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– by Dr. Sameer M. Dixit and Prof. Dr. Meeta Singh

Cervical cancer is the most preventable cancer in women. Ironically, it is also the biggest killer amongst all cancers in Nepali women. All women that are sexually-active are at risk of contracting it. Although there are no clear reports, it is estimated that 20 percent of all female cancers is linked to cervical cancer, most of those being in advanced clinical stages. Annually, in Nepal, there are an estimated 1,100 deaths due to cervical cancer.

Research worldwide has shown that Human Papillomavirus (HPV) is the major cause of cervical cancer in women. Specifically, about 5 types of HPV (16, 18, 31, 32 and 45) among about 100 known strains have been linked to cervical cancer. According to literature, persistence infection with one of 15 high-risk HPV types is considered a necessary cause for cervical cancer. Estimates worldwide have suggested that types 16 and 18 account for 70 percent of all cervical cancers. In Asia, this has been liked to 67 percent of all cervical cancers, with Southern Asia (where Nepal is located) linked to 80 percent of all cervical cancers.

There are preventive vaccines already developed and being used in developed countries against at least four of the high-risk HPV groups. Gardasil (manufactured by Merck) protects against HPV 6, 11, 16 and 18. Cervarix (manufactured by Glaxo Smithkline) protects against 16 and 18. These are recommended for young girls in three shots (primary and booster dosage).

In the United States, the Center for Disease Control recommends that female patients start regular cervical cancer screening at the age of 21 or within three years after first having sexual intercourse. The first test for the screening test for cancer of the cervix is the pap test which detects precancerous or cancers cells. The second recommended test is the HPV test, which looks for the human papillomavirus that can cause these cell changes leading to cervical cancer. While the smear test can be carried out by most pathology laboratories, HPV test requires advanced laboratory setup. In US and other developed countries, early intervention is now made possible by molecular detection technologies such as polymerase chain reaction (PCR) or real-time PCR. These tests enable detection of high-risk HPV in the cervix rather than relying on histopathological results alone. Thus, by regular screening for HPV, it is now possible to reduce the risk of developing cancer in women worldwide.

For a developing country like Nepal, accurate screening of cases of cancer of the cervix in Nepal continues to be a major problem. Very little, if any, literature reports exist on the type of HPV present in the population, and in cervical cancer cases. Even World Health Organization (WHO) does not have data on Nepali context to come up with an effective solution to the problem. Even though vaccines exist, without the knowledge of the HPV type prevalent here, the usefulness of such vaccines in Nepal is not proven.

Women who are sexually-active should visit their gynecologist for cervical cancer screening. Cervical cancer is totally preventable, so there is no excuse for not getting tested for it.

Molecular detection of HPV and its strain identification has never been tried in Nepali laboratories before. The primary screening method used in Nepal is the Pap Test – Pap smears can detect cervical cancers if smears are taken properly and interpreted by an experienced expert cytologist. Pap smears may not provide accurate detection of all suspect cases if the smear sample is not taken properly. However, if we can even screen some of the early stage cervical cancer patients using novel molecular tools such as PCR, we could be saving many more lives. PCR could be the preferred and more efficient method of detection of HPV and thereby detect cancer cervix in our country where there are very few pathologists. It must be taken into account that just the presence of HPV in the cervix does not necessarily indicate cervical cancer risk. In most cases, the low-risk viruses are shed off by the body automatically. However, detection of the virus provides the gynecologist evidence to screen the patient at regular intervals, thereby enabling early detection of abnormal cellular morphology in the case of cancer. Identification of any of the high-risk HPV is thus the key to early intervention of cervical cancer.

It is, therefore, highly recommended for all women who are sexually-active to visit their preferred gynecologist for cervical cancer screening. HPV type molecular screening is also now available in the city. October of every year is dedicated to cancer, worldwide. Cervical cancer is totally preventable, so there is no excuse for not getting tested for it.

Dr. Dixit is associated with the Center for Molecular Dynamics Nepal (CMDN). Dr. Singh is Head of Department, Gynecology/Obstetrics, Tribhuvan University Teaching Hospital (TUTH). CMDN in collaboration with Dept of Gynecology/Obstetrics, TUTH, is in the process of initiating HPV type study into cervical cancer in Nepal.

s.dixit@cmdn.org

This article has been taken from The Republica National Daily http://myrepublica.com/portal/index.php?action=news_details&news_id=24761

DR SAMEER M DIXIT & PROF DR MEETA SINGH

Mitochondrial and Y-chromosome diversity of the Tharus (Nepal): a reservoir of genetic variation.

BMC Evol Biol. 2009 Jul 2;9:154.

Fornarino S, Pala M, Battaglia V, Maranta R, Achilli A, Modiano G, Torroni A, Semino O, Santachiara-Benerecetti SA.

Dipartimento di Genetica e Microbiologia, Università di Pavia,Pavia, Italy. fornarin@pasteur.fr

Abstract

BACKGROUND: Central Asia and the Indian subcontinent represent an area considered as a source and a reservoir for human genetic diversity, with many markers taking root here, most of which are the ancestral state of eastern and western haplogroups, while others are local. Between these two regions, Terai (Nepal) is a pivotal passageway allowing, in different times, multiple population interactions, although because of its highly malarial environment, it was scarcely inhabited until a few decades ago, when malaria was eradicated. One of the oldest and the largest indigenous people of Terai is represented by the malaria resistant Tharus, whose gene pool could still retain traces of ancient complex interactions. Until now, however, investigations on their genetic structure have been scarce mainly identifying East Asian signatures.

RESULTS: High-resolution analyses of mitochondrial-DNA (including 34 complete sequences) and Y-chromosome (67 SNPs and 12 STRs) variations carried out in 173 Tharus (two groups from Central and one from Eastern Terai), and 104 Indians (Hindus from Terai and New Delhi and tribals from Andhra Pradesh) allowed the identification of three principal components: East Asian, West Eurasian and Indian, the last including both local and inter-regional sub-components, at least for the Y chromosome.

CONCLUSION: Although remarkable quantitative and qualitative differences appear among the various population groups and also between sexes within the same group, many mitochondrial-DNA and Y-chromosome lineages are shared or derived from ancient Indian haplogroups, thus revealing a deep shared ancestry between Tharus and Indians. Interestingly, the local Y-chromosome Indian component observed in the Andhra-Pradesh tribals is present in all Tharu groups, whereas the inter-regional component strongly prevails in the two Hindu samples and other Nepalese populations.The complete sequencing of mtDNAs from unresolved haplogroups also provided informative markers that greatly improved the mtDNA phylogeny and allowed the identification of ancient relationships between Tharus and Malaysia, the Andaman Islands and Japan as well as between India and North and East Africa. Overall, this study gives a paradigmatic example of the importance of genetic isolates in revealing variants not easily detectable in the general population.

PMID: 19573232 [PubMed – indexed for MEDLINE]PMCID: PMC2720951Free PMC Article

Pubmed: http://www.ncbi.nlm.nih.gov/pubmed/19573232

Full Text Article (PubMed Central): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720951/pdf/1471-2148-9-154.pdf

Kathmandu University Medical Journal has just published its latest issue at
http://nepjol.info/index.php/KUMJ.

Kathmandu University Medical Journal
Vol 8, No 2 (2010)
Table of Contents
http://nepjol.info/index.php/KUMJ/issue/view/250

http://kumj.com.np/home.php?fd=issue/30&page=cover

Editorials

——–
Patient safety: Prevention during care (151-152)
A Vaidya

Gendericide: A scary truth (153)
NS Shrestha

Original Articles

——–
Osteosynthesis of intercondylar humerus fracture using Bryan and Morrey
approach (154-157)
S Lakhey, S Sharma, RL Pradhan, BK Pandey, RR Manandhar, KP Rijal

Correlation of serum free prostate-specific antigen level with histological
findings in patients with prostatic disease (158-163)
M Lakhey, R Ghimire, R Shrestha, AD Bhatta

Antimicrobial susceptibility pattern and serotyping of Streptococcus
pneumoniae isolated from Kanti Children Hospital in Nepal (164-168)
B Rijal, S Tandukar, R Adhikari, NR Taludhar, PR Sharma, BM Pokharel, FC
Gami, A Shah, A Sharma, P Gauchan, JB Sherchand, T Burlakoti, HC Upreti, MK
Lalitha, K Thomas, M Steinhoff

Surgical abortion in second trimester: Initial experiences in Nepal
(169-172)
V Shrivastava, L Bajracharya, S Thapa

Effect of haemodynamic and metabolic predictors on echocardiographic left
ventricular mass in non-diabetic hypertensive patients (173-178)
N Gupta, P Karki, S Sharma, N Shrestha, P Acharya

Comparison of single versus multiple doses of antibiotic prophylaxis in
reducing post-elective Caesarean section infectious morbidity (179-184)
A Shakya, J Sharma

Objective voice analysis for vocal polyps following microlaryngeal
phonosurgery (185-189)
SiKC Toran, BK Lal

Prevalence of pharmacotherapy in the department of paediatric dentistry
(190-194)
KR Paudel, NK Sah, AK Jaiswal

Successes rate of endoscopic dacryocystorhinostomy at KMC (195-198)
S Shrestha, PK Kafle, S Pokhrel, M Maharjan, KC Toran

Use of double-balloon catheter in the management of epistaxis: A boon for
the periphery (199-202)
M Bista, C Baranwal, M Maharjan, P Kafle, S Shresth, KC Toran

Morbidity and early outcome of transurethral resection of prostate: A
prospective single-institute evaluation of 100 patients (203-207)
B Shrestha, JL Baidya

Upper gastro-intestinal bleeding: Aetiology and demographic profile based
on endoscopic examination at Dhulikhel Hospital, Kathmandu University
Hospital (208-211)
RB Gurung, G Joshi, N Gautam, P Pant, B Pokhrel, R Koju, TRS Bedi

Post partum haemorrhage: Prevalence, morbidity and management pattern in
Dhulikhel Hospital (212-215)
AS Dongol, A Shrestha, CD Chawla

Effect of preloading on haemodynamic of the patient undergoing surgery
under spinal anaesthesia (216-221)
J Singh, S Ranjit, S Shrestha, R Sharma, SB Marahatta

Near miss maternal morbidity and maternal mortality at Kathmandu Medical
College Teaching Hospital (222-226)
NS Shrestha, R Saha, C Karki

Acute appendicitis: Analysis of 518 histopathologically diagnosed cases at
the Kathmandu University Hospital, Nepal (227-230)
R Makaju, A Mohammad, A Shakya

Subclinical hypothyroidism in eastern Nepal: A hospital based study
(231-237)
V Rohil, AK Mishra, MK Shrewastwa, KD Mehta, M Lamsal, N Baral, S Majhi

Case Notes

——–
Alport’s syndrome (238-240)
P Bastola, SN Joshi, M Chaudhary, DN Shah

Spigelian hernia (241-243)
TP Bhatia, P Ghimire, ML Panhani

Multiple intracranial tubercular abscesses in a child (244-246)
M Narang, S Gomber, L Upreti, S Dua

Retinoblastoma in a 37 years old man in Nepal: A case report (247-250)
A Shrestha, RC Adhikari, R Saiju

Chronic bilateral dislocation of temporomandibular joint (251-256)
S Shakya, R Ongole, KN Sumanth, CE Denny

Audit

——–
An ultrasonographic evaluation of solitary muscular and soft tissue
cysticercosis (257-260)
P Sharma, S Neupane, M Shrestha, R Dwivedi, K Paudel

Initiating advanced laparoscopic surgery in a medical college hospital with
basic laparoscopic set up: Is it feasible and safe? (261-264)
PB Thapa

Variation of total serum cholesterol among the patient with thyroid
dysfunction (265-268)
P Risal, BR Maharjan, R Koju, RK Makaju, M Gautem

Review Articles
——–
Halitosis: Much beyond oral malodor (269-275)
R Ongole, N Shenoy

Short Communication

——–
Biomass combustion and potential health effects in the developing countries
(276-280)
SK Joshi, A Dahl, T Kristensen, P Roldin

Vaginal hysterectomy for pelvic organ prolapse in Nepal (281-284)
DK Sah, NR Doshi, CR Das

Book Reviews

——–
A-Z of Practical Paediatrics (285)
Hemang Dixit

Clinical Examination Methods in Orthopedics (286)
Rajeev Raj Manandhar

The Short Textbook of Medical Microbiology (287)
Badri Thapa

BioMed Central is offering a fund to help researchers in developing countries attend the conference, Parasite to Prevention. The conference, held in conjunction with Malaria Journal, takes place in Edinburgh, 20-22 October.

Researchers and graduate students from low-income and lower-middle income countries can apply for a conference bursary to cover the cost of their travel, accommodation and conference registration. Places are strictly limited. The scientific committee will award the conference bursaries based solely on the quality of the abstracts submitted.

The deadline to submit an abstract and apply for a bursary place is 6 August 2010.

This international conference brings together leading researchers and industry representatives who will review important recent findings in parasite and vector biology, disease pathophysiology and immunology, disease treatment, prevention and control. Attendees will learn about the latest developments in key areas and initiatives that are at the forefront of malaria research.

More speakers have now been confirmed for the conference, including Carol Sibley (University of Washington), Andrew Waters (Leiden University) and Tim Wells (Medicines for Malaria Venture).

David Brandling-Bennett, Senior Program Manager at the Bill and Melinda Gates Foundation will give a keynote address at the conference gala dinner on Thursday, 21 October.

Anyone not from low-income and lower-middle income countries, can still submit an abstract for consideration if you register before 6 August 2010.

Neonatal hypothermia and associated risk factors among newborns of southern Nepal

Luke C Mullany email, Joanne Katz email, Subarna K Khatry email, Steven C LeClerq email, Gary L Darmstadt email and James M Tielsch email

BMC Medicine 2010, 8:43doi:10.1186/1741-7015-8-43

Published: 8 July 2010

Abstract (provisional)

Background

Neonatal hypothermia is associated with an increased mortality risk for 28 days. There are few community-based data on specific risk factors for neonatal hypothermia. Estimates of association between neonatal hypothermia in the community and risk factors are needed to guide the design of interventions to reduce exposure.

Methods

A cohort of 23,240 babies in rural southern Nepal was visited at home by field workers who measured axillary temperatures for 28 days (213,316 temperature measurements). The cumulative incidence of hypothermia (defined as <35.0degreesC based on an analysis of the hypothermia-mortality risk relationship) was examined for any association with infant characteristics, care practices and parental, household, socioeconomic and demographic factors. Estimates were adjusted for age and ambient temperature.

Results

Ten percent of the babies (n=2342) were observed with temperatures of <35.0degreesC. Adjusted prevalence ratios (Adj PR) were increased among those who weighed< 2000 g [Adj PR=4.32 (3.73, 5.00)] or <1500 g [Adj PR=11.63 (8.10, 16.70)] compared to those of normal weight (>2500 g). Risk varied inversely along the entire weight spectrum: for every 100 g decrement hypothermia risk increased by 7.4%, 13.5% and 31.3%% for babies between 3000 g and 2500 g, 2500 g and 2000 g and <2000 g, respectively. Preterm babies (<34 weeks), females, those who had been first breastfed after 24 h and those with hypothermic mothers were at an increased risk. In the hot season the risk disparity between smaller and larger babies increased. Hypothermia was not associated with delayed bathing, hat wearing, room warming or skin-to-skin contact: they may have been practiced reactively and thereby obscured any potential benefit.

Conclusions

In addition to season in which the babies were born, weight is an important risk factor for hypothermia. Smaller babies are at higher relative risk of hypothermia during the warm period and do not receive the protective seasonal benefit apparent among larger babies. The need for year-round thermal care, early breastfeeding and maternal thermal care should be emphasized. Further work is needed to quantify the benefits of other simple neonatal thermal care practices.

Download Full Text Article

Source: Biomedcentral

The diarrheal outbreak in Far- and Mid-Western regions of Nepal in 2009 was a cause for genuine concern as it affected over 5,000 individuals and caused more than 200 deaths. In Jajarkot district alone, more than 100 people died in just four months, with over 400 affected. Scientifically speaking, a bacterial strain by the name of Vibrio cholera was identified in almost 39 percent of the 15 samples tested. However, V. cholera is not the only pathogen capable of causing severe or fatal diarrhea in developing countries, Nepal being an example. A number of other bacterial and viral pathogens have been implicated in diarrheal outbreaks worldwide. Those include a number of Escherichia coli strains, Aeromonas strains, Campylobacter strains, Shigella strains, Salmonella strains, as the most pathogenic ones. Campylobacter strains are sometimes associated with food poisoning in diarrheal cases while Salmonella strains are known to be mostly associated with foodstuff and in some cases with contaminated drinking water. Aeromonas species is primarily associated with water and is known to cause cholera-like diarrheal symptoms, thus increasing the possibility of false diagnosis of cholera when this may not actually be the case.

In the Nepali context, V. cholera types have been implicated often in a larger number of occasions. The first report of cholera in Nepal was officially published for the years 1958 to 1960 by a medical doctor visiting Nepal. A total of 410 deaths over a three-year period in Kathmandu, with more than 3,000 affected, were reported. An outbreak of acute diarrheal disease in Kavre district during the year 2005 showed 31 percent cases positive for V. cholera. Using molecular (DNA/RNA of organisms as targets) method, a Japanese research group found that recent outbreaks in the country were mainly due to the V. cholera. A very recent study using latest molecular methods carried out by Center for Molecular Dynamics Nepal in collaboration with Nepal Health Research Council has found that diarrheal outbreak may be caused not only by V. cholera alone, but in a combination with other virulent pathogens, including Aeromonas species.

To date, the detection of diarrheal pathogens in Nepal has relied almost extensively on microbiological (growth of pathogens in culture media), biochemical (by-products of pathogenic metabolism) and serological tests (immune response of host to pathogen). These methods may have been useful until the recent past, but with the advent of molecular technology, same cannot be said anymore. Thus, the limited laboratory facilities in the government sector appears to have prevented early diagnosis of the recent 2009 outbreak considering that the first presumptive identification of the causative agent was only carried out and made public three months after the start of the outbreak. This may have contributed to delayed treatment as it is hard for a clinician to effectively suggest the dosage and frequency of medication in outbreak situations without a proper screening mechanism in place.

Many of the deaths due to diarrhea in Nepal have been caused as a result of dehydration resulting from loss of water and electrolytes (intestinal malabsorption or increased secretion). Replacement of these losses by oral rehydration solution is the mainstay of therapy for individuals with watery diarrhea. The treatment of diarrhea by water or water supplemented with salts (Oral Rehydration Solution) has been extensively promoted in endemic pockets in Nepal where the incidence of diarrheal outbreaks is high. However, in extreme cases, antibiotic needs to be administered. As an example, if we just take the case of two different causative agents of diarrheal outbreaks in developing countries, Vibrio species and Aeromonas species, the critical importance of prior diagnosis becomes apparent. The recommended medication for Aeromonas species is usually Cefixime, and most third-generation and fourth-generation cephalosporins (a family of antibiotics). However, in the case of V. cholera, Tetracycline is the usual antibiotic of choice, and in some cases, doxycycline, and other broad-spectrum antibiotics (another family of antibiotics). Thus, there are clearly differences in medication for the two different species and wrong medication for either could lead to delayed recovery and in the long term, development of antibiotic resistance by the pathogen.

The principle of PDTC (Prevention, Diagnosis Treatment and Care) has been the guiding light in major disease management in Nepal and elsewhere. However, in the case of diarrheal outbreaks, the relative emphasis needs to be adjusted. While prevention remains the mainstay strategy to deal with the problem of diarrhea, the need for correct diagnosis has emerged as the most important prong of the ladder for effective and efficient management of diarrheal diseases and epidemics as well as prevention of such future outbreaks. One of the major reasons is that traditional methods require that the pathogen be grown (cultured) in the laboratory. A large number of pathogens cannot survive very well outside the human body and thus may not be detected although they are present in the body. Methods that do not require culture such as biochemical tests and serological tests take time and are not very indicative of the actual bacterial species present. Therefore, molecular methods are the future of any disease diagnostics.

A comprehensive screening for presence of major pathogens, both bacterial and viral, can be carried out using this type of technology which is already available in Nepal. The use of these modern methods would not only result in rapid diagnosis, but also enable highly-specific identification of the actual pathogen(s) involved in a diarrheal outbreak. Therefore, modern methods of diagnosis should be explored, and utilized by the government health sector as well as external development partners working in health sector, for better management of future outbreaks. The cost of such diagnostic procedures which may be higher than traditional methods initially can be lessened tremendously if the capacity-building for molecular diagnosis is promoted within the country.

Dr Sameer M Dixit, PhD is the Country Director of Center for Molecular Dynamics Nepal (CMDN). Dr Mahesh Maskey, DSc is the Former Chair, Nepal Health Research Council (NHRC)

Source : http://www.myrepublica.com/portal/index.php?action=news_details&news_id=15949

Bangalore, Dec 9, 2009: The Council of Scientific and Industrial Research (CSIR), India, has achieved completion of first ever human genome sequencing in India. Scientist of CSIR at the Institute of Genomics and Integrative Biology (IGIB), Delhi, have sequenced the human genome of an anonymous healthy Indian citizen. Addressing a press conference, Union Minister for Science and Technology, Mr Prithviraj Chavan said that this feat is unique in the sense that it has been achieved by a team of very young scientists. CSIR has been endeavoring to nucleate such teams in different niche technological areas as per the directive of Dr Manmohan Singh, President of CSIR and Prime Minister of India.

Elaborating the details of research on human genome, the Mr Chavan said that the first human genome sequence in the world was a result of the International Human Genome Project comprising scientists from the US, UK, France, Germany, Japan and China. The project formally started in 1990 and the sequencing was completed in 2003. This spectacular feat at that time was hailed equivalent to the man landing on the moon. India could not be a part of this large initiative as in the early nineties it lacked the necessary resources. With the completion of the first human genome sequence in India, the nation is now in the league of select few countries like the US, China, Canada, UK, and Korea who have demonstrated the capability to sequence and assemble complete human genomes. CSIR could achieve this by adopting new technologies and by effectively integrating complex computational tools with high throughput analytical capabilities.

The first human genome sequence in India took more than a decade with a spending of over one billion US dollars. CSIR scientists at IGIB finished the complete sequencing and assembly in much shorter time comparable with similar recent effort the world over. By using next generation technologies and skills, they successfully bridged the technological gap that existed a decade ago.

Mr Samir K Brahmachari, Director General of CSIR informed that the human genome has 3.1 billion base pairs. The team at IGIB generated over 51 gigabases of data using next generation sequencing technology, resulting in over 13x coverage of the human genome. This next-generation sequencing technology enables massively parallel sequencing of millions of genomic fragments of 76 base pairs, which are then mapped back to the reference genome. This humongous exercise was made possible with the CSIR supercomputing facility at IGIB.

The sequencing of the first human genome in India in conjunction with Indian Genome Variation program opens newer vistas for low-cost affordable healthcare and predictive medicine in future for the masses. This also opens up newer possibilities in disease diagnostics, treatment and sustaining low-cost drugs in the market.

This Article has been adapted from: © BioSpectrum Bureau

rabies-300x231KATHMANDU, Aug. 30 (Xinhua) — Nepali government is speeding work to introduce tissue-cultured anti-rabies vaccine for humans within two years. Presently the bio-technology is in its trial phase, local media reported on Sunday.

Lat Narayan Chaudhary, assistant zoonotic at Epidemiology and Disease Control Division under the Ministry of Health and Population, said they are sending the second batch of trial vaccines to referral laboratory of the World Health Organization (WHO) to test the quality of the product.

Talking to THT Online, he said the WHO has phased out the betapropiolactone inactivated sheep brain rabies vaccine, which used to be produced here, for human use.

The new technology will save the country 100 million Nepali rupees (some 1.3 million U.S. dollars) annually, which is presently spent on importing anti-rabies vaccine.

Chaudhary claims that the production can meet the domestic demand meeting the standard.

Source: news.xinhuanet.com