Kathmandu Medical College Teaching Hospital

OBJECTIVE: To assess the number of adult critical care beds in Asian countries and regions in relation to population size. DESIGN: Cross-sectional observational study. SETTING: Twenty-three Asian countries and regions, covering 92.1% of the continent's population. PARTICIPANTS: Ten low-income and lower-middle-income economies, five upper-middle-income economies, and eight high-income economies according to the World Bank classification. INTERVENTIONS: Data closest to 2017 on critical care beds, including ICU and intermediate care unit beds, were obtained through multiple means, including government sources, national critical care societies, colleges, or registries, personal contacts, and extrapolation of data. MEASUREMENTS AND MAIN RESULTS: Cumulatively, there were 3.6 critical care beds per 100,000 population. The median number of critical care beds per 100,000 population per country and region was significantly lower in low- and lower-middle-income economies (2.3; interquartile range, 1.4-2.7) than in upper-middle-income economies (4.6; interquartile range, 3.5-15.9) and high-income economies (12.3; interquartile range, 8.1-20.8) (p = 0.001), with a large variation even across countries and regions of the same World Bank income classification. This number was independently predicted by the World Bank income classification on multivariable analysis, and significantly correlated with the number of acute hospital beds per 100,000 population (r = 0.19; p = 0.047), the universal health coverage service coverage index (r = 0.35; p = 0.003), and the Human Development Index (r = 0.40; p = 0.001) on univariable analysis. CONCLUSIONS: Critical care bed capacity varies widely across Asia and is significantly lower in low- and lower-middle-income than in upper-middle-income and high-income countries and regions.

BACKGROUND: World Health Organization (WHO) estimates for deaths attributed to Non Communicable Diseases (NCDs) in Nepal have risen from 51% in 2010 to 60% in 2014. This study assessed the distribution and determinants of NCD risk factors among the Nepalese adult population. METHODS AND FINDINGS: A nationally representative cross-sectional survey was conducted from Jan to June 2013 on the prevalence of NCD risk factors using the WHO NCD STEPS instrument. A multistage cluster sampling method was used to randomly select the 4,200 respondents. The adjusted prevalence ratio (APR) was used to assess the determinants of NCD risk factors using a Poisson regression model. The prevalence of current smoking (last 30 days) was 19% (95%CI:16.6-20.6), and harmful alcohol consumption (≥60 g of pure alcohol for men and ≥40 g of pure alcohol for women on an average day) was 2% (95%CI:1.4-2.9). Almost all (99%, 95%CI:98.3-99.3) of the respondents consumed less than five servings of fruits and vegetables combined on an average day and 3% (95%CI:2.7-4.3) had low physical activity. Around 21% (95%CI:19.3-23.7) were overweight or obese (BMI≥25). The prevalence of raised blood pressure (SBP≥140 mm of Hg or DBP≥90 mm of Hg) and raised blood glucose (fasting blood glucose ≥126 mg/dl), including those on medication were 26% (95%CI:23.6-28.0) and 4% (95%CI:2.9-4.5) respectively. Almost one quarter of respondents, 23% (95%CI:20.5-24.9), had raised total cholesterol (total cholesterol ≥190 mg/dl or under current medication for raised cholesterol). he study revealed a lower prevalence of smoking among women than men (APR:0.30; 95%CI:0.25-0.36), and in those who had higher education levels compared to those with no formal education (APR:0.39; 95%CI:0.26-0.58). Harmful alcohol use was also lower in women than men (APR:0.26; 95%CI:0.14-0.48), and in Terai residents compared to hill residents (APR:0.16; 95%CI:0.07-0.36). Physical inactivity was lower among women than men (APR:0.55; 95%CI:0.38-0.80), however women were significantly more overweight and obese (APR:1.19; 95%CI:1.02-1.39). Being overweight or obese was significantly less prevalent in mountain residents than in hill residents (APR:0.41; 95%CI:0.21-0.80), and in rural compared to urban residents (APR:1.39; 95%CI:1.15-1.67). Lower prevalence of raised blood pressure was observed among women than men (APR:0.69; 95%CI: 0.60-0.80). Higher prevalence of raised blood glucose was observed among urban residents compared to rural residents (APR:2.05; 95%CI:1.29-3.25). A higher prevalence of raised total cholesterol was observed among the respondents having higher education levels compared to those respondents having no formal education (APR:1.76; 95%CI:1.35-2.28). CONCLUSION: The prevalence of low fruit and vegetable consumption, overweight and obesity, raised blood pressure and raised total cholesterol is markedly high among the Nepalese population, with variation by demographic and ecological factors and urbanization. Prevention, treatment and control of NCDs and their risk factors in Nepal is an emerging public health problem in the country, and targeted interventions with a multi-sectoral approach need to be urgently implemented.

OBJECTIVES: To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. DESIGN: Prospective cohort study. SETTING: 150 intensive care units in 16 Asian countries. PARTICIPANTS: 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. MAIN OUTCOME MEASURE: Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles. RESULTS: Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. CONCLUSIONS: While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.

While there is much debate on transformative change among academics and policymakers, the discussion on how to govern such change is still in its infancy. This article argues that transformative governance is needed to enable the transformative change necessary for achieving global sustainability goals. Based on a literature review, the article unpacks this concept of transformative governance. It is: integrative, to ensure local solutions also have sustainable impacts elsewhere (across scales, places, issues and sectors); inclusive, to empower those whose interests are currently not being met and represent values embodying transformative change for sustainability; adaptive, enabling learning, experimentation, and reflexivity, to cope with the complexity of transformative change; and pluralist, recognizing different knowledge systems. We argue that only when these four governance approaches are: implemented in conjunction; operationalized in a specific manner; and focused on addressing the indirect drivers underlying sustainability issues, governance becomes transformative.

Abstract The challenge of bacterial infection increases the risk of mortality and morbidity in acute and chronic wound healing. Silver nanoparticles (Ag NPs) are a promising new version of conventional antibacterial nanosystem to fight against the bacterial resistance in concern of the drug discovery void. However, there are several challenges in controlling the size and colloidal stability of Ag NPs, which readily aggregate or coalesce in both solid and aqueous state. In this study, a template‐guided synthesis of ultrafine Ag NPs of around 2 nm using water‐soluble and biocompatible γ‐cyclodextrin metal‐organic frameworks (CD‐MOFs) is reported. The CD‐MOF based synthetic strategy integrates AgNO 3 reduction and Ag NPs immobilization in one pot achieving dual functions of reduced particle size and enhanced stability. Meanwhile, the synthesized Ag NPs are easily dispersible in aqueous media and exhibit effective bacterial inhibition. The surface modification of cross‐linked CD‐MOF particles with GRGDS peptide boosts the hemostatic effect that further enhances wound healing in synergy with the antibacterial effect. Hence, the strategy of ultrafine Ag NPs synthesis and immobilization in CD‐MOFs together with GRGDS modification holds promising potential for the rational design of effective wound healing devices.

BACKGROUND: Chepang communities are one of the most deprived ethnic communities in Nepal. According to the National Pathfinder Survey, dental caries is a highly prevalent childhood disease in Nepal. There is no data concerning the prevalence of caries along with knowledge, attitude and oral hygiene practices among Chepang schoolchildren. The objectives of this study were to 1) record the prevalence of dental caries 2) report experience of dental pain 3) evaluate knowledge, attitude and preventive practices on oral health of primary Chepang schoolchildren. METHOD: A cross sectional epidemiological study was conducted in 5 government Primary schools of remote Chandibhanjyang Village Development Committee (VDC) in Chitwan district. Ethical approval was taken from the Institutional Review Board within the Research Department of the Institute of Medicine (IOM) Tribhuvan University. Consent was obtained from parents for conducting clinical examination and administrating questionnaire. Permission was taken from the school principal in all schools. Data was collected using a pretested questionnaire on 131 schoolchildren aged 8-16-year- olds attending Grade 3-5. Clinical examination was conducted on 361 school children aged 5-16 -year-olds attending grade 1-5. Criteria set by the World Health Organization (1997) was used for caries diagnosis. The questionnaires, originally constructed in English and translated into Nepali were administered to the schoolchildren by the researchers. SPSS 11software was used for data analysis. RESULTS: Caries prevalence for 5-6 -year-old was above the goals recommended by WHO and Federation of Dentistry international (FDI) of less than 50% caries free children. Caries prevalence in 5-6-year-olds was 52% and 12-13-year-olds was 41%. The mean dmft/DMFT score of 5-6 -year-olds and 12 -13-year -olds was 1.59, 0.31 and 0.52, 0.84 respectively. The DMFT scores increased with age and the d/D component constituted almost the entire dmft/DMFT index. About 31% of 8-16-year-olds school children who participated in the survey reported having suffered from oral pain. Further, the need for treatment of decayed teeth was reported at 100%. About 76% children perceived teeth as an important component of general health and 75% reported it was required to eat. A total 93% children never visited a dentist or a health care service. Out of 56% children reporting cleaning their teeth daily, only 24% reported brushing their teeth twice daily. About 86% of the children reported using toothbrush and toothpaste to clean their teeth. Although 61% children reported to have received oral health education, 82% children did not know about fluoride and its benefit on dental health. About 50% children reported bacteria as the main cause of tooth decay and 23% as not brushing teeth for gingivitis. Frequency of sugar exposure was low; 75% of children reported eating sugar rich food once daily. CONCLUSIONS: Caries prevalence of 5-6 -year- old Chepang school children is above the recommended target set by FDI/WHO. The study reported 31% schoolchildren aged 8-16-year old suffered oral pain and decayed component constituted almost the entire dmft/DMFT index. The brushing habit was reportedly low with only 24% of the children brushing twice daily. A nationwide scientifically proven, cost effective school based interventions is needed for prevention and control of caries in schoolchildren in Nepal.

BACKGROUND: Urinary Tract Infection (UTI) is one of the most common infectious diseases and people of all age-groups and geographical locations are affected. The impact of disease is even worst in low-resource developing countries due to unaware of the UTIs caused by multidrug-resistant (MDR) pathogens and the possibility of transfer of MDR traits between them. The present study aimed to determine the prevalence of MDR bacterial isolates from UTI patients, the antibiotic resistance pattern and the conjugational transfer of multidrug resistance phenotypes in Escherichia coli (E. coli). RESULTS: Two hundred and nineteen bacterial isolates were recovered from 710 urine samples at Kathmandu Model hospital during the study period. All samples and isolates were investigated by standard laboratory procedures. Among the significant bacterial growth (30.8%, 219 isolates), 41.1% isolates were MDR. The most prevailing organism, E. coli (81.3%, 178 isolates) was 38.2% MDR, whereas second most common organism, Citrobacter spp. (5%, 11 isolates) was found 72.7% MDR. Extended-spectrum β-lactamase (ESBL) production was detected in 55.2% of a subset of MDR E. coli isolates. Among the 29 MDR E. coli isolates, plasmids of size ranging 2-51 kb were obtained with different 15 profiles. The most common plasmid of size 32 kb was detected in all of the plasmid-harbored E. coli strains. The majority of E. coli isolates investigated for the multidrug resistance transfer were able to transfer plasmid-mediated MDR phenotypes along with ESBL pattern with a frequency ranging from 0.3 × 10-7 to 1.5 × 10-7 to an E. coli HB101 recipient strain by conjugation. Most of the donor and recipient strain showed high levels of minimum inhibitory concentration (MIC) values for commonly-used antibiotics. CONCLUSIONS: The high prevalence of multidrug resistance in bacterial uropathogens was observed. Particularly, resistance patterns were alarmingly higher for amoxycillin, co-trimoxazole, flouroquinolones and third-generation cephalosporins, which necessitate the re-evaluation of first and second line therapies for UTI. In addition, conjugational co-transfer of MDR phenotypes with ESBL-positive phenotypes was observed in MDR E. coli.

Increased awareness of the contributions of nonpoint source runoff to the degradation of water quality in the Mississippi River and Gulf of Mexico emphasizes the need to increase conservation practices that reduce nutrient export from agricultural lands. To achieve long-term conservation goals in agricultural landscapes, it is important to understand farmers9 perspectives on what practices are effective, practical, and economically attainable. We conducted a series of surveys, interspersed with focused outreach, of farmers in two agricultural watersheds in central Illinois in an attempt to better understand how outreach influenced their views on and adoption of conservation practices. Programs differed between the two watersheds in terms of the levels of intensity at which outreach efforts were conducted. Survey results suggest that more intensive outreach efforts, such as one-on-one landowner visits, localized workshops, and tours, can increase adoption of conservation practices associated with cost-share programs. Technical and financial assistance provided in a timely manner that did not interfere with planting and harvesting were major incentives among farmers in both watersheds to participate in cost-share conservation programs. Primary disincentives among farmers to enroll in cost-share programs were associated with multiple programmatic changes and complex application processes. Results indicate that there remains a need for outreach that increases awareness and implementation of conservation and best management practices specific to reducing agricultural runoff from tile-drained sources. Mitigation of nonpoint runoff will also require more effective management of nitrogen application rates and timing in order to conserve freshwater resources in Midwest agricultural landscapes and downstream waters. Integrated outreach teams comprised of stakeholders and local conservation agencies may lead to successful outreach efforts and reduce demands on limited conservation agency staff time.

BACKGROUND: Globally, diabetes is the top priority chronic disease. Health literary would be cost effective for prevention and control of diabetes and its consequences. This study was conducted to determine the level of diabetes related health knowledge, attitude and practice (KAP) among diabetic patient and factors associated with KAP. METHODS: An institutional based cross-sectional study was conducted using a non-probability sampling technique to select the diabetic patients. A total of 244 diabetic patients were interviewed from July to November 2014. Data was collected by face to face interview using structured interviewer rater questionnaires. Relative risk ratio (RRR) and 95% confidence interval (CI) of associated factors were estimated by a stepwise likelihood ratio method with multinomial logistic regression. RESULTS: More than half (52.5%) of all patients were female, 18% were illiterate, and 24.6% were from rural residence. The diabetes related risk factors were common among diabetic patients; 9.8% smoker, 16% alcohol drinking, and 17.6% reported low or no physical activity. Median score for knowledge, attitude, and practice were 81, 40 and 14 respectively. Among all patients, 12.3%, 12.7% and 16% had highly satisfactory knowledge, attitude and practice respectively. Using highly insufficient knowledge as the baseline, the likelihood of having a level of highly sufficient knowledge was 17 times higher among patients who have graduated and above level of education compared to those who were illiterate. Albeit this value was comparatively lower than insufficient level of knowledge. The probability of having a sufficient level of practice among diabetic patient with a history of smoking was 0.10 times lower than in patient with no history of smoking. CONCLUSIONS: Our study reveals a variation between diabetes related health knowledge, attitude and practice in Nepal among those who are affected by diabetes. Our results show the potential diabetes health literacy needs to be improved or developed for better health promotion.

BACKGROUND: Promotion of proper breastfeeding practices for the first six months of life is the most cost-effective intervention for reducing childhood morbidity and mortality. However, the adherence to breastfeeding recommendations in many developing countries is not satisfactory. The aims of the study were to determine breastfeeding and infant feeding patterns at nine months of age and to assess factors influencing exclusive breastfeeding practices. METHODS: In Bhaktapur, Nepal, we carried out a cross-sectional survey of 325 infants who came for measles vaccination at the age of nine months. Mothers were interviewed on details regarding feeding of their child and health since birth. RESULTS: Three quarters of all mothers reported that they did not receive any information on breastfeeding during the antenatal visit. Two hundred and ninety five (91%) mothers gave colostrum and 185 (57%) initiated breastfeeding within one hour of delivery. The prevalence of exclusively breastfeeding at 1, 3 and 6 months were 240 (74%), 78 (24%) and 29 (9%), and partial feeding was initiated in 49 (15%), 124 (38%) and 257 (79%) babies, respectively. The main reason, according to the mother, for introducing other foods before six months of age was insufficient breast milk. In logistic regression analyses, mother's knowledge on how long child should be given only breast milk and not living in joint families were associated positively with exclusive or predominant breastfeeding for four months or beyond. CONCLUSIONS: Despite the high proportion of mothers who initiated breastfeeding immediately after birth, continuation of exclusive breastfeeding for up to six months was not common. Very few mothers received any information on breastfeeding during the antenatal visit, indicating a need for counseling on exclusive breastfeeding. Possible options for this counseling could be during antenatal visits and at regular clinic visits for vaccination.

UNLABELLED: To compare the analgesic efficacy of local aesthetic with and without dexamethasone in supraclavicular brachial plexus block. METHODS: Forty patients undergoing arm, forearm and hand surgeries were randomly selected. The forty patients were divided in two groups of 20 each. In-group one, a brachial plexus block was done with 40-50 ml of local anaesthetic with 1:200,000 adrenaline and in the other group the block was performed with the same amount of local anaesthetics with dexamethasone. The onset of action and duration of analgesia in the two groups were compared and any complications of the procedure were noted. Statistical analysis was done using the independent sample t-test. RESULTS: The two groups were comparable in respect to age, sex, and weight. There was significant faster onset of action and prolonged duration of analgesia in the dexamethasone group than in the other group. There were no complications. CONCLUSION: Addition of dexamethasone for brachial plexus block significantly prolongs the duration of analgesia without any unwanted effects.

Introduction: Increase in extended-spectrum β-lactamases (ESBL) producing microbes in recent years has led to limitations of treatment options. This study aimed to assess the prevalence of ESBL producing E. coli and Klebsiella spp. at a tertiary hospital in Nepal. Methods: A total of 2209 non-repetitive mid-stream urine (MSU) samples were collected during the study period (March to September 2014). Identification of the isolates was done by Gram's staining followed by biochemical tests. Antibiotic susceptibility testing was done by modified Kirby-Bauer disc diffusion method and interpretation was done following Clinical and Laboratory Standard Institute (CLSI) guidelines, 2013. ESBL screening among E. coli and Klebsiella spp. isolates were done using ceftriaxone, cefotaxime, ceftazidime and cefpodoxime. The confirmation was done by phenotypic disc diffusion test (combined disc method) using ceftazidime (30µg) and ceftazidime plus clavulanic acid (30/10µg), and cefotaxime (30µg) and cefotaxime plus clavulanic acid (30/10µg) disc as per CLSI guidelines. Results: A total of 451 samples showed significant bacteriuria with 365 (80.9%) E. coli , 17 (3.8%) Klebsiella pneumoniae and 3 (0.7%) Klebsiella oxytoca . Of 451 isolates, 236 (52.3%) were found MDR strains. By combined disk test, 33 (91.7%) E. coli and 3 (8.3%) Klebsiella spp. were found ESBL producers. Conclusion: Higher prevalence of ESBL producing E. coli and Klebsiella spp. was observed warranting prompt need of surveillance for effective management of such MDR strains.

OBJECTIVES: This study determined the knowledge, attitude and practice/behaviour of cardiovascular health in residents of a semiurban community of Nepal. DESIGN: To increase the understanding of knowledge, attitude and practice/behaviour towards cardiovascular health, we conducted in-home interviews using a questionnaire based on the WHO STEPwise approach to surveillance and other resources, scoring all responses. We also recorded blood pressure and took anthropometric measurements. SETTING: Our study was conducted as part of the Heart-Health-Associated Research and Dissemination in the Community project in the Jhaukhel-Duwakot Health Demographic Surveillance Site in two urbanising villages near Kathmandu. PARTICIPANTS: The study population included 777 respondents from six randomly selected clusters in both villages. RESULTS: Seventy per cent of all participants were women and 26.9% lacked formal education. The burden of cardiovascular risk factors was high; 20.1% were current smokers, 43.3% exhibited low physical activity and 21.6% were hypertensive. Participants showed only poor knowledge of heart disease causes; 29.7% identified hypertension and 11% identified overweight and physical activity as causes, whereas only 2.2% identified high blood sugar as causative. Around 60% of respondents did not know any heart attack symptoms compared with 20% who knew 2-4 symptoms. Median percentage scores for knowledge, attitude and practice/behaviour were 79.3, 74.3 and 48, respectively. Nearly 44% of respondents had insufficient knowledge and less than 20% had highly satisfactory knowledge. Among those with highly satisfactory knowledge, only 14.7% had a highly satisfactory attitude and 19.5% and 13.9% had satisfactory and highly satisfactory practices, respectively. CONCLUSIONS: Our study demonstrates a gap between cardiovascular health knowledge, attitude and practice/behaviour in a semiurban community in a low-income nation, even among those already affected by cardiovascular disease.

BACKGROUND: Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies. METHODS: From September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid. FINDINGS: A total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765-1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230-480) in Kathmandu and 268 (202-362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144-216) and 103 (85-126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107-154) in Bangladesh, 46 (34-62) and 81 (56-118) in the Nepal sites, and 23 (19-29) and 1 (1-1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised. INTERPRETATION: Across diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for "high burden" of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines. FUNDING: Bill & Melinda Gates Foundation.

BACKGROUND: Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence. METHOD: The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis. RESULTS: The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality. CONCLUSION: The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

BACKGROUND: Fine Needle Aspiration Cytology (FNAC) is a simple and rapid diagnostic technique. Because of early availability of results, simplicity, minimal trauma and complications, the aspiration cytology is now considered a valuable diagnostic aid and is part and parcel of a pathologist's repertoire. OBJECTIVES: The aim of the study was to evaluate the results of fine needle aspiration cytology (FNAC) of lymph nodes in our institution in comparison to result of histopathology. MATERIALS AND METHODS: The present study on 130 patients of lymphadenopathy was conducted in the Department of Pathology Kathmandu Medical College Teaching hospital, Kathmandu from June 2006 to May 2008 (2 years). RESULTS: In this series of FNAC cervical lymph nodes were 66 (50.76%), and axillary lymph nodes were 20 (15.38%). Male to female ratio of the patients was 1: 0.9. The age of patients ranged from 3 to 85 years. FNAC diagnosis was found to be as follows : reactive hyperplasia 54( 41.55%), tubercular lymphadenitis 36 (28 %), metastatic carcinoma 16 (12.3%), granulomatous lymphadenitis 12 ( 9.2 % ), lymphoma 8 (6%) and suppurative lymphadenitis 4(3%) . Out of 28 cases of FNAC 26 (92.85%) were consistent with histopathological diagnosis of tubercular lymphadenitis. In metastatic carcinoma to lymph nodes sensitivity and specificity of FNAC were 100% each. CONCLUSION: FNAC is useful and reliable in diagnosing neoplastic and non- neoplastic lesions of lymph nodes. It helps in planning surgery for malignant cases, where definitive operative intervention can be performed in one session.

BACKGROUND: Poor mental health among medical students is widely acknowledged. Studies on mental health among medical students of Nepal are lacking. Therefore, we conducted a study to determine the prevalence of mental disorders. METHODS: A cross-sectional study was conducted among medical students at KIST Medical College and Teaching Hospital, Nepal from December 2016 to February 2017. Our survey instrument consisted of the Patient Health Questionnaire (PHQ) and questions about socio-demographic factors, smoking, marijuana use, suicidal ideation and thoughts of dropping out of medical school. RESULTS: The prevalence rates were 29.2% (95% CI, 24.4% - 34.3%) depression, 22.4% (95% CI, 18.0% - 26.9%) medium to highly severe somatic symptoms, 4.1% (95% CI, 2.0% - 6.2%) panic syndrome, 5.8% (95% CI, 3.4% - 8.3%) other anxiety syndrome, 5% (95% CI, 2.7% - 7.3%) binge eating disorder and 1.2% (95% CI, 0.0% - 2.3%) bulimia nervosa. Sixteen students [4.7% (95% CI, 2.4% - 6.9%)] seriously considered committing suicide while in medical school. Thirty-four students [9.9% (95% CI, 6.8% - 13.1%)] considered dropping out of medical school within the past month. About 15% (95% CI, 11.1% - 18.6%) of the students reported use of marijuana during medical school. CONCLUSIONS: We found high prevalence of poor mental health among medical students of Nepal. Future studies are required to identify the factors associated with poor mental health.

The future toll of the obesity epidemic will likely hit hardest in low- and middle-income countries. Ongoing urbanization promotes risk factors including sedentary lifestyle and fat- and sugar-laden diets. Low-income countries like Nepal experience a double disease burden: infectious diseases as well as rising incidence of noncommunicable diseases (e.g., cardiovascular disease and diabetes mellitus) frequently characterized by obesity. Nepal currently directs efforts towards curing disease but pays little attention to preventive actions. This article highlights obesity prevalence in Nepal, delineates the challenges identified by our pilot study (including low health literacy rates), and suggests strategies to overcome this trend.

BACKGROUND: Escherichia coli and Klebsiella pneumoniae are the major bacterial pathogens being isolated and reported from mid stream urine (MSU) specimens, globally. These uropathogens are mostly implicated as the major extended spectrum beta-lactamase (ESBL) producers, severely limiting the therapeutic management in cases of urinary tract infections. Limited studies had been reported from Nepal investigating the ESBL producers among uropathogens. This study was designed to assess the prevalence of ESBL producing E.coli and K. pneumoniae in urinary isolates at a centrally located major tertiary care hospital in Kathmandu valley, Nepal. METHODS: Between September 2011 and May 2012, during the nine months period, 6308 MSU specimens were collected aseptically from the same number of clinically suspected patients of urinary tract infections. The samples were cultured on MacConkey agar and blood agar. The isolates with significant bacteriuria (105 CFU / ml) were identified based on standard laboratory procedures. Antimicrobial susceptibility tests were carried out using various antimicrobial discs alongwith ceftriaxone on E.coli and K. pneumoniae isolates by Kirby Bauer disc diffusion method as per the recommendations of CLSI. On initial screening with ceftriaxone (30 μg) disc showing resistance was then confirmed for ESBL production by phenotypic confirmatory disc diffusion test (PCDDT) using ceftazidime (30 ug) and ceftazidime + clavulanic acid (30 μg + 10ug) disc as per guidelines of CLSI (2011). RESULTS: Out of a total of 6308 MSU specimens investigated for significant bacteriuria, E.coli isolates were 444 (7.04%) and K.pneuminiae were 145 (2.3%) making a total of 589 (9.34%). Initial screening with ceftriaxone disc revealed 155 isolates of E.coli and 70 isolates of K.pneumoniae to be resistant. Further testing by PCDDT method showed 60/444 (=13.51%) of E. coli and 24/145 (=16.55%) of K. pneumoniae isolates to be confirmed ESBL producers. These ESBL - producer uropathogens showed high degree of resistance to ceftriaxone (100.0%), amoxycillin, fluoroquinolones and co-trimoxazole. CONCLUSION: An emerging and moderately high prevalence of ESBL-producing E. coli and K. pneumoniae was observed and confirmed in the urinary isolates investigated. It is essential to have a regular and routine monitoring of ESBL producing clinical isolates in laboratory practice.

INTRODUCTION: Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal. METHODS: This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied. RESULTS: Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may "get stuck" in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity. CONCLUSION: The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.