Interaction of tacrolimus through hedgehog signaling pathway: An in vitro evaluation using rat hepatocytes.

Tacrolimus (TAC) is the drug of choice in immunosuppressive therapy for organ transplantation; however, adverse effects are still a major concern. The current study aims to decipher the short-term exposure of TAC on rat hepatocytes in relation to activation of hedgehog (HH) signaling pathway. Time dependent study was conducted using primary rat hepatocytes treated with TAC (36 µM) for 6, 12, 24 and 48 h. Western blot analysis was performed using cell lysate in order to analyze the regulation of HH pathway proteins including HHIP, SMO, PTCH, IHH, SHH, and GLI transcription factors. The study revealed change in protein expression of HH signaling molecules with activation of HH pathway, due to downregulation of HHIP, and enrichment of HH ligands with activation of SMO and GLI transcription factors. It is therefore, concluded that short term TAC exposure leads to upregulation of HH pathway in liver, which may initially act to repair the liver damage but can worsen the condition in case of prolonged immunosuppressive therapy. This insight could lead to understand association of off target effects of immunosuppressive drugs and occurrence of other liver diseases in transplant patients when it comes to long term immunosuppressive therapy. These findings also illuminate a novel direction that use of HH inhibitor might provide a therapeutic strategy for immune suppression related liver disorders.

Effect of Short-Term Tacrolimus Exposure on Rat Liver: An Insight into Serum Antioxidant Status, Liver Lipid Peroxidation, and Inflammation.

Tacrolimus (TAC) is an immunosuppressive drug, optimally used for liver, kidney, and heart transplant to avoid immune rejection. In retrospect, a multitude of studies have reported effects of TAC, such as nephrotoxicity, diabetes, and other complications. However, limited information is available regarding short-term exposure of TAC on the liver. Therefore, the present study was designed to unravel the effects of short-term exposure of TAC on a rat model. The animal model was established by TAC administration for 6, 12, 24, and 48 h time points. Liver histopathological changes were observed with PAS-D, reticulin stain, and immunostaining of PCNA and CK-7 coupled with glycogen quantification in a liver homogenate. TUNEL assay was performed to evaluate the DNA damage in the liver. Concentration of GSH and activities of SOD and CAT in the serum were measured to assess the antioxidant status, whereas liver tissue MDA level was measured as a biomarker of oxidative stress. Hepatic gene expression analysis of IL-10, IL-13, SOCS-2, and SOCS-3 was performed by RT-PCR. Results revealed marked changes in liver architecture of all TAC-treated groups, as evidenced by sinusoid dilation, hepatocyte derangement, glycogen deposition, and collapsed reticulin fibers. Significant increase in PCNA and CK-7 immunostaining along with the presence of TUNEL-positive cells was revealed in treatment groups as compared to the control group. Serum antioxidant enzyme status was markedly decreased, whereas the liver MDA level was increased in TAC treatment groups indicating oxidative stress induction. The gene expression profile of cytokines was significantly upregulated in treatment groups highlighting an inflammatory response. In conclusion, results of the current study propose that even a short-term TAC exposure can induce change in antioxidant status and lipid peroxidation. Therefore, these factors should be considered to avoid and minimize immunosuppression-related issues in a prolonged course of treatment.

Local recurrence after 'standard' abdominoperineal resection: do we really need ELAPE?

Introduction Low rectal cancers requiring abdominoperineal resection tend to have a worse prognosis than higher tumours, which may be treated by anterior resection. One of the reasons for this may be inadequate local surgery, in particular the narrow waist of the resection specimen of a standard abdominoperineal resection may be associated with a high positive circumferential resection margin. The extralevator abdominoperineal excision (ELAPE) aims to improve the R0 resection rate but carries significant morbidity. We examined our own results of standard abdominoperineal resection to assess the need for a change of policy. Methods We operformed a retrospective analysis of consecutive standard abdominoperineal resections for rectal cancer in a single centre from June 2002 to December 2011. Results A total of 102 patients underwent standard abdominoperineal resection with curative intent; 19 had no preoperative treatment, 42 had short course radiotherapy, 9 had long course radiotherapy and 32 had neoadjuvant chemotherapy followed by long course chemoradiotherapy. In 17/102(16.6%), there was a positive circumferential resection margin. Over a median follow up of 32 months, 20 patients developed recurrence of any type. Local recurrence occurred in five patients (two of which also had distant recurrence), of whom two had a positive circumferential resection margin (P = 0.10). Actuarial two-year local only recurrence was 3.4% and any recurrence was 17.7%. Overall five-year cancer specific survival was 77%. Conclusions In this series we found low rates of local recurrence after standard abdominoperineal resection even with a circumferential margin rate positivity of 16.6%.Performing an ELAPE in selected cases may improve these results further but is not necessarily required for all patients.

Leishman and Giemsa stain: a new reliable staining technique for blood/bone marrow smears.

INTRODUCTION: Peripheral blood and bone marrow smear examination is an important basic tool for the diagnosis of different haematological conditions including haematological malignancies. We created a newer modification of the conventional Leishman and Giemsa stains as Leishman and Giemsa (L&G) stain and compared the efficacy and reliability of this stain with conventional stains. The study was performed to evaluate the staining efficacy, feasibility, time and cost of L&G stain over the conventional Leishman and Giemsa stains. METHODS: A pilot study was carried out in the Department of Haematology of our hospital from October 2013 to December 2013. Hundred selected cases, each with peripheral blood and bone marrow smears were taken, and three sets of the smears were prepared from each sample--one for L&G stain and other two--one each for conventional Leishman and Giemsa stains. This staining is further incorporated in our routine standard operating protocols for staining of all the peripheral blood smears in automated stainer, Sysmex SP10. RESULT: The average grading score from each staining methods from all the three experts was compiled. The average grading score of L&G staining method was noted to be significantly higher than the other two methods (analysis of variance test, P value < 0.05). When modified L&G stain (C) was compared with stain conventional stains (A and B), a P value of <0.001 was noted in all parameters except between Leishman stain and L&G stain in mature RBC and WBC nucleus and RBC inclusions (P value between 0.05 and 0.001). CONCLUSION: L&G staining is a newer staining technique of immense help in high-throughput haematology laboratories by offering a time-saving, cost-effective and better staining option to conventional staining methods. It gives a better nuclear and cytoplasmic differential staining and can also be used in automated blood counters/stainer.

Axial quantitative ultrasound assessment of pediatric bone quality in eastern Nepal.

UNLABELLED: This study presents quantitative ultrasonography (QUS) bone quality data for an underrepresented, south Asian pediatric population from Nepal. Data were collected as part of a longitudinal study of growth and development. This study offers normative data and documents the effect of stunting, wasting, and underweight on the bone properties measured by QUS. INTRODUCTION: The purpose of this study was to (1) examine the bone quality of a rural, non-Western pediatric population using QUS, (2) explore variation in the trajectory of bone quality development between males and females, and (3) examine the impact of growth disruption(s) on bone quality. METHODS: A cross-sectional study of 860 children and adolescents aged 5-18 years from the Jirel ethnic group in eastern Nepal was performed. The Sunlight Omnisense 7000P was used to assess bone quality of the distal 1/3 radius and midshaft tibia. WHO reference standards were used to assess growth disruptions of height, weight, and BMI. RESULTS: QUS bone quality data for an underrepresented, non-Western pediatric population are presented for the radius and tibia. A sizable portion of the study participants were classified as stunted, wasted, and/or underweight. Despite this prevalence of growth disruption in the study sample, bone quality data conform to other documented populations with less growth disruption. Thus, this study offers normative data and documents the minimal effect of stunting, wasting, and underweight on the bone properties measured by QUS. CONCLUSIONS: Non-Western pediatric populations are significantly underserved with regard to simple, non-invasive screening tools that may help identify developmental disorders and assess bone health. The children and adolescents examined here represent normal growth and development for an underrepresented south Asian population. While this work demonstrates that stunting, wasting, or underweight status at time of QUS assessment is not associated with poor bone quality, we do suggest that further study is needed to examine possible cumulative effects of persistent disruptions that may lead to compromised bone quality in later adolescence.

Assessment of Genetic Variability in the Coding Sequence of Melatonin Receptor Gene (MTNR1A) in Tropical Arid Sheep Breeds of India.

Seasonal behaviour in sheep, which varies in tropical and temperate environmental conditions, is a matter of study, because it can provide a clue to address the problem of seasonality in sheep. Melatonin receptor is the membrane-bound G-coupled receptor, sensing the message of photoperiodic cues thorough melatonin. Restriction fragment length polymorphism (RFLP) studies were carried out to assess the variability of gene at G612A and C606T SNPs in MTNR1A gene, which have been studied to be markers for out-of-season breeding. Allelic frequency distribution corresponded to higher frequency of GG and CC genotype, in tropical arid sheep breed in comparison with temperate region sheep breed. PCR amplification of MTNR1A gene of 30 animals was performed and single nucleotide polymorphisms (SNPs) identification was carried out using Lasergene software. Seven SNPs/mutations were identified, but most of them were synonymous, except the one G706A, leading to substitution of valine by isoleucine. Polyphen-2 analysis of G706A mutation revealed that it is a benign mutation. Two important SNPs C426T and G555A, which were identified in temperate sheep breeds, could not be traced in Magra and Marwari breeds of sheep. Thus, the Magra and Marwari breeds of tropical, arid region demonstrated the presence of both polymorphic SNPs markers G612A and C606T, associated with out-of-season breeding. GG and CC genotypes were having a higher prevalence in the studied population.

Menopausal Health Status of Women of Kapilvastu District of Nepal.

BACKGROUND: Women face numerous health problems in their post-reproductive and menopausal years, including issues such as pelvic pain, incontinence and obstetric fistula. In Nepal, the importance of these health issues is increasing with the aging of the population, yet women are often unable to access adequate health care due to entrenched gender structures and misconceptions regarding menopause. This study aimed to describe the prevalence of menopause, the associated health problems and their severity amongst women aged 40-60 years in Kapilvastu. METHODS: A descriptive study was conducted in Kapilvastu district. Multi stage cluster sampling technique was adopted: Illakas of Kapilvastu were identified, then one Village Development Committee (VDC) from each Illaka of the district, and two wards from each of these VDCs, were selected randomly. RESULTS: The median age of onset of menopause was 47 years (25 th and 75 percentiles = 43 and 50 years), and >90% of women had entered menopause by 54. All symptoms in the Menopause Rating Scale were experienced to some extent by at least 30% of women, even amongst the premenopausal group. The most common problems experienced by menopausal women were: sexual problems (81.7%, 95%CI: 78.0-85.4), physical and mental exhaustion (81.5%, 95%CI: 77.8-85.2) and joint and muscular discomfort (78.5%, 95%CI: 74.6-82.4). The symptoms most frequently deemed "severe" or "very severe" were: sexual problems (40.5%), joint and muscular discomfort (27.4%), and sleep problems (21.0%). th CONCLUSIONS: Middle-aged women in Kapilvastu experienced menopausal symptoms to a substantial degree. The prevalence and severity of these symptoms increased with the menopausal transition, and with increasing age. Menopause itself did not appear to be the primary risk factor for typical "menopausal" symptoms.

Genetic polymorphisms of CYP2E1 and GSTM1 loci and susceptibility to anti-tuberculosis drug-induced hepatotoxicity.

BACKGROUND: Host genetic factors that influence predisposition to anti-tuberculosis drug-induced hepatotoxicity (DIH) are not clear in the Indian population. OBJECTIVE: To investigate the possible association of DIH with polymorphism at the RsaI site of the 5-prime untranslated region of CYP2E1 and GSTM1 'null' mutations. METHODS: In this prospective study, 113 tuberculosis (TB) patients with DIH and 201 TB patients receiving anti-tuberculosis treatment without developing hepatotoxicity (non-DIH) constituted cases and controls, respectively. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed to analyse genetic polymorphisms of CYP450 2E1 at the RsaI site and 'null' GSTM1 mutations. PCR-RFLP results were compared between 185 non-DIH and 105 DIH patients RESULTS: A high frequency of c1c1 genotypes of CYP2E1 was commonly encountered, and the difference between DIH and non-DIH patients was not significant (75.14% vs. 77.14%). The genotypic distribution of c2c2 was significantly higher in the DIH than in the non-DIH group (4.8% vs. 0.5%, OR 8.58, P = 0.03). However, adjustment for age, sex and serum albumin differences yielded an OR of 2.75, making it non-significant (P = 0.26). Homozygous 'null' mutation frequencies at the GSTM1 gene in DIH and non-DIH patients were observed that were not significantly different (40% and 37%, respectively, P = 0.61). CONCLUSION: RsaI variants of the CYP2E1 gene and GSTM1 'null' mutation were not associated with risk of DIH in a north Indian population.

Prevalence of high level gentamicin and vancomycin resistance among clinical isolates of enterococci from a tertiary care hospital in central Nepal.

High level aminoglycoside resistance is an established phenomenon in enterococci. With the increasing use of broad spectrum cephalosporins and glycopeptides, vancomycin resistant enterococci are being increasingly reported from different parts of the world. The objective of our study was to determine the prevalence of high level gentamicin resistant (HLAR) enterococci among the clinical isolates in our hospital and to find the minimum inhibitory concentration (MIC) of vancomycin against these isolates. The enterococci isolated over a year (n = 41) were subjected to HLAR screening by disc diffusion and MIC of vancomycin by agar dilution method. HLAR prevalence was 63%. MIC of vancomycin showed none in the resistant range. However, 4 (9.7%) isolates were in the intermediate range heralding the eminent emergence of VRE if adequate control measures are not implemented in time.

Assessment of district health system within inter-sectoral context in Nepal.

BACKGROUND: Inter-sectoral coordination has been one of the different factors in the district health system that produces efficient output which has been identified by the Alma Ata declaration as an essential component to achieve notion of 'Health for All'. This study was therefore aimed to describe the major four key functions of the health systems and to find out the situation of inter-sectoral coordination in Nepal. METHODS: A mixed method with Focus Group Discussion (FGD) and In-Depth Interview with relevant personnel to collect the majority of the data was carried out from June 2012 to November 2012 from six districts selected purposively based on the health performance indicators. RESULTS: The major findings in relation to the key functions of district health systems showed that the overall management of the district health system happens under the leadership of chief of District Health Office of Public health office with the cooperation of all the personnel in different sections in a predetermined pattern and inter-sectoral coordination and collaboration exist only to a very limited extent. CONCLUSIONS: The major constraints for inter-sectoral coordination to be effective is lack of its planning and enforcement where inter-sectoral coordination could be important for both preventive and promotive health care, waste management, water supply and sanitation, health service utilization, pesticides and human health, agriculture and nutrition, air pollution. The main components in the district health system needs an immediate attention and inter-sectoral effort should be initiated from the central level and implemented in all the levels.

Prevalence of metabolic syndrome in chronic kidney disease: a hospital based cross-sectional study.

BACKGROUND: The components of metabolic syndrome (MetS) are the established risk factors of chronic kidney disease (CKD). Therefore, MetS and interplay of its various components, have deleterious effects on patients with chronic kidney disease. The aims of our study was to find out the prevalence of MetS in chronic kidney disease patients and to find out the association of each component of MetS with chronic kidney disease. METHODS: A Hospital based cross-sectional study was carried out from February 2008 to August 2009. One hundred and sixty confirmed chronic kidney disease diagnosed patients were included in this study. Chronic kidney disease was defined from national kidney foundation guidelines. Anthropometric measurements of subjects were noted in a semi-structured pro-forma. Fasting blood sample was collected for the estimation of fasting blood glucose, triglyceride and HDL-cholesterol. Chronic kidney disease patients were diagnosed as having the metabolic syndrome by using the modified National Cholesterol Education Program Adult Treatment Program III criteria. Data were assessed by the t-test and Chi Square Test. RESULTS: Sixty (37.5%) of the chronic kidney disease patients had MetS according to modified National Cholesterol Education Program Adult Treatment Program III criteria. The prevalence of hypertension, high fasting blood glucose, high triglyceride, low HDL Cholesterol and high waist circumference in chronic kidney disease patients was 112 (70.0%), 36 (22.5%), 74(46.25%), 98 (61.25%) and 30 (18.75%) respectively. Among the five components of the metabolic syndrome, waist circumference has the highest positive predictive value (73.34%) for chronic kidney disease. CONCLUSIONS: MetS occurs in more than one-third of chronic kidney disease patients. The prevalence of individual components of MetS is higher in chronic kidney disease patients.

Dyslipidaemia in chronic kidney disease in Nepalese population.

Patients having chronic kidney disease (CKD) are at higher risk for cardiovascular disease (CVD). Dyslipidaemia is a potential risk factor for CVD in CKD cases. In this study our aim was to find out the dyslipidaemia in patients with different stages of CKD. This hospital based cross-sectional study was conducted in department of biochemistry, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Total of 163 CKD cases and 163 non-CKD healthy controls were enrolled. CKD was defined and classified as per national kidney foundation guidelines. We analyzed fasting lipid profile including total cholesterol, HDL-C, LDL-C and TG. Significant difference in mean value of serum total cholesterol, HDL-C, LDL-C and TG were found in different stage of CKD and non-CKD groups (p value <0.05). CKD cases 33.75% and 21.47% of non-CKD controls had hypercholesterolemia (Odds ratio 1.86, p value 0.013). CKD cases 32.5% and 17.18% of non-CKD controls had low HDL-C (Odds ratio 2.32, P-value 0.001). CKD cases 38.03% and 33.13% of non-CKD controls had high LDL-C (Odds ratio 1.24, p value 0.297). CKD cases 35.58% and 19.01% of non-CKD controls had hypertriglyceridemia (Odds ratio 2.35, P-value 0.001). CKD had a higher prevalence of dyslipidaemia compared to non-CKD controls. Dyslipidaemia was also found in early stages of CKD.

Assessment of chronic kidney disease in Nepalese people with hypertension.

Hypertension is one of the leading causes to develop chronic kidney disease (CKD) and could be a risk factor for progression of CKD to end stage renal disease (ESRD).Uncontrolled hypertension worsens CKD. Hypertension control may contribute to prevent CKD in early stages and retards the progression of CKD stages to ESRD. Prevalence of CKD in people with diagnosed and chronic hypertension is known to be high, but little is known about the prevalence of CKD in those with newly diagnosed Hypertension. Present work was undertaken to see the prevalence of CKD among people with newly diagnosed hypertension. In this cross-sectional study, we accessed the CKD in newly diagnosed hypertensive patients and determined the association between hypertension and CKD. CKD was defined as either kidney dysfunction or kidney damage or both as per National Kidney Foundation Guidelines. 106 of newly diagnosed patients and 106 of normotensive controls were recruited in the study. 51.9% of newly diagnosed hypertensive patients and 23.6% of normotensive controls had CKD which was statistically significant (p-value <0.001). Difference in the mean value in eGFR and spot urine ACR (mg/mmol) between hypertensive patients and normotensive controls was statistically significant (p-Value <0.001). Both systolic BP and diastolic BP negative significantly correlated with eGFR (p-Value < 0.001 and 0.024 respectively) and positive significantly correlated with ACR (p-Value 0.003 and 0.003 respectively). The prevalence of CKD is high among people with newly diagnosed hypertension. Those, people might benefit from interventions aimed at preventing development and/or progression of both CKD and hypertension.

Association of thyroid dysfunction among infertile women visiting infertility center of Om Hospital, Kathmandu, Nepal.

Infertility is one of the medial, social and psychological burdens in this part of world. Thyroid dysfunction can lead to menstrual disturbance, anovulatory cycles, and decreased fecundity. Proper management of thyroid dysfunction canresult restoration of normal fertility. Therefore it is very important to screen thyroid abnormalities among women with infertility. This study aimed to determine association of thyroid dysfunction among infertile women. This study comprises total of 735 primary infertile women with age ranging from 20 to 35 years. Blood samples were collected and subjected for estimation of thyroid hormones. Out of 735 cases 547 (74.4%) were euthyroid. 56 (7.6%) have primary hypothyroidism, 31 (4.2%) have primary hyperthyroidism, 87 (11.8%) have subclinical hypothyroidism, and 8 (1.1%) have subclinical hyperthyroidism.

In-vitro assessment of cell-mediated immunity by demonstrating effector-t cells for diagnosis of tuberculosis in Nepalese subjects.

The immune response against mycobacterium tuberculosis (MTB) is cell mediated. T-cells become sensitized when they encounter MTB antigens and subsequently activated effector T-cells produce a number of cytokines including interferon- gamma (INF-gamma) to fight the infecting organisms. Demonstration of either production of INF-gamma or presence of effector T-cells sensitized to MTB specific antigens in vitro can be diagnostic for TB infection. Aim of this study was to determine the efficacy of commercially available T-SPOT.TB kit which is used for the in vitro diagnosis of TB infection and to determine if this test has any cross reactivity in leprosy patients. Blood sample was taken from 30 sputum AFB positive, 30 sputum AFB negative healthy controls and 10 cases of paucibacillary leprosy patients. The blood samples were processed to separate peripheral blood mononuclear cells. The final cell suspensions were cultured along with MTB specific antigens namely- Early Secretory Antigenic Target (ESAT-6) and Culture Filtrate Protein (CFP 10) along with negative and positive controls. The production of INF-gamma was demonstrated by enzyme linked immunospot (ELISPOT) assay technique. All AFB positive samples produced INF-gamma after exposure to MTB specific antigens. 4 (16.6%) of healthy controls were also found reactive for INF-gamma. The sensitivity and "specificity" for active disease of the ELISPOT (T-SPOT.TB) in respect to AFB microscopy was 100% and 85.7% respectively. Assessment of CMI against tuberculosis, by demonstrating effector T-cell sensitized to MTB antigens can be use to aid the diagnosis of tuberculosis. T-SPOT.TB has no cross reactivity with leprosy patients.

Estimation of serum uric acid in cases of hyperuricaemia and gout.

INTRODUCTION: Gout is crystal deposit arthritis and is an ancient disease. The biologic precursor to gout is hyperuricaemia. The prevalence of hyperuricaemia and gout has an increasing trend all over the world including the developing countries. The purpose of this study is to estimate serum uric acid level in hyperuricaemic and gout patients attending a medical college hospital. METHODS: A consecutive 150 hyperuricaemics and 150 gout patients attending Tribhuwan University Teaching Hospital from June to September 2007 were included in this study. The serum uric acid level was measured by the enzymatic (PAP- Uricase) method. The patients with acute gout were interviewed and relevant information was obtained. RESULTS: Males comprised 84% of gout cases. Hyperuricaemia was common in both sexes. The mean age for gout was 47.49 and 56.65 years in males and females respectively. The mean age for the first gout attack was 42.1 +/- 14.0 years. Family history was positive in 22% of cases. The overall mean serum uric acid level in hyperuricaemics was 7.2 +/- 0.7 mg/dL and 8.4 +/- 1.1 mg/dL in acute gout (p 0.0001). The mean serum uric acid level was significantly (p 0.0001) high among males both at the asymptomatic phase and at acute gout. Gout was more common in non-vegetarians (95%) and alcoholics (65.3%). Serum uric acid level was inversely related with the amount of daily water intake (p 0.0001). CONCLUSIONS: Serum uric acid level is significantly high among the male gouty arthritic patients. However, it is also high among asymptomatic hyperuricaemic cases of both sexes.

Association of cardiovascular risk factors in hypertensive subjects with metabolic syndrome defined by three different definitions.

INTRODUCTION: Different authorities have put forward their criteria to define metabolic syndrome (MetS). The aim of this study was to find the prevalence of MetS in hypertensive individuals by the available three different definitions from National Cholesterol Education Program (NCEP), International diabetes Federation (IDF) and WHO and their association with other cardiac risk factors. METHODS: After anthropometric measurements fasting blood was analyzed for glucose, lipids, high sensitivity C-reactive protein (hsCRP) and anti-oxidized LDL antibody in 150 hypertensive individuals. A ten-year coronary heart disease risk was predicted using the Framingham risk score (FRS). RESULTS: The prevalence of MetS was 54.7 % by NCEP, 42.0 % by IDF) and 18.7 % by WHO. As many as 63.4 % had MetS by any definition, while only 9.4 % fulfilled all the criteria of the three definitions. The association of cardiac risk factors also varied according to the definition used. hsCRP was significantly elevated in MetS compared to non-MetS. Body mass index, waist circumference and HDL-C were associated in MetS defined by NCEP and IDF. FRS was higher in MetS defined by Adult Treatment Panel and WHO definitions. An increase in urine albumin and a decrease in eGFR were associated with MetS individuals defined by WHO only. CONCLUSION: There is a wide variation in the prevalence of MetS and associated cardiac risk factors according to three different definitions used. The different cardiac risk factors among MetS also vary with the definitions used. However, hsCRP and emerging risk factor are significantly elevated in hypertensive individuals with MetS as defined by all definitions.

Effectiveness and efficiency of Aama Surakshya Karyakram in terms of barriers in accessing maternal health services in Nepal.

BACKGROUND: The Family Health Division along with the MoHP developed a policy that recommended provision of incentives to all delivering mother by removing the parity condition and termed Safe Delivery Incentive Programme (SDIP) to make it more appropriate. The SDIP was branded as AamaSurakshyaKaryakram (ASK). The main objective of the study was to find out the effectiveness and efficiency of AamaSurakshyaKaryakram to address barrier in accessing maternal health services in Nepal. METHODS: An exploratory and cross sectional descriptive study was conducted by quantitative and qualitative tools and techniques. To provide comprehensive coverage, five districts have been selected representing four development (eastern, central, western and far-western) and three (mountain, hill and flat) ecological region were selected. RESULTS: Out of 47 exit client interviews conducted in this study, 51 percent were done in Sunsari, followed by Sarlahi (17%), Dadeldhura (17%), and Arghakhanchi (15%). Most of these mothers (94%) delivered their children in the hospitals, and rest (6%) in PHCCs. Sixty percent mothers were in the age group of 20-25 years, while 45 percent were from Tarai/Madhesi group followed by Brahmins/Chhetries group (34%). Total 70% mothers were found to be literate. 55% mothers were found to be visiting health facilities during labour pain. 2% mothers were visiting heath facilities before labour pain started. Rest mothers were visiting health facilities after one or two days of labour pain. Total 70% mothers were able to reach the health facility within 60 minutes, while 13 percent mothers were able to reach the facility more than 3 hours, and 17% were in between. All mothers who visited PHCCs were able to reach the facility within 60 minutes while analyzing health facility-wise. CONCLUSIONS: Mothers delivered at home as they were not well prepared to go to health facility. Lack of transportation facility hindered for institutional delivery. None of them figured out that there was a provision of transport incentive; they only knew that there was a cash payment, but they didn't know exactly for what specific purpose mothers were receiving such payments. Ask found to be effective and efficient in order to address barriers occurring inside the health facility and financial barrier except geo-graphical barrier in accessing maternal health services in Nepal.