Method This is the prospective cross sectional study done in department of radiology Dhulikhel hospital, Kathmandu University Hospital between January 2015 to January 2016 with complain of infertility. Hysterosalpingography was performed using ionic contrast medium (10-20 ml of 76% urograffin) under digital fluoroscopy. Radiographic films were obtained and analyzed. Demographic data and radiological findings were reviewed and the obtained data analyzed with SPSS version 16. Result Out of the total 100 patient, 75 had primary infertility while 25 had secondary infertility. The age ranged from 19 to 43 years with mean age of 27.75 years. Normal Hysterosalpingography findings were seen in 37% cases. Tubal abnormalities were seen in 34%, uterine abnormalities in 23% and both tubal and uterine abnormalities in 6% patients. The most common tubal abnormality detected on Hysterosalpingography was tubal block 75%. Out of the 30 patients who had tubal block, unilateral block was noted in 76.7% patients whereas bilateral block was noted in 23.3%. Hydrosalphinx was seen in 25% cases with tubal abnormality. Among the 29 cases with various uterine abnormalities, bicornuate uterus 9% was the most common abnormality Conclusion Hysterosalpingography is an easily available radiographic procedure that can demonstrate a wide variety of uterine and tubal abnormalities for the initial assessment of infertility which can avoid unnecessary and sometimes more aggressive procedures.

Histopathological Changes in the Chorionic Villi and Endometrial Decidual Tissues in the Product of Conception of Spontaneous Abortion Cases.

Background Spontaneous abortion refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age or expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother. The Maternal Mortality Morbidity Survey of Nepal 2008/09 reported that 7% of maternal deaths in Nepal were due to complications related to abortion. Objective The main objective of this study was to examine the histopathological changes in the chorionic villi and endometrial decidual tissue in products of conception obtained from women with spontaneous abortion. Method This is a retrospective study of 111 patients admitted in the Department of Obstetrics and Gynecology at Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH) with the diagnosis of spontaneous abortion during the period of January 2013 to January 2014. Result Among 111 cases of spontaneous abortions, products of conception was seen in 73 (65.77%) and with only one cases of choriocarcinoma. Majority of cases belongs to age group 21-30 years. The most common decidual changes were inflammation (41.4%) followed by fibrin deposition 29.7%. Majority of the cases shows hydropic changes as histopathological changes in chorionic villi. In the present study, minimum age of lady was 15 years and the maximum age was 45 years and the mean age was 25.09±5.58 years at the time of abortion. Among the cases, maximum 69 (62.2%) of them belonged to age group 21-30 years. Correlating the age group with number of abortions was found to be significantly different (Chi-square= 92.35, df= 3, p < 0.001) among four different age groups. Conclusion The histopathological diagnosis of spontaneous abortion will help in further management of the patient. Further study is required to know the cause of different histopathlogical changes in villi as well as in the decidua.

Incidence of nuchal cord, mode of delivery and perinatal outcome: a notable experience in Dhulikhel Hospital - Kathmandu University Hospital.

With the advent of ultrasound as a means of providing quality antenatal care, there is an increase in the diagnosis of nuchal cord in fetuses. The major cause of foetal or neonatal death during labor and in postpartum period is birth asphyxia and tight nuchal cord is a cause of birth asphyxia. Whilst there are instances in which fetuses with 3 to 4 loops of cord around the neck have been delivered by normal vaginal delivery, some cases have to be delivered by caesarean section due to foetal distress caused by a single loop of cord around the neck. The reason for conducting this study was also to analyze the incidence and other aspects of nuchal cord. Dhulikhel Hospital labour registry was reviewed between Jan 2010 and Dec 2011. A total of 289 cases with at least one loop of nuchal cord were recorded as study case. For comparison, 965 controls were randomly selected from the 4219 unaffected singleton births delivered during the same time period. Of 1254 neonates, nuchal cord was present at 6.85% of deliveries (n = 289). Of these the incidence was 6.57% at preterm, 49.13% at term, 39.79% at postdated and 4.50% at postterm. A total of 151 had one loop and 138 had two or more loops. There was significant difference in the maternal age and birth weight of among three groups (control, with one loop and with two or more loops) in this study (p = 0.002) and (p = 0.000) respectively. However, the incidence was not affected by caste, parity, gestational age, antenatal site, neonatal intensive care unit admission and other perinatal complications. Most were primigravida (62.98%) and about 85.12% were delivered vaginally but caesarean section had to be done in 30 cases. And 2.8% cases required neonatal intensive care unit admission for prematurity. Obstetrician working in the periphery should refer the clients to a tertiary care center to confirm a suspicion of nuchal cord (non-engaged foetal head, decreased foetal movements, meconium stained liquor, foetal distress or malpresentation etc.) and also as a routine basis for ultrasound. Clients with confirmed complication should be managed in tertiary hospitals or institutions with the facility of ultrasound, cardiotocography and emergency surgery. This would improve the health of both the mother and fetus.

Nuchal translucency in normal fetus and its variation with increasing crown rump length (CRL) and gestational age.

BACKGROUND: Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies. OBJECTIVE: To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus. METHODS: Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis. RESULTS: The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p <0.001). There was increase in the incidence of NT thickness more than or equal to 2.5mm; 1.7% in fetus between 12-12.9 weeks of gestation to 15.1% in fetus between 14.0-14.9 weeks. CONCLUSION: Our study offers normative data of NT thickness in normal fetus, which can be used as reference to screen various chromosomal and congenital abnormalities between 11- 14 weeks of gestation. NT thickness increased with increasing CRL and a false positive rate increases with increasing gestational age.

Intrauterine foetal death and its probable causes: two years experience in Dhulikhel Hospital-Kathmandu University Hospital.

BACKGROUND: World health Organization definition of intrauterine foetal demise encompasses any abortion or fetal demise prior to expulsion from its mother, and recommends different protocols according to gestational age. However, conventionally and also in our institution, foetal demise prior to 28 weeks of gestation is managed as abortion in a manner different from foetal demise post 28 weeks of gestation. OBJECTIVE: To find the incidence and characteristics of pregnancies that resulted in stillbirths. METHODS A retrospective study, done in Dhulikhel Hospital, Kathmandu University Hospital in the year 2010 and 2011, among 4219 deliveries and 97 fetal deaths. Cases of multiple pregnancy and fetal death diagnosed by ultrasound before the 28th week of gestation were excluded. The included intrauterine foetal demise cases (n=90) were compared with a control group of randomly selected pregnancies (n=537) delivered during the same time period. Assumed predictors of stillbirth were examined through inferential ways (Chi square, t test) using SPSS Version 13.0 for Windows. RESULTS: Incidence of intrauterine foetal demise was 2.13% in the year 2010 and 2011. Mothers in the stillbirth group were slightly older than mothers of live-born infants (25.47±5.64 years vs 23.62±4.31 years, p value=0.000). A slightly higher proportion of women in the stillbirth group were of Tamang ethnic origin and primiparous (p=0.011, 0.000). Foetus expelled after IUFD had lower weight compared to live births, (2925.14±444.14 gram vs 2182.78±821.04 gram, p=0.000) for gestational age. The stillborn babies were generally born at an earlier gestational age, as would be expected (p=0.000). Incidence of intrauterine foetal demise gradually decreases as parity advances. The incidence was higher in patients receiving antenatal care outside Dhulikhel Hospital, Kathmandu University Hospital. CONCLUSIONS: While comparing the subject with the theme of the national conference of Nepal Society of Obstetricians and Gynaecologist, most of the cases were mother not receiving antenatal care or those receiving antenatal care in the periphery, There is no denying that there would be a massive improvement in women's health if the co-ordination between the peripheral health care center and tertiary care center was to be improved.

Preterm gestation along with partial hydatidiform mole and alive foetus.

Gestational trophoblastic disease encompasses a diverse group of lesion. If molar changes in the placenta are known along with an alive fetus then the situation is difficult to manage. We present successfully managed case of partial degeneration of placenta in molar pregnancy with an alive fetus at second stage of preterm labour.

A study on mode of delivery and conduct of labour in women with vaginal birth after caesarean section in Dhulikhel Hospital.

Vaginal birth after caesarean section is the delivery of a baby through the vagina after a previous cesarean delivery. For this to be conducted safely and responsibly emergency obstetric care must be available. To study the different modes of delivery in Dhulikhel Hospital (DH), evaluate the frequency of attempted and successful vaginal birth after caesarean section and, in the VBAC group, to identify those factors that may influence outcome and safety. The study was a retrospective study of all women who were delivered via different routes and the subgroup who underwent attempted vaginal birth after caesarean section in DH from January 2007 to December 2009. In this study factors associated with the successful VBAC were also analyzed. During the study period a total of 4215 deliveries conducted in DH and a total of 890 lower segment caesarean sections (21.1% of all deliveries) were performed. Of the 890 caesareans performed, 743 were primary and 147 were repeat (69 were repeat elective and 78 were repeat emergency). In this period an additional 33 women with previous lower segment caesarean sections had a successful vaginal delivery. Hence 18.3% (33/180) vaginal birth after caesarean sections was conducted successfully among women with previous caesarean). The results of this study indicate that vaginal birth after caesarean section is a clear feature of obstetric practice in DH. This is possible because of the vigilance in managing these women and the availability in this hospital setting of resources for immediate cesarean section.

Ambispective study on Mac Donald suturing in pregnant ladies with cervical incompetence in Dhulikhel Hospital.

BACKGROUND: Cervical incompetence is one of the main contributors to repeated pregnancy loss, accounting for approximately 25% of the cases. Typically it results in progressive cervical dilatation, leading to a painless second- or early-third-trimester abortion. OBJECTIVES: The main objective of the study was to explore the benefit from cervical cerclage in pregnant women with anatomical cervical incompetence. METHODS: In a review of the operation and labour registers from January 2006 till January 2010, a total of 38 cervical cerclage procedures were performed at Dhulikhel Hospital (DH). In the study caste, parity, gestational age, diagnostic criteria, postoperative complications and pregnancy outcomes of the cases were analyzed. RESULTS: Two of the 38 cases didn't come for delivery at Dhulikhel Hospital (Kathmandu University Teaching Hospital). Four women haven't delivered at the time of data analysis. So pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. Of them 18 cases (47%) were Brahmin, 22 cases (58%) were between 20-25 years old and 32 cases (84%) were from Kavre district. All cases were booked cases (they had antenatal care in the hospital) and 14 patients (37%) were third gravida. Most cases had 2 to 4 antenatal visits prior to suturing. Two cases were diagnosed with a bicornuate uterus. 21 cases (55%) had a previous history of at least one dilatation and evacuation. 33 cases (87%) were diagnosed with cervical incompetence clinically and confirmed by ultrasound. The remaining 13% were assessed, in the absence of a history of midtrimester abortion, of having a high suspicion of cervical incompetence after midtrimester scan with measurement of cervical length. In 18 cases (47%), cervical cerclage were done at 15 to 20 weeks of gestation. The postoperative period was uneventful in all 38 cases. All cases (32) delivered in DH were assisted by consultant obstetricians. 19 out 32 cases (59%) were delivered vaginally at term. CONCLUSIONS: 38 cases were included in the study. Pregnancy outcomes were analyzed among 32 cases while rests of the variables were analyzed among 38 cases. 31 out 32 cases were delivered with good foetal weight. It clearly shows pregnant women with anatomical cervical incompetence were benefitted from cervical cerclage. The authors recommend an early trans vaginal scan in any patient with a history of mid trimester abortion or preterm labour. The cervical cerclage procedure therefore should be available more widely to benefit those patients with proven or strongly suspected cervical incompetence.

Dose-response model for Burkholderia pseudomallei (melioidosis).

AIMS: The objective of this study was development of a dose-response model for exposure to Burkholderia pseudomallei in different animal hosts and analysis of the results. The data sets with which the model was developed were taken from the open literature. METHODS AND RESULTS: All data sets were initially tested for a trend between dose and outcome using the Cochran-Armitage test. Only data showing a statistically significant trend were subjected to further analysis (fitting with parametric dose-response relationships). Dose-response relationships (exponential, beta-Poisson and log-probit) were fit to data using the method of maximum likelihood estimation. CONCLUSIONS: Dose-response analysis of BALB/c mice, C57BL/6 mice, guinea pigs and diabetic rats showed that BALB/c mice exposed intranasally (i.n.) and guinea pigs exposed intraperitoneally (i.p.) are significantly more sensitive to B. pseudomallei than C57BL/6 mice exposed i.n. and diabetic rats exposed i.p. SIGNIFICANCE AND IMPACT OF THE STUDY: The results confirmed the findings of a study of outbreak data that the diabetic population is more susceptible to infection with B. pseudomallei than the general population. The low dose prediction from best fit dose-response models can be used to draw guidelines for public health decision making processes, including consideration of sensitive subpopulations.

An open, randomized, comparative study of efficacy and safety of risperidone and haloperidol in schizophrenia.

OBJECTIVES: In the last decade there have been numerous randomized controlled trials comparing the efficacy and safety of second generation antipsychotics and conventional antipsychotics in the treatment of schizophrenia, but most of them have been conducted in the western population. This study compared the efficacy and safety of risperidone versus haloperidol in the Nepalese context, in order to add on to the very few literatures available on this topic in the South East Asia region and compare them. METHODS: Patients with the diagnosis of schizophrenia were randomly assigned to receive risperidone 4-6 milligrams (mg) per day and haloperidol 10-20 mg per day, and were followed up for 6 weeks. Assessment were done on the day of the diagnostic interview and days 7, 14, 28 and 42 (end point). During the assessment periods Positive and Negative Syndrome Scale (PANSS) was administered to monitor the progress in psychopathology and Udvalg for Kliniske Undersogelser (UKU) side effects rating scale was applied to rate the treatment emergent adverse effects. RESULTS: Both risperidone and haloperidol were associated with substantial baseline- to- endpoint reduction in symptom severity. After one week of treatment, the improvement in schizophrenia with risperidone was significantly better than haloperidol in terms of PANSS- total Score (-45.4 versus -29.5), negative subscale score (-14.3 versus -6.68) and general psychopathology subscale score (-20.9 versus -13.7). At the end point of the study, the benefit was maintained in total score (-52.1 versus -43.1), though the negative subscale score still showed tendency for greater improvement in psychopathology with risperidone. The side effects profile did not show significant differences except in extrapyramidal symptoms. Thirty-eight percent of risperidone treated patients had to resort to anti-parkinsonian treatment compared to 78% in haloperidol treatment group. CONCLUSION: Similar to the studies in the western countries, Asia and Indian subcontinent, both risperidone and haloperidol were effective in the reduction of psychopathological symptoms in this group of Nepalese population with the diagnosis of schizophrenia. However, risperidone was quicker and better then haloperidol and risperidone had a better safety profile. This is important, because extrapyramidal side effects of neuroleptics are responsible for non-compliance and increased cost in terms of us of anti-parkinsonian medication.