Postnatal hypothermia and cold stress among newborn infants in Nepal monitored by continuous ambulatory recording.

AIMS: To describe the pattern of hypothermia and cold stress after delivery among a normal neonatal population in Nepal; to provide practical advice for improving thermal care in a resource limited maternity hospital. METHODS: The principal government funded maternity hospital in Kathmandu, Nepal, with an annual delivery rate of 15,000 (constituting 40% of all Kathmandu Valley deliveries), severe resource limitations (annual budget Pounds 250,000), and a cold winter climate provided the setting. Thirty five healthy term neonates not requiring special care were enrolled for study within 90 minutes of birth. Continuous ambulatory temperature monitoring, using microthermistor skin probes for forehead and axilla, a flexible rectal probe, and a black ball probe placed next to the infant for ambient temperature, was carried out. All probes were connected to a compact battery powered Squirrel Memory Logger, giving a temperature reading to 0.2 degree C at five minute intervals for 24 hours. Severity and duration of hypothermia, using cutoff values of core temperature less than 36 degrees C, 34 degrees C, and 32 degrees C; and cold stress, using cutoff values of skin-core (forehead-axilla) temperature difference greater than 3 degrees C and 4 degrees C were the main outcome measures. RESULTS: Twenty four hour mean ambient temperatures were generally lower than the WHO recommended level of 25 degrees C (median 22.3 degrees C, range 15.1-27.5 degrees C). Postnatal hypothermia was prolonged, with axillary core temperatures only reaching 36 degrees C after a mean of 6.4 hours (range 0-21.1; SD 4.6). There was persistent and increasing cold stress over the first 24 hours with the core-skin (axillary-forehead) temperature gap exceeding 3 degrees C for more than half of the first 24 hours. CONCLUSIONS: Continuous ambulatory recording identifies weak links in the "warm chain" for neonates. The severity and duration of thermal problems was greater than expected even in a hospital setting where some of the WHO recommendations had already been implemented.     

Two year audit of perinatal mortality at Kathmandu Medical College Teaching Hospital.

Introduction: Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life. Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths. Aims and objectives: This study was carried out to determine perinatal mortality rate (PMR) and the factors responsible for perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 (Kartik 2060 B.S. to Ashoj 2062). Methodology: This is a prospective study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005. Details of each perinatal death were filled in the standard perinatal death audit forms of the Department of Pediatrics, KMCTH. Perinatal deaths were analyzed according to maternal characteristics like maternal age, parity, type of delivery and fetal characteristics like sex, birth weight and gestational age and classify neonatal deaths according to Wigglesworth's classification and comparison made with earlier similar study. Results: Out of the 1517 total births in the two year period, 22 were still births (SB) and 10 were early neonatal deaths (ENND). Out of the 22 SB, two were of < 1 kg in weight and out of 10 ENND, one was of <1 kg. Thus, perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births. The important causes of perinatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight. According to Wigglesworth's classification, 43.8% of perinatal deaths were in Group I, 12.5% in Group II, 28.1% in Group III, 12.5% in Group IV and 12.5% in Group V. Discussion: The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births. There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH. Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths. Conclusion: Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths. Prevention of preterm births, better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths. Key words: Perinatal mortality rate (PMR), still births, early neonatal death (ENND), Total perinatal death (PND).     

Strong human immunodeficiency virus (HIV)-specific CD4+ T cell responses in a cohort of chronically infected patients are associated with interruptions in anti-HIV chemotherapy

Virus-specific CD4+ T-helper cell function is important in controlling human immunodeficiency virus (HIV) infection but is impaired in patients with progressive HIV disease. It has been reported that after highly active antiretroviral therapy (HAART), HIV-specific lymphoproliferative responses remain absent, whereas responses to non-HIV microbial antigens are restored. However, in analyzing immune responses in a cohort of chronically infected adults on HAART, we observed strong HIV-specific CD4+ T cell responses of Th-1 phenotype in 11 of 22 patients. The magnitude and frequency of HIV-specific lymphoproliferative responses was strongly associated with previous interruptions in HAART (P=.001). In contrast, the magnitude of CD8+ T cell responses to HIV Gag, Pol, Env, and Nef was similar in patients who had and those who had not interrupted HAART. We conclude that (1) a significant proportion of chronically HIV-infected patients on HAART can generate strong HIV-specific CD4+ and CD8+ T cell immunity and (2) transient interruptions in antiviral treatment may prime or boost HIV-specific CD4+ T-helper responses.     

Rickets with alopecia-remission following a course of 1-α-hydroxy vitamin D3 therapy

A child is described with rickets and alopecia who did not respond to high doses of vitamin D₃ but who responded to a small dose of 1--hydroxyvitamin D₃. Treatment was continued for 2 years and then stopped. She has not shown any signs of relapse 1 year after stopping treatment. Her alopecia, however, has remained unchanged. One year after stopping treatment, her serum 25-hydroxycholecalciferol and parathormone levels were within normal limits but serum 1,25-dihydroxycholecalciferol was elevated.Abbreviations 25 OH D₃ 25-hydroxycholecalciferol - 1,25 (OH)₂ D₃ 1,25-dihydroxycholecalciferol - 1--OH D₃ 1--hydroxy vitamin D - VDDR II vitamin D dependent rickets type II     

Prevalence of HBV infection among the healthy Nepalese males: a serological survey

Sera from 478 healthy Nepalese male population, inhabiting various districts of five development regions of Nepal were collected from October 1996 to March 1997 and examined for the presence of HBsAg by third generation ELISA and Latex agglutination test in the laboratory of Central Department of Microbiology, Tribhuvan University, Kirtipur. The surface antigen was detected by ELISA in 4.0% (19/478) of subjects studied. However, different results were obtained in Latex agglutination test. The correlation between the results obtained from these two different tests is statistically significant (chi2=85.11, P<0.05). The results obtained from ELISA showed the probability of Nepal to fall in WHO category of intermediate endemicity zone for hepatitis B infection. The percent positivity of HBsAg was found to increase steadily from Eastern (2%) to Far Western (6.2%) development regions. Among the districts studied, Kailali district gave characteristically high prevalence followed by Rukum and Kaski. Other, districts representing for the prevalence are Sankhuwasabha, Jhapa, Ramechhap, Sarlahi, Dhanusa, Baglung, Gulmi, Palpa and Dang. None of the samples represented from Kathmandu valley were positive for HBsAg. The age groups of 16-20 years and 36-40 years were found to be associated with the hepatitis B infection. Furthermore, various percent prevalence of the infection were encountered from 16 to 40 years subjects and a single case was also observed from 63 years old man. All the samples recorded positive for HBsAg from ELISA were assayed for the amount of ALT as a liver function test. Where, 15.8% (3/19) of the infected subjects had impaired liver function, hence it showed that, the subjects with high ALT to be the possible carrier of the HBV. Conversely, the remaining 84.2% (16/19) of the total HBsAg positive subjects were concluded to have the infection either at incubation or at prodrome period.     

The association between nutritional status and handgrip strength in older Rwandan refugees

OBJECTIVES: To investigate the association between nutritional status and handgrip strength in older Rwandan refugees. DESIGN: Cross-sectional study. SETTING: Rwandan refugee camp located in Karagwe district in the north-west of Tanzania. The study was carried out in the post-emergency phase. The response rate was 85%. SUBJECTS: A total of 413 men and 415 women aged 50-92 y participated in the study. METHODS: Weight, height, mid-upper-arm circumference (MUAC) and triceps skinfold were obtained using standard techniques. For people with visible kyphosis, height was estimated from armspan using regression equations developed from non-kyphotic subjects within the sample. Handgrip was measured using a mechanical handgrip dynamometer. Information regarding physical activity and health status was obtained by interview and clinical screening. RESULTS: Handgrip strength (kg) was significantly higher in men than in women (30.3+/-6.7 vs 22.3+/-5.1), and significantly lower in each older age group in both sexes. Handgrip strength was positively correlated to BMI (body mass index) and AMA (arm muscle area). The relative risk of impaired handgrip strength in individuals with poor nutritional status (BMI<18.5 kg/m(2)) compared with those of adequate nutritional status was 1.75. After controlling for potential confounders (sex, age and height), BMI remained a significant contributor to the variation in handgrip strength. CONCLUSION: Poor nutritional status is associated with poor handgrip strength independent of sex, age and height, in this refugee population. This may indicate that underweight older people are likely to have more difficulties in functioning independently in the community. Research is needed to investigate if improving nutritional status can lead to better functional ability. SPONSORSHIP: Department for International Development (UK) and HelpAge International.     

Brain tumours in children

A 10 years old, female patient presented with symptoms of abnormal movement of the body for 5 years, deviation of mouth to left side for 12 days and difficulty in walking for 12 days. We report a very rare case of Brain Stem gliomas. Clinical and imaging findings were suggestive of Brain Stem gliomas. Key words: Brain tumors, Intracranial space occupying lesion.