Evaluating the effectiveness of the Emergency Neurological Life Support educational framework in low-income countries.

BackgroundThe Emergency Neurological Life Support (ENLS) is an educational initiative designed to improve the acute management of neurological injuries. However, the applicability of the course in low-income countries in unknown. We evaluated the impact of the course on knowledge, decision-making skills and preparedness to manage neurological emergencies in a resource-limited country.MethodsA prospective cohort study design was implemented for the first ENLS course held in Asia. Knowledge and decision-making skills for neurological emergencies were assessed at baseline, post-course and at 6 months following course completion. To determine perceived knowledge and preparedness, data were collected using surveys administered immediately post-course and 6 months later.ResultsA total of 34 acute care physicians from across Nepal attended the course. Knowledge and decision-making skills significantly improved following the course (p=0.0008). Knowledge and decision-making skills remained significantly improved after 6 months, compared with before the course (p=0.02), with no significant loss of skills immediately following the course to the 6-month follow-up (p=0.16). At 6 months, the willingness to participate in continuing medical education activities remained evident, with 77% (10/13) of participants reporting a change in their clinical practice and decision-making, with the repeated use of ENLS protocols as the main driver of change.ConclusionsUsing the ENLS framework, neurocritical care education can be delivered in low-income countries to improve knowledge uptake, with evidence of knowledge retention up to 6 months

Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal

Antimicrobial resistance (AMR) continues to be a serious global public issue. Unnecessary and inappropriate use of antimicrobials has been identified as a major contributing factor for AMR. Implementation of antimicrobial stewardship programs (ASPs) is valued as a key strategy to combat AMR. Although ASP is a key intervention to improve appropriate use of antibiotics, there is limited experience and research to describe its implementation in low-income countries such as Nepal. Grande International Hospital (GIH) is the first health organization in Nepal to implement and sustain a multidisciplinary ASP and infection control program. Challenges faced in implementing ASP include lack of acceptance from physicians, lack of knowledge regarding antibiotic prescribing, lack of staff for ASP activities, limitations in diagnostic testing to inform ASP, and limitations in antibiotic choice due to antibiotic unavailability. Our ASP includes the following components: an ASP committee, an antibiotic prescribing reference guide with dosage recommendations, inpatient formulary restriction system, educational outreach and programming for physicians and other stakeholders, and periodic review and revision of the program and reference guide. The ASP provided opportunities to address several knowledge gaps across our healthcare institution including improved knowledge and competency regarding rational use of antibiotics, access to quality medicines and better care to patients. It is our hope that, by describing the challenges and opportunities we experienced while implementing our ASP, we can support and encourage other institutions to adapt and implement ASPs in Nepal and other resource-limited settings

Self-Dual N=(1,0) Supergravity in Eight Dimensions with Reduced Holonomy Spin(7)

We construct chiral N=(1,0) self-dual supergravity in Euclidean eight-dimensions with reduced holonomy Spin(7), including all the higher-order interactions in a closed form. We first establish the non-chiral N=(1,1) superspace supergravity in eight-dimensions with SO(8) holonomy without self-duality, as the foundation of the formulation. In order to make the whole computation simple, and the generalized self-duality compatible with supersymmetry, we adopt a particular set of superspace constraints similar to the one originally developed in ten-dimensional superspace. The intrinsic properties of octonionic structure constants make local supersymmetry, generalized self-duality condition, and reduced holonomy Spin(7) all consistent with each other.Comment: 14 pages, no figures. Some missing references, typos and grammatical errors have been corrected with other relatively minor improvement

Self-dual non-Abelian N = 1 tensor multiplet in D = 2+ 2 dimensions

We present a self-dual non-Abelian N=1 supersymmetric tensor multiplet in D=2+2 space-time dimensions. Our system has three on-shell multiplets: (i) The usual non-Abelian Yang-Mills multiplet (A_\mu{}^I, \lambda{}^I) (ii) A non-Abelian tensor multiplet (B_{\mu\nu}{}^I, \chi^I, \varphi^I), and (iii) An extra compensator vector multiplet (C_\mu{}^I, \rho^I). Here the index I is for the adjoint representation of a non-Abelian gauge group. The duality symmetry relations are G_{\mu\nu\rho}{}^I = - \epsilon_{\mu\nu\rho}{}^\sigma \nabla_\sigma \varphi^I, F_{\mu\nu}{}^I = + (1/2) \epsilon_{\mu\nu}{}^{\rho\sigma} F_{\rho\sigma}{}^I, and H_{\mu\nu}{}^I = +(1/2) \epsilon_{\mu\nu}{\rho\sigma} H_{\rho\sigma}{}^I, where G and H are respectively the field strengths of B and C. The usual problem with the coupling of the non-Abelian tensor is avoided by non-trivial Chern-Simons terms in the field strengths G_{\mu\nu\rho}{}^I and H_{\mu\nu}{}^I. For an independent confirmation, we re-formulate the component results in superspace. As applications of embedding integrable systems, we show how the {\cal N} = 2, r = 3 and {\cal N} = 3, r = 4 flows of generalized Korteweg-de Vries equations are embedded into our system.Comment: 21 pages, 0 figure

Combination of convalescent plasma therapy and repurposed drugs to treat severe COVID-19 patient with multimorbidity.

Combination of convalescent plasma therapy and repurposed drugs such as dexamethasone and remdesivir could be beneficial for severe COVID-19 patients with obesity and chronic diseases such as diabetes and hypertension

An international prospective study of INICC analyzing the incidence and risk factors for catheter-associated urinary tract infections in 235 ICUs across 8 Asian Countries

Background: Identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in 235 ICUs in 8 Asian countries: India, Malaysia, Mongolia, Nepal, Pakistan, the Philippines, Thailand, and Vietnam. Methods: From January 1, 2014, to February 12, 2022, we conducted a prospective cohort study. To estimate CAUTI incidence, the number of UC days was the denominator, and CAUTI was the numerator. To estimate CAUTI RFs, we analyzed 11 variables using multiple logistic regression. Results: 84,920 patients hospitalized for 499,272 patient days acquired 869 CAUTIs. The pooled CAUTI rate per 1,000 UC-days was 3.08; for those using suprapubic-catheters (4.11); indwelling-catheters (2.65); trauma-ICU (10.55), neurologic-ICU (7.17), neurosurgical-ICU (5.28); in lower- middle-income countries (3.05); in upper-middle-income countries (1.71); at public-hospitals (5.98), at private-hospitals (3.09), at teaching-hospitals (2.04). The following variables were identified as CAUTI RFs: Age (adjusted odds ratio [aOR] = 1.01; 95% CI = 1.01-1.02; P < .0001); female sex (aOR = 1.39; 95% CI = 1.21-1.59; P < .0001); using suprapubic-catheter (aOR = 4.72; 95% CI = 1.69-13.21; P < .0001); length of stay before CAUTI acquisition (aOR = 1.04; 95% CI = 1.04-1.05; P < .0001); UC and device utilization-ratio (aOR = 1.07; 95% CI = 1.01-1.13; P = .02); hospitalized at trauma-ICU (aOR = 14.12; 95% CI = 4.68-42.67; P < .0001), neurologic-ICU (aOR = 14.13; 95% CI = 6.63-30.11; P < .0001), neurosurgical-ICU (aOR = 13.79; 95% CI = 6.88-27.64; P < .0001); public-facilities (aOR = 3.23; 95% CI = 2.34-4.46; P < .0001). Discussion: CAUTI rate and risk are higher for older patients, women, hospitalized at trauma-ICU, neurologic-ICU, neurosurgical-ICU, and public facilities. All of them are unlikely to change. Conclusions: It is suggested to focus on reducing the length of stay and the Urinary catheter device utilization ratio, avoiding suprapubic catheters, and implementing evidence-based CAUTI prevention recommendations

Posterior reversible encephalopathy syndrome in association with exacerbation of chronic obstructive pulmonary disease: a case report

Abstract Background Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical and neurological entity. There are varieties of comorbid conditions which are associated with PRES. Chronic obstructive pulmonary disease (COPD) is a rare predisposing factor for the development of PRES. Case presentation A 55 year old female who was being treated for acute exacerbation of COPD developed altered sensorium and multiple episodes of seizure. Characteristic imaging findings and associated clinical symptoms led us to a diagnosis of PRES in our patient. Conclusion Association of PRES and COPD is a rare entity. The diagnosis of PRES should be brought to mind if there is encephalopathy or seizure in COPD exacerbation

Salt effects on surfactant aggregation and dye-micelle complexation

137-143Physical parameters for characterizing the structure of micelles are necessary for their surface chemical understanding. The effects of salts on physical characteristics (viz. critical micelle concentration, aggregation behaviour, counter ion binding, dye binding, etc.) of micelles have been investigated. The critical micelle concentration of ionic surfactant (sodium dodecylsulphate) has been found to decrease with addition of salt while for nonionic surfactants (Tweens) the change is insignificant.The aggregation number as well as safranine T and phenosafranine micelle binding constants show increase for ionic micelles in salt environment. The effects of salt in the above regards on nonionic micelles are negligible

Accidentally Missed Guidewire during Insertion of a Dialysis Catheter

Missed guidewire is a rare and potentially avoidable complication of central venous cannulation. Unsupervised insertion by trainees, distraction during insertion, and high workload may increase the risk. Simple measures such as holding onto the wire at all times until removal from the vessel, routine use of central venous catheter insertion checklist, and vigilant supervision of the trainees may help prevent missing of the guidewire