Manipal College of Medical Sciences

BACKGROUND: In recent years there has been a growing appreciation of the issues of quality of life and stresses involved medical training as this may affect their learning and academic performance. However, such studies are lacking in medical schools of Nepal. Therefore, we carried out this study to assess the prevalence of psychological morbidity, sources and severity of stress and coping strategies among medical students in our integrated problem-stimulated undergraduate medical curriculum. METHODS: A cross-sectional, questionnaire-based survey was carried out among the undergraduate medical students of Manipal College of Medical Sciences, Pokhara, Nepal during the time period August, 2005 to December, 2006. The psychological morbidity was assessed using General Health Questionnaire. A 24-item questionnaire was used to assess sources of stress and their severity. Coping strategies adopted was assessed using brief COPE inventory. RESULTS: The overall response rate was 75.8% (407 out of 525 students). The overall prevalence of psychological morbidity was 20.9% and was higher among students of basic sciences, Indian nationality and whose parents were medical doctors. By logistic regression analysis, GHQ-caseness was associated with occurrence of academic and health-related stressors. The most common sources of stress were related to academic and psychosocial concerns. The most important and severe sources of stress were staying in hostel, high parental expectations, vastness of syllabus, tests/exams, lack of time and facilities for entertainment. The students generally used active coping strategies and alcohol/drug was a least used coping strategy. The coping strategies commonly used by students in our institution were positive reframing, planning, acceptance, active coping, self-distraction and emotional support. The coping strategies showed variation by GHQ-caseness, year of study, gender and parents' occupation. CONCLUSION: The higher level of psychological morbidity warrants need for interventions like social and psychological support to improve the quality of life for these medical students. Student advisors and counselors may train students about stress management. There is also need to bring about academic changes in quality of teaching and evaluation system. A prospective study is necessary to study the association of psychological morbidity with demographic variables, sources of stress and coping strategies.

BACKGROUND: Self-medication and non-doctor prescribing of drugs is common in developing countries. Complementary and alternative medications, especially herbs, are also commonly used. There are few studies on the use of these medications in Pokhara Valley, Western Nepal. METHODS: Previously briefed seventh semester medical students, using a semi-structured questionnaire, carried out the study on 142 respondents. Demographic information and information on drugs used for self-medication or prescribed by a non-allopathic doctor were collected. RESULTS: Seventy-six respondents (54%) were aged between 20 to 39 years. The majority of the respondents (72 %) stayed within 30 minutes walking distance of a health post/medical store. 59% of these respondents had taken some form of self-medication in the 6-month period preceding the study. The common reasons given for self-medication were mild illness, previous experience of treating a similar illness, and non-availability of health personnel. 70% of respondents were prescribed allopathic drugs by a non-allopathic doctor. The compounder and health assistant were common sources of medicines. Paracetamol and antimicrobials were the drugs most commonly prescribed. A significantly higher proportion of young (<40 years) male respondents had used self-medication than other groups. CONCLUSIONS: Self-medication and non-doctor prescribing are common in the Pokhara valley. In addition to allopathic drugs, herbal remedies were also commonly used for self-medication. Drugs, especially antimicrobials, were not taken for the proper duration. Education to help patients decide on the appropriateness of self-medication is required.

BACKGROUND: Delay in diagnosis of pulmonary tuberculosis results in increasing severity, mortality and transmission. Various investigators have reported about delays in diagnosis of tuberculosis. We aimed at summarizing the data on these delays in diagnosis of tuberculosis. METHODS: A systematic review of literature was carried out. Literature search was done in Medline and EMBASE from 1990 to 2008. We used the following search terms: delay, tuberculosis, diagnosis, and help-seeking/health-seeking behavior without language restrictions. In addition, indices of four major tuberculosis journals were hand-searched. Subject experts in tuberculosis and authors of primary studies were contacted. Reference lists, review articles and text book chapters were also searched. All the studies were assessed for methodological quality. Only studies carried out on smear/culture-positive tuberculosis patients and reporting about total, patient and health-care system delays were included. RESULTS: A total of 419 potential studies were identified by the search. Fifty two studies qualified for the review. The reported ranges of average (median or mean) total delay, patient delay, health system delay were 25-185 days, 4.9-162 days and 2-87 days respectively for both low and high income countries. Average patient delay was similar to health system delay (28.7 versus 25 days). Both patient delay and health system delay in low income countries (31.7 days and 28.5 days) were similar to those reported in high income countries (25.8 days and 21.5 days). CONCLUSION: The results of this review suggest that there is a need for revising case-finding strategies. The reported high treatment success rate of directly observed treatment may be supplemented by measures to shorten the delay in diagnosis. This may result in reduction of infectious cases and better tuberculosis control.

BACKGROUND: Studies from developed countries have reported on host-related risk factors for extra-pulmonary tuberculosis (EPTB). However, similar studies from high-burden countries like Nepal are lacking. Therefore, we carried out this study to compare demographic, life-style and clinical characteristics between EPTB and PTB patients. METHODS: A retrospective analysis was carried out on 474 Tuberculosis (TB) patients diagnosed in a tertiary care hospital in western Nepal. Characteristics of demography, life-style and clinical features were obtained from medical case records. Risk factors for being an EPTB patient relative to a PTB patient were identified using logistic regression analysis. RESULTS: The age distribution of the TB patients had a bimodal distribution. The male to female ratio for PTB was 2.29. EPTB was more common at younger ages (< 25 years) and in females. Common sites for EPTB were lymph nodes (42.6%) and peritoneum and/or intestines (14.8%). By logistic regression analysis, age less than 25 years (OR 2.11 95% CI 1.12-3.68) and female gender (OR 1.69, 95% CI 1.12-2.56) were associated with EPTB. Smoking, use of immunosuppressive drugs/steroids, diabetes and past history of TB were more likely to be associated with PTB. CONCLUSION: Results suggest that younger age and female gender may be independent risk factors for EPTB in a high-burden country like Nepal. TB control programmes may target young and female populations for EPTB case-finding. Further studies are necessary in other high-burden countries to confirm our findings.

INTRODUCTION: Urinary tract infection (UTI) is the most common nosocomial infection among hospitalised patients. Area-specific monitoring studies aimed to gain knowledge about the type of pathogens responsible for UTIs and their resistance patterns may help the clinician to choose the correct empirical treatment. Recent reports have shown increasing resistance to commonly-used antibiotics. We aimed to study the antibiotic resistance pattern of the urinary pathogens isolated from hospitalised patients. METHODS: Three urine samples were collected by the mid-stream "clean catch" method from 1,680 clinically-suspected cases of urinary tract infections from inpatients of various clinical departments during one year. The samples were tested microbiologically by standard procedures. Antibiotic susceptibility of the isolated pathogens was tested for commonly-used antibiotics by Kirby-Bauer technique according to NCCLS guidelines. RESULTS: Significant bacteriuria was present in 71.7 percent of the samples, 17 percent were sterile, 4.8 percent showed insignificant bacteriuria, and 6.5 percent non-pathogenic bacteriuria. The most common pathogens isolated were Escherichia coli (59.4 percent), Klebsiella spp (15.7 percent) and Enterococcus faecalis (8.1 percent). The mean susceptibility was high for amikacin (87.2 percent), ciprofloxacin (74.8 percent), ceftazidime (71.5 percent) and gentamicin (70.4 percent) but low for nitrofurantoin (35 percent), cephalexin (49.7 percent) and ampicillin (50.5 percent). Escherichia coli was found to be most susceptible to amikacin (98 percent) followed by gentamicin (87.9 percent), ceftazidime (80.8 percent), norfloxacin (78.4 percent) and cotrimoxazole (77.9 percent). CONCLUSION: A high isolation rate of pathogens from urine samples of clinically-suspected UTI shows a good correlation between clinical findings and microbiological methods. The antibiotics commonly used in UTIs are less effective. Since the present study was a cross-sectional study, regular monitoring is required to establish reliable information about resistance pattern of urinary pathogens for optimal empirical therapy of patients with nosocomial UTIs.

BACKGROUND: Road Traffic Accident (RTA) is one among the top five causes of morbidity and mortality in South-East Asian countries.(1) Its socioeconomic repercussions are a matter of great concern. Efficient addressing of the issue requires quality information on different causative factors. RESEARCH QUESTION: What are different epidemiological determinants of RTA in western Nepal? OBJECTIVE: To examine the factors associated with RTA. STUDY DESIGN: Prospective observational. SETTING: Study was performed in a tertiary healthcare delivery institute in western Nepal. PARTICIPANTS: 360 victims of RTA who reported to Manipal Teaching hospital in one year. STUDY VARIABLES: Demographic, human, vehicular, environmental and time factors. STATISTICAL ANALYSIS: Percentages, linear and logarithmic trend and Chi-square. RESULTS: Most of the victims i.e. 147 (40.83%) were young (15 to 30 years); from low i.e. 114 (31.66%) and mid i.e. 198 (55%) income families and were passengers i.e. 153 (42.50%) and pedestrians i.e. 105 (29.16%). Sever accidents leading to fatal outcome were associated with personal problems (P<0.01, chi(2) - 8.03), recent or on-day conflicts (P<0.001, chi(2) - 18.88) and some evidence of alcohol consumptions (P<0.001, chi(2) - 30.25). Increased prevalence of RTA was also noticed at beginning i.e. 198 (55%) and end i.e. 69 (19.16%) of journey; in rainy and cloudy conditions (269 i.e. 74.72%) and in evening hours (3 to 7 p.m. 159 i.e. 44.16%). Out of 246 vehicles involved; 162 (65.85%) were old and ill maintained. The contributions of old vehicle to fatal injuries were 33 (50%). Head injury was found in 156 (43.33 %) cases and its associated case fatality rate was 90.90%. In spite of a good percentage receiving first aid i.e. 213 (59.16%) after RTA; there was a notable delay (174 i.e. 48.33% admitted after 6 h) in shifting the cases to the hospitals. The estimated total days lost due to hospital stay was 4620 with an average of 12.83 days per each case. CONCLUSION: Most of the factors responsible for RTA and its fatal consequences are preventable. A comprehensive multipronged approach can mitigate most of them.

BACKGROUND: The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%. The purpose of our study was to assess care seeking behaviour of the mothers during childhood illness and to determine the predictors of mother's care seeking behaviour. METHODS: A cross-sectional survey was conducted in the immunization clinics of Pokhara city, Kaski district, western Nepal. A trained health worker interviewed the mothers of children suffering from illness during the preceding 15 days. RESULTS: A total of 292 mothers were interviewed. Pharmacies (46.2%) were the most common facilities where care was sought followed by allopathic medical practitioners (26.4%). No care was sought for 8 (2.7%) children and 26 (8.9%) children received traditional/home remedies. 'Appropriate', 'prompt' and 'appropriate and prompt' care was sought by 77 (26.4%), 166 (56.8%) and 33 (11.3%) mothers respectively. The mothers were aware of fever (51%), child becoming sicker (45.2%) and drinking poorly (42.5%) as the danger signs of childhood illness. By multiple logistic regression analysis total family income, number of symptoms, mothers' education and perceived severity of illness were the predictors of care seeking behaviour. CONCLUSION: The results of the present study show that the mothers were more likely to seek care when they perceived the illness as 'serious'. Poor maternal knowledge of danger signs of childhood illness warrants the need for a complementary introduction of community-based Integrated Management of Childhood Illness programmes to improve family's care seeking behaviour and their ability to recognize danger signs of childhood illness. Socioeconomic development of the urban poor may overcome their financial constraints to seek 'appropriate' and 'prompt' care during the childhood illness.

BACKGROUND: In Nepal, tuberculosis (TB) is a major problem. Worldwide, six previous epidemiologic studies have investigated whether indoor cooking with biomass fuel such as wood or agricultural wastes is associated with TB with inconsistent results. OBJECTIVES: Using detailed information on potential confounders, we investigated the associations between TB and the use of biomass and kerosene fuels. METHODS: A hospital-based case-control study was conducted in Pokhara, Nepal. Cases (n = 125) were women, 20-65 years old, with a confirmed diagnosis of TB. Age-matched controls (n = 250) were female patients without TB. Detailed exposure histories were collected with a standardized questionnaire. RESULTS: Compared with using a clean-burning fuel stove (liquefied petroleum gas, biogas), the adjusted odds ratio (OR) for using a biomass-fuel stove was 1.21 [95% confidence interval (CI), 0.48-3.05], whereas use of a kerosene-fuel stove had an OR of 3.36 (95% CI, 1.01-11.22). The OR for use of biomass fuel for heating was 3.45 (95% CI, 1.44-8.27) and for use of kerosene lamps for lighting was 9.43 (95% CI, 1.45-61.32). CONCLUSIONS: This study provides evidence that the use of indoor biomass fuel, particularly as a source of heating, is associated with TB in women. It also provides the first evidence that using kerosene stoves and wick lamps is associated with TB. These associations require confirmation in other studies. If using kerosene lamps is a risk factor for TB, it would provide strong justification for promoting clean lighting sources, such as solar lamps.

BACKGROUND: About 98% of newborn deaths occur in developing countries, where most newborns deaths occur at home. In Nepal, approximately, 90% of deliveries take place at home. Information about reasons for delivering at home and newborn care practices in urban areas of Nepal is lacking and such information will be useful for policy makers. METHODS: A cross-sectional survey was carried out in the immunisation clinics of Pokhara city, western Nepal during January and February, 2006. Two trained health workers administered a semi-structured questionnaire to the mothers who had delivered at home. RESULTS: A total of 240 mothers were interviewed. Planned home deliveries were 140 (58.3%) and 100 (41.7%) were unplanned. Only 6.2% of deliveries had a skilled birth attendant present and 38 (15.8%) mothers gave birth alone. Only 46 (16.2%) women had used a clean home delivery kit and only 92 (38.3%) birth attendants had washed their hands. The umbilical cord was cut after expulsion of placenta in 154 (64.2%) deliveries and cord was cut using a new/boiled blade in 217 (90.4%) deliveries. Mustard oil was applied to the umbilical cord in 53 (22.1%) deliveries. Birth place was heated throughout the delivery in 88 (64.2%) deliveries. Only 100 (45.8%) newborns were wrapped within 10 minutes and 233 (97.1%) were wrapped within 30 minutes. Majority (93.8%) of the newborns were given a bath soon after birth. Mustard oil massage of the newborns was a common practice (144, 60%). Sixteen (10.8%) mothers did not feed colostrum to their babies. Prelacteal feeds were given to 37(15.2%) newborns. Initiation rates of breast-feeding were 57.9% within one hour and 85.4% within 24 hours. Main reasons cited for delivering at home were 'preference' (25.7%), 'ease and convenience' (21.4%) for planned deliveries while 'precipitate labor' (51%), 'lack of transportation' (18%) and 'lack of escort' during labor (11%) were cited for the unplanned ones. CONCLUSION: High-risk home delivery and newborn care practices are common in urban population also. In-depth qualitative studies are needed to explore the reasons for delivering at home. Community-based interventions are required to improve the number of families engaging a skilled attendant and hygiene during delivery. The high-risk traditional newborn care practices like delayed wrapping, bathing, mustard oil massage, prelacteal feeding and discarding colostrum need to be addressed by culturally acceptable community-based health education programmes.

SARS-CoV-2 infection associated respiratory disease- COVID-19 has evolved into a pandemic but, being a new form of virus, pathogenesis of disease causation is not fully understood and drugs and vaccines against this virus are still being tested so that no effective drugs or vaccines have been advised by regulatory authority. In this context, the Ministry of AYUSH, Government of India has recommended ‘Ayush Kwath’ to improve the immunity and combat the infection. Our objective of this literature review is to review the role of immunity in pathogenesis of COVID-19 and role of Ayush Kwath against the virus and regulation of immunity. Current review was conducted using a search of available literature on COVID-19 and immunity, Vyadhikshamatwa, Ayurveda and COVID-19, Rasayana, Coronavirus, SARS-CoV-2, immunomodulatory effects of medicinal plants; Tulsi/Holy Basil/Ocimum sanctum, Dalchini/Cinnamon/Cinnamomum zeylanicum, Sunthi/Ginger/Zingiber officinale and Marich/Black Pepper/Piper nigrum. Ayurveda, being an ancient science have both medicinal and cultural values and had stimulated our kitchen and influenced what we ate in different seasons and the remedies we used for common ailments. Herbs such as Tulsi, Marich, Sunthi, Dalchini are the most commonly used and easily available drugs in home. Thus, Ayush Kwath due to its immune-modulatory, antiviral, anti-oxidant, anti-inflammatory, anti-platelet, anti-atherosclerotic, hepato-protective, reno-protective properties; seems to be effective in immuno-regulation for controlling viral infections like COVID-19. Further pre-clinical and clinical trials need to be done for the evaluation of safety and efficacy of this polyherbal formulation.

Sample size determination is one of the central tenets of medical research. If the sample size is inadequate, then the study will fail to detect a real difference between the effects of two clinical approaches. On the contrary, if the sample size is larger than what is needed, the study will become cumbersome and ethically prohibitive. Apart from this, the study will become expensive, time consuming and will have no added advantages. A study which needs a large sample size to prove any significant difference in two treatments must ensure the appropriate sample size. It is better to terminate such a study when the required sample size cannot be attained so that the funds and manpower can be conserved. When dealing with multiple sub-groups in a population the sample size should be increased the adequate level for each sub-group. To ensure the reliability of final comparison of the result, the significant level and power must be fixed before the sample size determination. Sample size determination is very important and always a difficult process to handle. It requires the collaboration of a specialist who has good scientific knowledge in the art and practice of medical statistics. A few suggestions are made in this paper regarding the methods to determine an optimum sample size in descriptive and analytical studies.Key Words: Sample size; Power analysis; Medical researchDOI: 10.3126/nje.v1i1.4100Nepal Journal of Epidemiology 2010;1 (1):4-10

BACKGROUND: Methicillin resistant Staphylococcus aureus (MRSA) is a major human pathogen associated with nosocomial and community infections. Panton Valentine leukocidin (PVL) is considered one of the important virulence factors of S. aureus responsible for destruction of white blood cells, necrosis and apoptosis and as a marker of community acquired MRSA. This study was aimed to determine the prevalence of PVL genes among MRSA isolates and to check the reliability of PVL as marker of community acquired MRSA isolates from Western Nepal. METHODS: A total of 400 strains of S. aureus were collected from clinical specimens and various units (Operation Theater, Intensive Care Units) of the hospital and 139 of these had been confirmed as MRSA by previous study. Multiplex PCR was used to detect mecA and PVL genes. Clinical data as well as antimicrobial susceptibility data was analyzed and compared among PVL positive and negative MRSA isolates. RESULTS: Out of 139 MRSA isolates, 79 (56.8 %) were PVL positive. The majority of the community acquired MRSA (90.4 %) were PVL positive (Positive predictive value: 94.9 % and negative predictive value: 86.6 %), while PVL was detected only in 4 (7.1 %) hospital associated MRSA strains. None of the MRSA isolates from hospital environment was found positive for the PVL genes. The majority of the PVL positive strains (75.5 %) were isolated from pus samples. Antibiotic resistance among PVL negative MRSA isolates was found higher as compared to PVL positive MRSA. CONCLUSION: Our study showed high prevalence of PVL among community acquired MRSA isolates. Absence of PVL among MRSA isolates from hospital environment indicates its poor association with hospital acquired MRSA and therefore, PVL may be used a marker for community acquired MRSA. This is first study from Nepal, to test PVL among MRSA isolates from hospital environment.

BACKGROUND: Majority of Nepalese women live in remote rural areas, where health services are not easily accessible. We determined the validity of Menopause Rating Scale (MRS) as a screening tool for identification of women with severe menopausal symptoms and cut-off MRS score for referral. METHODS: A cross-sectional survey was carried out between February and August, 2008. Trained health workers administered MRS and a questionnaire to 729 women (40 to 65 years) attending health screening camps in Kaski district of Western Development Region of Nepal. Information about demographics, menopausal status, and use of hormone replacement therapy (HRT), chronic disease, self-perceived general health and reproductive history was also collected. Menopausal status was classified according to the Staging of Reproductive Ageing Workshop (STRAW). We calculated rates of menopausal symptoms, sensitivity, and specificity and likelihood ratios of MRS scores for referral to a gynaecologist. We also carried out multivariate analyses to identify the predictors for referral to a gynaecologist for severe symptoms. RESULTS: A total 729 women were interviewed. Mean age at menopause was 49.9 years (SD 5.6). Most frequently reported symptoms were, sleeping problems (574, 78.7%), physical and mental exhaustion (73.5%), hot flushes (508, 69.7%), joint and muscular discomfort (500, 68.6%) and dryness of vagina (449, 61.6%). Postmenopausal women (247, 33.9%) and perimenopausal (215, 29.5%) women together experienced significantly higher prevalence of all symptoms than the premenopausal (267, 36.6%) women. MRS score of ≥16 had highest ratio for (sensitivity + specificity)/2. Women who reported urogenital symptoms [OR 5.29, 95% CI 2.59, 10.78], and self perceived general health as poor [OR 1.29, 95% CI 1.11, 1.53] were more likely to be referred to a gynaecologist for severe menopausal symptoms. While women reporting somatic [OR 0.72, 95% CI 0.63, 0.82] and psychological [OR 0.86, 95% CI 0.74, 0.99] symptoms were less likely to be referred. CONCLUSION: MRS may be used as a screening tool at a cut-off score of ≥16 with least misclassification rate. However, its utility may be limited by woman's general health status and occurrence of urogenital symptoms.

BACKGROUND: There are various factors which construct the perception of stigma in both leprosy affected persons and unaffected persons. The main purpose of this study was to determine the level of perceived stigma and the risk factors contributing to it among leprosy affected person attending the Green Pastures Hospital, Pokhara municipality of western Nepal. METHODS: A cross-sectional study was conducted among 135 people affected by leprosy at Green Pastures Hospital and Rehabilitation Centre. Persons above the age of 18 were interviewed using a set of questionnaire form and Explanatory Model Interview Catalogue (EMIC). In addition, two sets of focused group discussions each containing 10 participants from the ward were conducted with the objectives of answering the frequently affected EMIC items. RESULTS: Among 135 leprosy affected persons, the median score of perceived stigma was 10 while it ranged from 0-34. Higher perceived stigma score was found in illiterate persons (p=0.008), participants whose incomes were self-described as inadequate (p=0.014) and who had changed their occupation due to leprosy (p=0.018). Patients who lacked information on leprosy (p=0.025), knowledge about the causes (p=0.02) and transmission of leprosy (p=0.046) and those who had perception that leprosy is a severe disease (p<0.001) and is difficult to treat (p<0.001) had higher perceived stigma score. Participants with disfigurement or deformities (p=0.014), ulcers (p=0.022) and odorous ulcers (p=0.043) had higher perceived stigma score. CONCLUSION: The factors associated with higher stigma were illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat. Similarly, visible deformities and ulcers were associated with higher stigma. There is an urgent need of stigma reduction strategies focused on health education and health awareness programs in addition to the necessary rehabilitation support.

Abstract Background Objects frequently touched by patients and healthcare workers in hospitals harbor potential pathogens and may act as source of infectious agents. This study aimed to determine the bacterial contamination of common hospital objects frequently touched by patients, visitors and healthcare workers. Methods A total of 232 samples were collected from various sites like surface of biometric attendance devices, elevator buttons, door handles, staircase railings, telephone sets and water taps. Isolation, identification and antibiotic susceptibility testing of the isolates was performed by standard microbiological techniques. Biofilm forming ability of the S. aureus isolates was tested by a microtitre plate method. Results A total of 232 samples were collected and 219 bacterial isolates were recovered from 181 samples. Staphylococcus aureus was the most common bacterial isolate (44/219). Majority of S. aureus isolates were recovered from elevator buttons, biometric attendance devices and door handles. Among the S. aureus isolates, 36.3% (16/44) were methicillin resistant Staphylococcus aureus (MRSA) while remaining were methicillin sensitive Staphylococcus aureus (MSSA). Out of 44 S. aureus isolates, 12 (29.5%) were multidrug resistant and 14 (31.8%) were biofilm producers. The majority of MRSA isolates 62.5% (10/16) were biofilm producers. Acinetobacter was the most common Gram negative isolate followed by E coli and Pseudomonas species. Conclusions High bacterial contamination of frequently touched objects with variety of potential pathogens and normal flora was detected. S. aureus was the most common bacterial isolate. Biofilm forming ability offers additional survival advantage to the organisms on these objects. Present study highlights the need of improved hand hygiene among healthcare workers and regular cleaning/disinfection of sites of frequent public contact.

BACKGROUND: In future, increase in the number of healthcare professionals is dependent on the career interest among present undergraduate medical students. Based on their interest to pursue their specialty, the availability of medical doctors in each specialty could be done. AIMS: This study was to find out future career interest and factors that influence undergraduate medical students to choose their future specialization. MATERIALS AND METHODS: The study was carried out among first-year medical students from five countries. The students were asked to complete an 8-item questionnaire. Two thousand one hundred fifty three participants were enrolled in the study. Data were analyzed in Microsoft-Excel and Statistical Package for the Social Sciences. RESULTS: Of the 2153 participants, only 1470 responded. Among the 1470 participants, 169 participants were excluded due to the ambiguity in responses, finally making it to 1301participants. Among them, Anatomy (49.3%) followed by Biochemistry (26.7%) and Physiology (24%) were the most preferred subjects. CONCLUSIONS: Anatomy was the most preferred basic science subject among the other subjects and the students were interested to pursuing surgery in future. Furthermore, the most preferred future specialties were surgery, internal medicine and pediatrics with gender variations; males preferring surgery and females in obstetrics and gynecology.

BACKGROUND: College students are vulnerable to tobacco addiction. Tobacco industries often target college students for marketing. Studies about prevalence of tobacco use and its correlates among college students in Nepal are lacking. METHODS: A cross-sectional survey was carried out in two cities of western Nepal during January-March, 2007. A pre-tested, anonymous, self-administered questionnaire (in Nepali) adapted from Global Youth Tobacco Survey (GYTS) and a World Bank study was administered to a representative sample of 1600 students selected from 13 junior colleges by two-stage stratified random sampling. RESULTS: Overall prevalence of 'ever users' of tobacco products was 13.9%. Prevalence among boys and girls was 20.5% and 2.9% respectively. Prevalence of 'current users' was 10.2% (cigarette smoking: 9.4%, smokeless products: 6.5%, and both forms: 5.7%). Median age at initiation of cigarette smoking and chewable tobacco was 16 and 15 years respectively. Among the current cigarette smokers, 58.7% (88/150) were smoking at least one cigarette per day. Most (67.8%) 'Current users' purchased tobacco products by themselves from stores or got them from friends. Most of them (66.7%) smoked in tea stalls or restaurants followed by other public places (13.2%). The average daily expenditure was 20 Nepalese rupees (approximately 0.3 USD) and most (59%) students reported of having adequate money to buy tobacco products. Majority (82%) of the students were exposed to tobacco advertisements through magazines/newspapers, and advertising hoardings during a period of 30 days prior to survey. The correlates of tobacco use were: age, gender, household asset score and knowledge about health risks, family members, teachers and friends using tobacco products, and purchasing tobacco products for family members. CONCLUSION: School/college-based interventions like counseling to promote cessation among current users and tobacco education to prevent initiation are necessary. Enforcement of legislations to decrease availability, accessibility and affordability of tobacco products and policies to change social norms of tobacco use among parents and teachers are necessary to curb the tobacco use among college students.

INTRODUCTION: Studies have shown self-medication to be common among medical students. These studies are however, few in Nepal. The present study assessed knowledge, attitude, and practice of self-medication among second and fourth semesters' undergraduate medical students and studied differences in knowledge and attitude (if any) among different subgroups of the respondents. MATERIALS AND METHODS: A cross-sectional survey was conducted using a questionnaire among basic science medical students of Manipal College of Medical Sciences, Nepal. Semester of study, gender, age, nationality, and the profession of their parents were noted. Students' knowledge and attitude about self-medication was studied by noting their degree of agreement with a set of 40 statements using a Likert-type scale. The average scores and frequency of occurrence of particular behaviors among different categories of respondents were compared using appropriate statistical tests. RESULTS: Two hundred and seventy-six of the 295 (93.6%) students participated. The mean (SD) knowledge, attitude, and total scores were 74.54 (6.92), 67.18 (5.68), and 141.73 (10.76) with maximum possible scores 100, 100 and 200, respectively. There was no significant difference in scores according to respondents' gender, age, and the profession of their parents. However, the mean knowledge, attitude and total scores were significantly different among students of different nationalities. Mean scores of fourth semester students were significantly higher compared to second semester students. There were differences in knowledge and total scores among students of different nationalities. Eighty two percent of respondents had self-medicated during the one year period preceding the study; 149 respondents (54%) shared that previous experience with the medicine was one of the information sources for self-medication. Prevalence of self-medication among respondents according to semester of study, gender, age, and profession of the parents was not significantly different. The use of self-medication was more common among Sri Lankan respondents compared to Nepalese. Painkillers (73.2%), antipyretics (68.8%), and antimicrobials (56.2%) were most commonly used for self-medication. CONCLUSION: Students' knowledge and attitude about self-medication is good. The prevalence of self-medication among medical students was high.

OBJECTIVE: To assess rates of initiation of breast-feeding and exclusive breast-feeding within 2 months after delivery and to determine the factors influencing exclusive breast-feeding. DESIGN: A health worker-administered questionnaire survey was carried out during the time period 1 August-30 September 2005. SETTING: Immunisation clinics of Pokhara, a submetropolitan city in western Nepal. SUBJECTS: Three hundred and eighty-five mothers who had delivered a child within the previous 2 months. RESULTS: The rates of initiation within 1 h and within 24 h of delivery were 72.7 and 84.4%, respectively. Within 2 months after delivery, exclusive breast-feeding was practised by 82.3% of the mothers. Breast milk/colostrum was given as the first feed to 332 (86.2%) babies but 17.2% of them were either given expressed breast milk or were put to the breast of another lactating mother. Pre-lacteal feeds were given to 14% of the babies. The common pre-lacteal feeds given were formula feeds (6.2%), sugar water (5.9%) and cow's milk (2.8%). Complementary feeds were introduced by 12.7% of the mothers. By logistic regression analysis, friends' feeding practices, type of delivery and baby's first feed were the factors influencing exclusive breast-feeding practice of the mothers. CONCLUSIONS: Despite the higher rates of initiation and exclusive breast-feeding, practices such as pre-lacteal feeds and premature introduction of complementary feeds are of great concern in this urban population. There is a need for promotion of good breast-feeding practices among expectant mothers and also the community, especially the families, taking into account the local traditions and customs.

Cavitas sensors and point-of-need sensors capable of providing physical and biochemical information from the oral cavity and saliva have attracted great attention because they offer remarkable advantages for noninvasive sensing systems. Herein, we introduce the basic anatomy and physiology of important body cavities to understand their characteristics as it is a pivotal foundation for the successful development of in-mouth devices. Next, the advanced development in lab-in-a-mouth sensors and point-of-need sensors for analyzing saliva are explained. In addition, we discuss the integrations of artificial intelligence and electronic technologies in smart sensing networks for healthcare systems. This review ends with a discussion of the challenges, future research trends, and opportunities in relevant disciplines. Mouthguard-based sensors and conventional salivary sensing devices will continue to be significant for the progress in the next-generation sensing technologies and smart healthcare systems.