Manipal Teaching Hospital

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.

Public health surveillance conducted by health departments in the United States has improved in completeness and timeliness owing to electronic laboratory reporting. However, the collection of detailed clinical information about reported cases, which is necessary to confirm the diagnosis, to understand transmission, or to determine disease-related risk factors, is still heavily dependent on manual processes. The increasing prevalence and functionality of electronic health record (EHR) systems in the United States present important opportunities to advance public health surveillance. EHR data have the potential to further increase the breadth, detail, timeliness, and completeness of public health surveillance and thereby provide better data to guide public health interventions. EHRs also provide a unique opportunity to expand the role and vision of current surveillance efforts and to help bridge the gap between public health practice and clinical medicine.

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.

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.

Motherhood confers upon a woman the responsibility of raising a child. This process also changes the way in which she is perceived in society and at her workplace. It can necessitate her to take more than available leave options, and job security can be at risk. Significant social and personal adjustments are necessary to cope with such a situation. A working mother, especially one who has the good fortune to be able to balance her home and work, enjoys the stimulation that a job or career provides. She develops the ability of raising a useful member of society and at the same time gains financial independence. Along with motherhood, work adds to the completeness of being a woman.

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.

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: 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.

BACKGROUND: Information about antibiotic use and resistance patterns of common microorganisms are lacking in hospitals in Western Nepal. Excessive and inappropriate use of antibiotics contributes to the development of bacterial resistance. The parameter: Defined daily dose/100 bed-days, provides an estimate of consumption of drugs among hospital in-patients. This study was carried out to collect relevant demographic information, antibiotic prescribing patterns and the common organisms isolated including their antibiotic sensitivity patterns. METHODS: The study was carried out over a 3-month period (01.04.2002 to 30.06.2002) at the Manipal Teaching Hospital, Western Nepal. The median number of days of hospitalization and mean +/- SD cost of antibiotics prescribed during hospital stay were calculated. The use of antibiotics was classified for prophylaxis, bacteriologically proven infection or non-bacteriologically proven infection. Sensitivity patterns of the common organisms were determined. Defined daily dose/100 bed-days of the ten most commonly prescribed antibiotics were calculated. RESULTS: 203 patients were prescribed antibiotics; 112 were male. Median duration of hospitalization was 5 days. 347 antibiotics were prescribed. The most common were ampicillin, amoxicillin, metronidazole, ciprofloxacin and benzylpenicillin. Mean +/- SD cost of antibiotics was 16.5 +/-13.4 US dollars. Culture and sensitivity testing was carried out in 141 patients. The common organisms isolated were H. influenzae, E. coli, K. pneumoniae and S. aureus. CONCLUSIONS: Antibiotic resistance is becoming a problem in the Internal Medicine ward. Formulation of a policy for hospital antibiotic use and an educational programme especially for junior doctors is required.

OBJECTIVES: To analyze the prescriptions of out-patients for rational prescribing and dispensing and to evaluate the patient's knowledge regarding use of drugs, using INRUD indicators. METHODS: A cross-sectional, descriptive study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal during the time period from June 10th to August 19th 2004. RESULTS: Totally 247 prescriptions were randomly selected for analysis, wherein 720 drugs were prescribed. Only 15% of drugs were prescribed by generic name, 21.67% of the total drugs consisted of fixed-dose combinations, only 40% of drugs were from the Essential drug list of Nepal and 29.44% (n=212) were from the WHO Essential drug list. It was found that more than half (54.17%) of the drugs were from Nepalese National Formulary and 35.69% were from WHO model formulary. Dermatological products were most commonly prescribed followed by drugs acting on central nervous system, antimicrobials and drugs acting on cardiovascular system. Among the drugs dispensed, 79.16% were oral followed by topical (18.19%) and parenteral forms (2.98%). Diagnosis was mentioned only in 3.23% (n=8) of the prescriptions and the average cost per prescription was found to be 241.11 Nepalese rupees (US$ 3.26). It was found out that pharmacist labelled only 0.4% of the medication envelopes with the name of the patient. However, 82.6% of the medication envelopes were labelled with name of the drug and 87.0% with drug strength. Only 53.8% (n=133) of the patient knew both the duration of the therapy and administration time of drugs. CONCLUSION: There is a need for educational intervention for prescribers and both managerial and educational intervention for the hospital pharmacists to improve prescribing and dispensing.

BACKGROUND: Neonatal sepsis is one of the commonest causes of neonatal mortality in the developing world. The neonatal intensive care units (NICUs) today face one common problem of tackling sepsis and neonatologists remain constantly baffled by the changing patterns of microbial flora and their sensitivity patterns. With the neonatal services coming of age in Nepal this retrospective analysis spread over a period of six years has become very pertinent. MATERIALS AND METHODS: We conducted a retrospective study over a period of six years to study the prevalence of different organisms causing septicaemia in the community and at our hospital and the antibiotic susceptibility pattern. In all 265 cases of suspected sepsis were screened using a panel consisting of CRP, ANC and I/T ratio and subsequently confirmed by cultures. The cases were early onset (n=44), late onset (n=56) and nosocomial groups (n=40). The data for the intramural (n=32) and extramural (n=68) cases was analysed separately. RESULTS: One hundred nineteen cultures out of the 131 positives were obtained from blood (44.92%) and the remaining were isolated from urine (6.11 %) and CSF (4.58 %). The most common organism to be isolated was staphylococcus aureus (42.75%) followed by klebsiella pneumoniae (18.32%)and escherechia coli (12.21%). Staphylococcus was isolated from 36.84%, 45.16% and 31.81% of the cultures obtained from neonates in the in-born, out-born and the nosocomial groups respectively while klebsiella pneumoniae [18.32 %] was seen in 21.05 %, 17.39 % and 36.36 % in each of the three groups. Pseudomonas aeruginosa [6.11 %] was isolated from 13.64 % of the nosocomial cultures compared to 8.7 % of the out-borns while it was not seen in the in-borns. Other organisms isolated were much less in number, included - pathogenic streptococci, acinetobacter and enterobacter species. Coagulase negative staphylococci (CoNS) was seen in 4.39 % [n=4] and 9.09 % [n=4] of the same groups respectively. The gram positive organisms displayed a high degree of resistance to most penicillins and cephalosporins but glycopeptides and monobactams were effective in them. There was a high incidence of resistance noted with most third generation cephalosporins and aminoglycosides amongst most gram negative organisms where-in cefepime and imepenem were effective in most cases. CONCLUSIONS: Staphylococcal sepsis is not only common in community acquired infections but also in nosocomial sepsis. There is an emerging resistance to cephalosposrins probably attributable to extended spectrum betalactamases. Further large-scale multicentre studies are required to generalise the data for the whole country.

PURPOSE: The objectives of this study were to characterise the sexual health of street-connected adolescents in Eldoret, Kenya, analyse gender disparity of risks, estimate the prevalence of sexually transmitted infections (STIs), and identify factors associated with STIs. METHODS: A cross-sectional study of street-connected adolescents ages 12-21 years was conducted in Eldoret, Kenya. Participants were interviewed and screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus-2, syphilis and HIV. Descriptive statistics and logistic regression were used to identify factors associated with having any STI. RESULTS: Of the 200 participants, 81 (41%) were female. 70.4% of females and 60.5% of males reported sexual activity. Of those that participated in at least one STI test, 28% (55/194) had ≥1 positive test, including 56% of females; 14% (28/194) had >1 positive test. Twelve females and zero males (6% overall, 14.8% of females) were HIV positive. Among females, those with HIV infection more frequently reported transactional sex (66.7% vs. 26.1%, p=0.01), drug use (91.7% vs. 56.5%, p=0.02), and reported a prior STI (50.0% vs. 14.7%, p<0.01). Having an adult caregiver was less likely among those with HIV infection (33.3% vs. 71.0%, p=0.04). Transactional sex (AOR 3.02, 95% CI (1.05 to 8.73)), a previous STI (AOR 3.46 95% CI (1.05 to 11.46)) and ≥2 sexual partners (AOR 5.62 95% (1.67 to 18.87)) were associated with having any STI. CONCLUSIONS: Street-connected adolescents in Eldoret, Kenya are engaged in high-risk sexual behaviours and females in particular have a substantial burden of STIs and HIV. There is a need for STI interventions targeted to street-connected youth.

Abstract Rationale The burden of critical care is greatest in resource-limited settings. Intensive care unit (ICU) outcomes at public hospitals in Kenya are unknown. The present study is timely, given the Kenyan Ministry of Health initiative to expand ICU capacity. Objectives To identify factors associated with mortality at Moi Teaching and Referral Hospital and validate the Mortality Probability Admission Model II (MPM0-II). Methods A retrospective cohort of 450 patients from January 1, 2013, to April 5, 2015, was evaluated using demographics, presenting diagnoses, interventions, mortality, and cost data. Results ICU mortality was 53.6%, and 30-day mortality was 57.3%. Most patients were male (61%) and at least 18 years old (70%); the median age was 29 years. Factors associated with high adjusted odds of mortality were as follows: age younger than 10 years (adjusted odds ratio [aOR], 3.59; P ≤ 0.001), ages 35–49 years (aOR, 3.13; P = 0.002), and age above 50 years (aOR, 2.86; P = 0.004), with reference age range 10–24 years; sepsis (aOR, 3.39; P = 0.01); acute stroke (aOR, 8.14; P = 0.011); acute respiratory failure or mechanical ventilation (aOR, 6.37; P &amp;lt; 0.001); and vasopressor support (aOR, 7.98; P &amp;lt; 0.001). Drug/alcohol poisoning (aOR, 0.33; P = 0.005) was associated with lower adjusted odds of mortality. MPM0-II discrimination showed an area under the receiver operating characteristic curve of 0.78 (95% confidence interval, 0.72–0.82). The result of the Hosmer-Lemeshow test for calibration was significant (P &amp;lt; 0.001). Conclusions In a Kenyan public ICU, high mortality was noted despite the use of advanced therapies. MPM0-II has acceptable discrimination but poor calibration. Modification of MPM0-II or development of a new model using a prospective multicenter global collaboration is needed. Standardized triage and treatment protocols for high-risk diagnoses are needed to improve ICU outcomes.

AIM: Drug-drug interaction (DDI) is of major concern in patients with complex therapeutic regimens. The involvement of cardiovascular medicines in drug interaction is even higher. However, reports of DDI between these groups of drugs are few. The study aims to identify the potential DDI among hospitalized cardiac patients. Furthermore, we assessed the possible risk factors associated with these interactions. SUBJECTS AND METHODS: The Type of study prospective observational study was conducted from May 2012 to August 2012 among hospitalized cardiac patients. Cardiac patients who were taking at least two drugs and who had a hospital stay of at least 24 h were enrolled. The medications of the patients were analyzed for possible interactions using the standard drug interaction database - Micromedex -2 (Thomson Reuters) × 2.0. RESULTS: From a total of 150 enrolled patients, at least one interacting drug combination was identified among 32 patients. The incidence of potential DDI was 21.3%. A total of 48 potentially hazardous drug interactions were identified. Atorvastatin/azithromycin (10.4%), enalapril/metformin (10.4%), enalapril/potassium chloride (10.4%), atorvastatin/clarithromycin (8.3%) and furosemide/gentamicin (6.3%) were the most common interacting pairs. Drugs most commonly involved were atorvastatin, enalapril, digoxin, furosemide, clopidogrel and warfarin. Majority of interactions were of moderate severity (62.5%) and pharmacokinetic (58.3%) in nature. Increased number of medicines, prolonged hospital stays and comorbid conditions were the risk factors found associated with the potential DDI. CONCLUSIONS: This study highlighted the need of intense monitoring of patients who have identified risk factors to help detect and prevent them from serious health hazards associated with drug interactions.

A drug utilisation review was carried out in the medical outpatient department of the Manipal teaching hospital, a tertiary care hospital in Pokhara, western Nepal, to determine the prescribing frequency of commonly used drugs. An attempt was made to relate prescription data to age and sex of the patients. A total of 530 prescriptions were analysed, and the mean +/- SD drugs per prescription was 2.15 +/- 1.71; 67.4% of the drugs were prescribed by brand name and only 39.56% of the drugs prescribed were from the WHO essential drug list. The average cost of drugs per prescription was US$2.75 +/- 2.21. The frequency of prescribing of antiulcer drugs, antibiotics, antiasthma drugs, antihypertensives and analgesics was 24.15% (n=128), 23.96% (n=127), 20.56% (n=109), 19.81% (n=105) and 15.09% (n=80), respectively. This study revealed considerable scope for educating prescribers to improve their prescribing practice.

BACKGROUND: In Nepal, more than 90% of the deliveries take place at home where birth weight is often not recorded. In developing countries, low birth weight (LBW, <2500 grams) accounts for 60-80% of neonatal deaths. Early identification and referral of LBW babies for extra essential newborn care is vital in preventing neonatal deaths. Studies carried out in different populations have suggested that the use of newborn anthropometric surrogates of birth weight may be a simple and reliable method to identify LBW babies in a home setting. However, a reliable anthropometric surrogate to identify LBW babies and its cut-off point is not known for Nepalese newborns. METHODS: A cross-sectional study was carried out in Western Regional Hospital, Pokhara between April and June, 2006. All consecutive full-term, singleton, live born babies were included. To ensure reliability and avoid inter-observer bias one of the investigators weighed all the newborns and carried out anthropometric measurements within 24 hours after birth. Circumferences of head, chest, mid-upper arm, thigh and calf were measured according to standard techniques. Non-parametric receiver operating characteristic (ROC) curve analyses were carried out using bootstrap to calculate 95% confidence intervals of areas under the curve (AUC). The cut-points with lowest total misclassification rate were chosen to identify LBW babies. RESULTS: Out of 400 newborns studied, 204 (51%) were males and 196 (49%) were females. The mean birth weight was 3029 +/- 438 grams and 34 (8.5%) newborns were LBW. By ROC-AUC analyses, head circumference (AUC = 0.89, 95% CI 0.85 to 0.93) and chest circumference (AUC = 0.86, 95% CI 0.80 to 0.91) were identified as the optimal surrogate indicators of LBW babies. The optimal cut-points for head circumference and chest circumference to identify LBW newborns were > or = 33.5 cm and > or = 30.8 cm respectively. CONCLUSION: Head and chest circumferences were the best anthropometric surrogates of LBW among Nepalese newborns. Further studies are needed in the field to cross-validate our results.

OBJECTIVES: Hearing loss is a neglected international health problem. The greatest burden of ear disease is in low-income countries where there is also a lack of resources. In this context, screening for otological disease may be worthwhile. Cupris© has developed an otoscopy device that offers the possibility of low-cost mass screening in remote communities. We evaluated the validity of this device in diagnosing ear disease and in determining whether referral to an ENT centre is warranted. DESIGN: Cross-sectional study. SETTING: Outpatient clinic, Nepal. PARTICIPANTS: All adults and children were invited to take part over a 2-day period. The Cupris© device was used to record participants otological history and examination. Stored history and images were assessed in the United Kingdom by a Consultant-grade ENT Surgeon, who provided a diagnosis and decided whether referral to an ENT centre was warranted. After screening with the Cupris© device, participants were immediately assessed by a UK trained ENT Consultant Surgeon using a standard otoscope ("standard assessment"). A diagnosis was recorded for each participant and a decision was made as to whether referral to an ENT centre was warranted. OUTCOMES: Concordance in primary diagnosis (analysed per ear) and concordance in the decision to refer (analysed per patient). Cohen's kappa coefficient for inter-rater agreement in diagnosis. RESULTS: Fifty-six patients agreed to participate. In four patients, the quality of video recorded precluded a diagnosis or management plan. These patients were excluded from subsequent analysis, leaving 52 patients for analysis. The same diagnosis was reached for 99 of 104 ears when comparing the Cupris© device to standard assessment (95% concordance), with Cohen's kappa coefficient of 0.89. The decision as to whether a patient should be referred to an ENT centre for further assessment was the same for all 52 participants when comparing the Cupris© device to standard assessment. CONCLUSIONS: When compared to standard assessment, the Cupris© device is a valid tool for the diagnosis of ear disease and decision for onward referral. It shows considerable promise for use by trained non-medical workers, as a low-cost and portable tool to screen for ear disease in remote settings, particularly in low- and middle-income countries.

BACKGROUND: Chromoblastomycosis is a chronic fungal infection caused by several pigmented fungi commonly seen in tropical and subtropical climates. AIM: To evaluate the epidemiologic, clinical and pathological characteristics of chromoblastomycosis in our patients. METHODS: This retrospective and prospective study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal. Clinical features and histopathology of all the cases diagnosed as chromoblastomycosis during the last eight years were studied. RESULTS: A total of 13 cases of chromoblastomycosis were diagnosed during the period of 1999-2006. The disease was seen predominantly in middle-aged male farmers and those from rural areas. The lesions commonly involved the lower extremity and were single or multiple in number. They clinically presented as verrucous or nodular growths. Out of these 13 cases, three were diagnosed clinically as squamous cell carcinoma and one as psoriasis. The histopathological features included sclerotic bodies in 12 cases (92%), microabscess formation in 10 cases (76.9%), pseudoepitheliomatous hyperplasia in nine cases (69.2%) and granuloma in eight cases (61.5%). CONCLUSION: Farming is the commonest occupation in patients with chromoblastomycosis. Early histological diagnosis helps in effective management of the condition.

BACKGROUND: Carcinoma of gall bladder is the most common malignancy of the billiary tract. Most of the cases are diagnosed as an incidental case among patients undergoing cholecystectomy. OBJECTIVES: To establish the rate of incidental carcinoma of gall bladder in patients undergoing routine cholecystectomy to study the demographic profile and prognosis of these patients. METHODS: A retrospective study was carried out in Fishtail Hospital and Research Center, Pokhara during 1998-2009. The surgical notes, hospital records and histopathology reports of 783 patients undergoing routine cholecystectomy were studied. RESULTS: Out of 783 cases, gall bladder cancer was detected in 10(1.28%) of cases and was more common in females (M:F ratio 1:2.3) and the mean age of occurrence was 63.8 years. Most of the cases diagnosed were at their early stages and none of them were in T3 and T4 stages. Six of these patients have survived till a mean follow up duration of 23.7 months. CONCLUSION: The rate of incidental carcinoma of gall bladder is 1.28%.