Is routine Vitamin A supplementation still justified for children in Nepal? Trial synthesis findings applied to Nepal national mortality estimates

Background The World Health Organization has recommended Vitamin A supplementation for children in low- and middle-income countries for many years to reduce child mortality. Nepal still practices routine Vitamin A supplementation. We examined the potential current impact of these programs using national data in Nepal combined with an update of the mortality effect estimate from a meta-analysis of randomized controlled trials. Methods We used the 2017 Cochrane review as a template for an updated meta-analysis. We conducted fresh searches, re-applied the inclusion criteria, re-extracted the data for mortality and constructed a summary of findings table using GRADE. We applied the best estimate of the effect obtained from the trials to the national statistics of the country to estimate the impact of supplementation on under-five mortality in Nepal. Results The effect estimates from well-concealed trials gave a 9% reduction in mortality (Risk Ratio: 0.91, 95% CI 0.85 to 0.97, 6 trials; 1,046,829 participants; low certainty evidence). The funnel plot suggested publication bias, and a meta-analysis of trials published since 2000 gave a smaller effect estimate (Risk Ratio: 0.96, 95% CI 0.89 to 1.03, 2 trials, 1,007,587 participants), with the DEVTA trial contributing 55.1 per cent to this estimate. Applying the estimate from well-concealed trials to Nepal’s under-five mortality rate, there may be a reduction in mortality, and this is small from 28 to 25 per 1000 live births; 3 fewer deaths (95% CI 1 to 4 fewer) for every 1000 children supplemented. Conclusions Vitamin A supplementation may only result in a quantitatively unimportant reduction in child mortality. Stopping blanket supplementation seems reasonable given these data

Should all pregnant women take calcium supplements in Nepal? GRADE evidence to policy assessment

Background The WHO recommends oral calcium supplementation (1.5–2.0 g) in pregnant women to reduce the risk of pre-eclampsia living in areas with low dietary calcium intake. Although maternal mortality is high in Nepal and eclampsia causes at least 20% of maternal deaths, implementing WHO recommendations would be a major undertaking. Objective This review aimed to assess whether the current evidence supports the blanket supplementation of calcium to prevent pre-eclampsia among pregnant women in Nepal. Methods We used a structured approach to appraise the evidence for calcium supplementation in Nepal. We identified what may influence the impact of calcium supplementation in Nepal and conducted a situation analysis in the country covering maternal mortality, pre-eclampsia occurrence, and existing government policy provisions for supplementation. We also consulted with experts and government officials to explore their perspectives and experience on supplementation. We then used AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) to appraise the Cochrane Systematic Review of calcium supplementation. Finally, we used these data in a GRADE (Grading of Recommendations Assessment, Development and Evaluation)–Evidence to Decision framework to reach a policy recommendation. Results Our assessment of the Cochrane Review showed that the recommendation made by the WHO is based on weak evidence and trial findings that are not consistent between studies. The Cochrane Review found low certainty of the evidence for benefit (reduction in pre-eclampsia and maternal mortality). Conversely, there is a high certainty of the evidence of undesirable effects (HELLP [haemolysis, elevated liver enzymes and low platelets] syndrome) although this is uncommon. The likely absolute reduction in maternal deaths projected to Nepal was estimated to be low, while the implementation costs were high. Stakeholders also raised several concerns regarding feasibility, acceptability, appropriate dosing, and risk communication. Conclusions This review concludes that the blanket supplementation of calcium cannot be recommended in Nepal. A better approach may be to identify high-risk pregnant women and manage their antenatal visits and delivery to prevent mortality from pre-eclampsia

Hemoperitoneum among Pediatric Abdominal Trauma Patients Visiting in Emergency Department of a Tertiary Care Centre: A Descriptive Cross-sectional study

Introduction: Pediatric abdominal trauma presents a major challenge for first-line responders in the Emergency Department for assessment and management. The Focused assessment sonography for trauma is a readily available, easy-to-use, and affordable tool for detecting hemoperitoneum during the initial assessment of trauma in the Emergency Department for adult traumatic patients. The aim of this study was to find the prevalence of hemoperitoneum among pediatric abdominal trauma patients visiting the Emergency Department of tertiary care centre through Focused assessment with sonography for trauma examination technique. Methods: This was a descriptive cross-sectional study conducted in the Emergency Department of a tertiary care hospital from 7 April 2019 to 7 April 2020. Among 413 pediatric trauma patients, 93 children (1 to 17 years) admitted to the Emergency Department who underwent focused assessment with sonography for trauma examination were included in the study. Ethical approval was obtained from the Institutional Review Committee (Approval number: 111/19). Convenience sampling was used. Point estimate and 90% Confidence Interval were calculated. Results: Among 93 children receiving focused assessment with sonography for trauma imaging in the Emergency Department with a history of blunt abdominal trauma, the prevalence of hemoperitoneum was 18 (19.34%) (12.61-26.09, 90% Confidence Interval). Conclusions: The prevalence of hemoperitoneum was similar to other studies conducted in a similar setting

Emergency Medicine Education and Research in Nepal: Challenges and Opportunities

Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this. The symposium was arranged into four different sessions as listed below: • To familiarize with the history and current state of EM from Global Emergency Medicine perspective. • To highlight the different clinical experiences and advancements in EM in Nepal. • To emphasize the importance and possibilities in EM education and research in Nepal. • To discuss the roadmap to develop and establish EM as a recognized medical speciality in Nepal. The overall objectives of the symposium were to discuss the challenges faced by current Emergency Medicine providers and identify the opportunities for the future development and recognition in Nepal. The most important current task for Nepal’s emergency physicians of advocating for policies, programs, and funding to support further development of the specialty was realized. Rural and urban emergency service providers from academic and non-academic institutions, governmental/non-governmental organizations and international medical institutions attended the symposium. General Practice (GP) residents, medical officers, medical students, interns and paramedics were among active participants

Effect of Music Therapy on Intensity of Labor Pain among Primigravid Mothers admitted in a Tertiary Level Hospital

Background: Childbirth is a most welcomed and positive life experience for the majority of women, despite the pain. Most of them manage it well with minimal assistance while few of them require some intervention to reduce the pain. The objective of this study was to find out the effect of music therapy on intensity of labor pain among primigravid women. Methods: A quasi-experimental pre-test post-test non-equivalent control group design was used. Sample consisted of 42 primigravid women admitted in labor room of a teaching hospital in Kathmandu. The intensity of labor pain was measured using Visual Analogue Scale and Behavior Rating Scale in latent and active phase of labor in both experimental and control groups. Then 30 minutes of music therapy was provided to the experimental group in the latent and active phase of labor. The post-test was carried out in both groups after the music therapy to experimental group during the latent and active phase using the same instruments. The collected data was entered in Statistical Package for Social Sciences version 16. Descriptive statistics and inferential statistics were used to describe the findings. Findings: The mean difference of total pain between experimental and control groups during latent phase was 1.9 (t=2.31, p=0.023) in pre-test and 6.57 (t=3.91, p=0.000) in post-test. The mean difference of total pain between experimental and control groups during active phase was 1.00 (t=1.08, p=0.286) during pre-test and 6.95(t=3.744, p=0.001) during post-test. Conclusions: Music therapy tends to reduce labor pain both during the latent and active phase of labor

The Correlation between Interleukin 33 and Psoriasis: A Systematic Review and Meta-Analysis

Psoriasis is a common genetic autoimmune disorder with a global prevalence of 2–3%. The clear pathogenesis of psoriasis is not fully understood, but hyperproliferation and inflammation of the epidermis with marked infiltration of immune cells have been indicated in psoriasis with such cells producing different types of cytokines- interleukin. As such a new member of the IL-1 cytokine family, in some research, IL-33 has been linked with psoriasis showing high serum concentration of IL-33 in human psoriatic plaques compared to normal healthy skin. Despite this, the association between IL-33 and psoriasis is not clear. Herein, in this review, we aim to investigate the correlation between serum IL-33 levels and psoriasis. We conducted meta-analysis using fixed or random-effects models to calculate pooled standard mean differences. We found that the mean IL-33 serum levels were reported between 0.35 pg/mL to 586 pg/mL in the psoriatic group and 0 pg/mL to 87.7 pg/mL in the healthy control group. Out of five, four individual studies included in the analysis reported statistically significant differences in IL-33 levels, the pooled estimate (SMD = 0.340 95% CI: −0.308 to 0.988), however, did not indicate a significant relation between IL-33 and psoriasis. This analysis revealed no significant difference between serum IL-33 levels in the psoriatic population in comparison to healthy controls. This may be because we did not include any animal studies, lab-based studies, any other markers mixed together, or any other cases of diseases mixed together. However, further research is warranted to confirm the reported association as this analysis is limited by the low-quality and observational nature of the included studies

Qualitative Analysis of 400 Life Stories from Children and Young People Working in the Worst Forms of Child Labour in Nepal

CLARISSA (Child Labour: Action-Research-Innovation in South and South‑Eastern Asia) is a large-scale research programme on the worst forms of child labour. It aims to identify, evidence, and promote effective multi‑stakeholder action to tackle the drivers of the worst forms of child labour in selected supply chains in Nepal and Bangladesh. This paper captures the perspectives of 400 children and young people working in the worst forms of child labour (WFCL) – mostly in the adult entertainment sector in Kathmandu, Nepal – to aid understanding about WFCL and how it can be brought to an end. Underpinning this paper is a thematic qualitative analysis of 400 life stories collected in locations where there is a high prevalence of work in the adult entertainment sector. This paper includes rich detail from those life stories and uncovers the micro-level detail and nuance within themes. The objective of this qualitative analysis was to build a stronger knowledge base on pathways into child labour and children’s lived experiences of child labour. This analysis should be considered as a companion analysis to the participatory collective analysis carried out by children themselves: Life Stories From Kathmandu’s Adult Entertainment Sector: Told and Analysed by Children and Young People