Maharajgunj Medical Campus

Abstract Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities 1,2 . This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity 3–6 . Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing—and in some countries reversal—of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.

Abstract High blood cholesterol is typically considered a feature of wealthy western countries 1,2 . However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world 3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health 4,5 . However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol—which is a marker of cardiovascular risk—changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million–4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Antibiotics are essential treatments, especially in the developing world like World Health Organization (WHO) Southeast Asian region where infectious diseases are still the most common cause of death. In this part of the world, antibiotics are purchased and used without the prescription of a physician. Self-medication of antibiotics is associated with the risk of inappropriate drug use, which predisposes patients to drug interactions, masking symptoms of an underlying disease, and development of microbial resistance. Antibiotic resistance is shrinking the range of effective antibiotics and is a global health problem. The appearance of multidrug-resistant bacterial strains, which are highly resistant to many antibiotic classes, has raised a major concern regarding antibiotic resistance worldwide. Even after decades of economic growth and development in countries that belong to the WHO Southeast Asian region, most of the countries in this region still have a high burden of infectious diseases. The magnitude and consequence of self-medication with antibiotics is unknown in this region. There is a need for evidence from well-designed studies on community use of antibiotics in these settings to help in planning and implementing specific strategies and interventions to prevent their irrational use and consequently to reduce the spread of antibiotic resistance. To quantify the frequency and effect of self-medication with antibiotics, we did a systematic review of published work from the Southeast Asian region.

BACKGROUND: Evidence on the burden of depression, internet addiction and poor sleep quality in undergraduate students from Nepal is virtually non-existent. While the interaction between sleep quality, internet addiction and depressive symptoms is frequently assessed in studies, it is not well explored if sleep quality or internet addiction statistically mediates the association between the other two variables. METHODS: We enrolled 984 students from 27 undergraduate campuses of Chitwan and Kathmandu, Nepal. We assessed sleep quality, internet addiction and depressive symptoms in these students using Pittsburgh Sleep Quality Index, Young's Internet Addiction Test and Patient Health Questionnaire-9 respectively. We included responses from 937 students in the data analysis after removing questionnaires with five percent or more fields missing. Via bootstrap approach, we assessed the mediating role of internet addiction in the association between sleep quality and depressive symptoms, and that of sleep quality in the association between internet addiction and depressive symptoms. RESULTS: Overall, 35.4%, 35.4% and 21.2% of students scored above validated cutoff scores for poor sleep quality, internet addiction and depression respectively. Poorer sleep quality was associated with having lower age, not being alcohol user, being a Hindu, being sexually active and having failed in previous year's board examination. Higher internet addiction was associated with having lower age, being sexually inactive and having failed in previous year's board examination. Depressive symptoms were higher for students having higher age, being sexually inactive, having failed in previous year's board examination and lower years of study. Internet addiction statistically mediated 16.5% of the indirect effect of sleep quality on depressive symptoms. Sleep quality, on the other hand, statistically mediated 30.9% of the indirect effect of internet addiction on depressive symptoms. CONCLUSIONS: In the current study, a great proportion of students met criteria for poor sleep quality, internet addiction and depression. Internet addiction and sleep quality both mediated a significant proportion of the indirect effect on depressive symptoms. However, the cross-sectional nature of this study limits causal interpretation of the findings. Future longitudinal study, where the measurement of internet addiction or sleep quality precedes that of depressive symptoms, are necessary to build upon our understanding of the development of depressive symptoms in students.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global spread of coronavirus disease (COVID-19). Our understanding of the impact this virus has on the nervous system is limited. Our review aims to inform and improve decision-making among the physicians treating COVID-19 by presenting a systematic analysis of the neurological manifestations experienced within these patients. METHODS: Any study, released prior to May 20, 2020, that reported neurological manifestations in patients infected by SARS-CoV-2 was systematically reviewed using the PRISMA (Preferred Reporting Items for Systemic review and Meta-Analysis) statement. RESULTS: Our systematic review included data from 37 articles: twelve retrospective studies, two prospective studies, and the rest case reports/series. The most commonly reported neurological manifestations of COVID-19 were myalgia, headache, altered sensorium, hyposmia, and hypogeusia. Uncommonly, COVID-19 can also present with central nervous system manifestations such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis, peripheral nervous manifestations such as Guillain-Barré syndrome and Bell's palsy, and skeletal muscle manifestations such as rhabdomyolysis. CONCLUSION: While COVID-19 typically presents as a self-limiting respiratory disease, it has been reported in up to 20% of patients to progress to severe illness with multi-organ involvement. The neurological manifestations of COVID-19 are not uncommon, but our study found most resolve with treatment of the underlying infection. Although the timeliness of this review engages current challenges posed by the COVID-19 pandemic, readers must not ignore the limitations and biases intrinsic to an early investigation.

OBJECTIVE: This study is a systematic review of the peer-reviewed literature to identify the correlates of mobile screen media use among children aged 8 years and less. SETTING: Home or community-based studies were included in this review while child care or school-based studies were excluded. PARTICIPANTS: Children aged 8 years or less were the study population. Studies that included larger age groups without subgroup analysis specific to the 0-8 years category were excluded. Eight electronic databases were searched for peer-reviewed English language primary research articles published or in press between January 2009 and March 2017 that have studied correlates of mobile screen media use in this age group. OUTCOME MEASURE: Mobile screen media use was the primary outcome measure. Mobile screen media use refers to children's use of mobile screens, such as mobile phones, electronic tablets, handheld computers or personal digital assistants. RESULTS: Thirteen studies meeting the inclusion criteria were identified of which a total of 36 correlates were examined. Older children, children better skilled in using mobile screen media devices, those having greater access to such devices at home and whose parents had high mobile screen media use were more likely to have higher use of mobile screen media devices. No association existed with parent's age, sex and education. CONCLUSION: Limited research has been undertaken into young children's mobile screen media use and most of the variables have been studied too infrequently for robust conclusions to be reached. Future studies with objective assessment of mobile screen media use and frequent examination of the potential correlates across multiple studies and settings are recommended. TRIAL REGISTRATION NUMBER: This review is registered with PROSPERO International Prospective Register of Ongoing Systematic Reviews (registration number: CRD42015028028).

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

The health system in Nepal is characterized by a wide network of health facilities and community workers and volunteers. Nepal's Interim Constitution of 2007 addresses health as a fundamental right, stating that every citizen has the right to basic health services free of cost. But the reality is a far cry. Only 61.8% of the Nepalese households have access to health facilities within 30 min, with significant urban (85.9%) and rural (59%) discrepancy. Addressing barriers to health services needs urgent interventions at the population level. Recently (February 2015), the Government of Nepal formed a Social Health Security Development Committee as a legal framework to start implementing a social health security scheme (SHS) after the National Health Insurance Policy came out in 2013. The program has aimed to increase the access of health services to the poor and the marginalized, and people in hard to reach areas of the country, though challenges remain with financing. Several aspects should be considered in design, learning from earlier community-based health insurance schemes that suffered from low enrollment and retention of members as well as from a pro-rich bias. Mechanisms should be built for monitoring unfair pricing and unaffordable copayments, and an overall benefit package be crafted to include coverage of major health services including non-communicable diseases. Regulations should include such issues as accreditation mechanisms for private providers. Health system strengthening should move along with the roll-out of SHS. Improving the efficiency of hospital, motivating the health workers, and using appropriate technology can improve the quality of health services. Also, as currently a constitution drafting is being finalized, careful planning and deliberation is necessary about what insurance structure may suit the proposed future federal structure in Nepal.

Birth weight of a child is an important indicator of its vulnerability for childhood illness and chances of survival. A large number of infant deaths can be averted by appropriate management of low birth weight babies and prevention of factors associated with low birth weight. The prevalence of low birth weight babies in Nepal is estimated to be about 12-32%.Our study aimed at identifying major determinants of low birth weight among term babies in Nepal. A hospital-based retrospective case control study was conducted in maternity ward of Tribhuvan University Teaching Hospital from February to July 2011. A total of 155 LBW babies and 310 controls were included in the study. Mothers admitted to maternity ward during the study period were interviewed, medical records were assessed and anthropometric measurements were done. Risk factors, broadly classified into proximal and distal factors, were assessed for any association with birth of low-birth weight babies. Regression analysis revealed that a history of premature delivery (adjusted odds ratio; aOR5.24, CI 1.05-26.28), hard physical work during pregnancy (aOR1.48, CI 0.97-2.26), younger age of mother (aOR1.98, CI 1.15-3.41), mothers with haemoglobin level less than 11gm/dl (aOR0.51, CI0.24-1.07) and lack of consumption of nutritious food during pregnancy (aOR1.99, CI 1.28-3.10) were significantly associated with the birth of LBW babies. These factors should be addressed with appropriate measures so as to decrease the prevalence of low birth weight among term babies in Nepal.

In the last decades, prevalence of non-communicable diseases (NCDs) has escalated in Nepal. This study reviews existing evidence on the burden of non-communicable diseases in Nepal using the framework developed by Arksey and O'Malley for scoping reviews. A total of 110 articles were identified from database searches, and four from additional searches. The titles and abstracts were reviewed using predetermined screening criteria. We limited our search to existing literature in English language and included all studies regardless of year of study. Both observational and interventional studies were included. Studies conducted outside Nepal and studies not reporting prevalence of NCDs were excluded. Additionally, we searched reference lists of included publications. All previous reports of Step Wise Surveillance to NCDs (STEPS Surveys) were included in the review. Finally, a total of 60 articles were included in this review. Limited studies on population-based prevalence of mental illness, chronic respiratory diseases, cardiovascular diseases, and road traffic accidents were found. There were limitations in the studies related to generalizability due to small sample sizes, non-random sampling and lack of studies from certain region of country. Nevertheless, high prevalence of hypertension and diabetes was found. Similarly, hospital-based studies reported high burden of cardiovascular diseases among outpatient contacts. Population-based cancer registries do not exist in Nepal. However, existing studies report 8,000-10,000 cancer deaths annually in Nepal. The most common cancer site in males was the lung, followed by the oral cavity and gastric, while the first three in females were cervix uteri, breast and lung. Prevalence of psychiatric morbidity was also high. Despite alarming burden of NCDs, the country's response is weak. Nepal needs to build non-communicable disease programmes with focus on disease prevention and management as well as awareness activities in urban and rural settings at community level.

BACKGROUND: Healthcare ethics is neglected in clinical practice in LMICs (Low and Middle Income Countries) such as Nepal. The main objective of this study was to assess the current status of knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses in a tertiary teaching hospital in Nepal. METHODS: This was a cross sectional study conducted among resident doctors (n = 118) and ward nurses (n = 86) in the largest tertiary care teaching hospital of Nepal during January- February 2016 with a self-administered questionnaire. A Cramer's V value was assessed to ascertain the strength of the differences in the variables between doctors and nurses. Association of variables were determined by Chi square and statistical significance was considered if p value was less than 0.05. RESULTS: Our study demonstrated that a significant proportion of the doctors and nurses were unaware of major documents of healthcare ethics: Hippocratic Oath (33 % of doctors and 51 % of nurses were unaware), Nuremberg code (90 % of both groups were unaware) and Helsinki Declaration (85 % of doctors and 88 % of nurses were unaware). A high percentage of respondents said that their major source of information on healthcare ethics were lectures (67.5 % doctors versus 56.6 % nurses), books (62.4 % doctors versus 89.2 % nurses), and journals (59 % doctors versus 89.2 % nurses). Attitude of doctors and nurses were significantly different (p < 0.05) in 9 out of 22 questions pertaining to different aspects of healthcare ethics. More nurses had agreement than doctors on the tested statements pertaining to different aspects of healthcare ethics except for need of integration of medical ethics in ungraduate curricula (97.4 % doctors versus 81.3 % nurses),paternalistic attitude of doctor was disagreed more by doctors (20.3 % doctors versus 9.3 % nurses). Notably, only few (9.3 % doctors versus 14.0 % nurses) doctors stood in support of physician-assisted dying. CONCLUSIONS: Significant proportion of doctors and nurses were unaware of three major documents on healthcare ethics which are the core principles in clinical practice. Provided that a high percentage of respondents had motivation for learning medical ethics and asked for inclusion of medical ethics in the curriculum, it is imperative to avail information on medical ethics through subscription of journals and books on ethics in medical libraries in addition to lectures and training at workplace on medical ethics which can significantly improve the current paucity of knowledge on medical ethics.

OBJECTIVES: The IFCC Committee on Reference Intervals and Decision Limits coordinated a global multicenter study on reference values (RVs) to explore rational and harmonizable procedures for derivation of reference intervals (RIs) and investigate the feasibility of sharing RIs through evaluation of sources of variation of RVs on a global scale. METHODS: For the common protocol, rather lenient criteria for reference individuals were adopted to facilitate harmonized recruitment with planned use of the latent abnormal values exclusion (LAVE) method. As of July 2015, 12 countries had completed their study with total recruitment of 13,386 healthy adults. 25 analytes were measured chemically and 25 immunologically. A serum panel with assigned values was measured by all laboratories. RIs were derived by parametric and nonparametric methods. RESULTS: The effect of LAVE methods is prominent in analytes which reflect nutritional status, inflammation and muscular exertion, indicating that inappropriate results are frequent in any country. The validity of the parametric method was confirmed by the presence of analyte-specific distribution patterns and successful Gaussian transformation using the modified Box-Cox formula in all countries. After successful alignment of RVs based on the panel test results, nearly half the analytes showed variable degrees of between-country differences. This finding, however, requires confirmation after adjusting for BMI and other sources of variation. The results are reported in the second part of this paper. CONCLUSION: The collaborative study enabled us to evaluate rational methods for deriving RIs and comparing the RVs based on real-world datasets obtained in a harmonized manner.

BACKGROUND: Malnutrition in mothers and children is a significant public health challenge in developing countries such as Nepal. Although undernutrition in children has been gradually decreasing, the coexistence of various forms of malnutrition in mothers and children has continued to rise globally. There is a gap in knowledge of the coexistence of such multiple burdens of malnutrition in the Nepalese context. The aims of this study were to explore the coexistence of various forms of malnutrition and associated factors among mother-child pairs residing in the same household. METHODS: A total sample of 2261 mother-child pairs from the Nepal Demographic and Health Survey (NDHS) 2016 were included in the study. Anthropometric measurements and hemoglobin levels of children and anthropometric measurements of their mothers were collected. Bivariate and multivariable logistic regression models were used to assess the factors associated with the double burden of malnutrition (DBM) and the triple burden of malnutrition (TBM). RESULTS: Prevalence of DBM and TBM was 6.60% (95% CI: 5.13-8.84) and 7.00% (95% CI: 5.42-8.99) respectively in the same households. In the adjusted multivariable logistic regression models, mothers with short stature (AOR = 4.18, 95% CI: 2.04-8.52), from the richest wealth quintile (AOR = 2.46, 95% CI: 1.17-5.15), aged over 35 years (AOR = 3.08, 95% CI: 1.20-7.86), and those who had achieved at least secondary level education (AOR = 2.05, 95% CI: 1.03-4.07) were more likely to suffer from the DBM. Similarly, mothers with short stature (AOR = 5.01, 95% CI: 2.45-10.24), from the richest wealth quintile (AOR = 2.66, 95% CI: 1.28-5.54), aged over 35 years (AOR = 3.41, 95% CI: 1.26-9.17), and those who had achieved at least secondary level education (AOR = 2.05, 95% CI: 1.00-4.18) were more likely to suffer from the TBM. CONCLUSIONS: Overall, there is a low prevalence of double and triple burden of malnutrition among mother-child pairs in Nepal. Older mothers with short stature and those from richer wealth quintiles were more likely to suffer from double and triple burden of malnutrition.

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.

BACKGROUND: spp. Global efforts on controlling multidrug-resistant (MDR) organisms have been hampered by their ability to escape antibacterial drugs. This study was undertaken to determine the prevalence of ESKAPE pathogens with prime focus on biofilm production and antibiotic resistance. METHODS: genes. All the isolates were processed for biofilm detection by the tube adherence method. RESULTS: gene was detected in all the VRE isolates. CONCLUSION: This study estimates the burden of the ESKAPE organisms and their antimicrobial resistance pattern in a hospital setting. A high percentage of drug resistance and biofilm production was noted; hence antimicrobial resistance surveillance targeting ESKAPE pathogens should be incorporated in the infection control policy in Nepal.

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections and a leading cause of death among patients in Intensive Care Unit (ICU). The South East Asian Region is a part of the world with limited health resources where infectious diseases are still underestimated. We aimed to review the literature in this part of the world to describe incidence, mortality and microbiological evidence of VAP and explore preventive and control strategies. We selected 24 peer-reviewed articles published from January 1, 2000 to September 1, 2020 from electronic databases and manual searching for observational studies among adult patients diagnosed with VAP expressed per thousand days admitted in ICU. The VAP rates ranged from 2.13 to 116 per thousand days, varying among different countries of this region. A significant rate of mortality was observed in 13 studies ranging from 16.2% to 74.1%. Gram negative organisms like Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella pneumoniae and Gram-positive organisms like Staphylococcus aureus and Enterococcus species were frequently found. Our findings suggest an alarming situation of VAP among patients of most of the countries of this region with increasing incidence, mortality and antibiotic resistance. Thus, there is an urgent need for cost effective control and preventive measures like interventional studies and educational programs on staff training, hand hygiene, awareness on antibiotic resistance, implementation of antibiotic stewardship programs and appropriate use of ventilator bundle approach.

The clinicopathological manifestations of cutaneous tuberculosis are diverse. The precise diagnosis is often overlooked, due to clinical presentations as those of cutaneous diseases with different etiology and the relative paucity of the pathogens in the lesions. Meanwhile, almost all of the diagnostic methods confer lower sensitivity and specificities which augments further diagnostic challenges. This article revises the current scenario of the disease's physiopathology and underscores clinicopathological challenges, due to multifaceted presentations of cutaneous tuberculosis, in the diagnosis.

BACKGROUND: Little evidence exists on the connections between nutrition, diet intake, and quality of life (QoL) among people living with HIV (PLHIV). The study aimed to estimate the prevalence of under-nutrition among PLHIV in Nepal, and identify risk factors and assess correlations with PLHIVs' QoL and nutritional status. METHODS: This quantitative cross-sectional study used Body Mass Index (BMI) as an indicator for nutritional status, and additional information on opportunistic infections (OIs), CD4 count, and World Health Organization (WHO) clinical staging was collected from medical records. Participants were asked to complete surveys on food security and QoL. Descriptive analysis was used to estimate the prevalence of under nutrition. To assess associations between nutrition status and independent variables, bivariate and multivariate analysis was completed. Spearman's rank correlation test was used to assess the association between nutritional status and QoL. RESULTS: One in five PLHIVs was found to be under nourished (BMI <18.5 kg/m(2)). Illiteracy, residence in care homes, CD4 cells count <350 cells/mm(3), OIs, and illness at WHO clinical stages III and IV were found to be significant predictors of under nutrition. BMI was significantly correlated with three domains of QoL (psychological, social and environmental). CONCLUSION: Nutrition interventions should form an integral part of HIV care programs. Understanding the presence of OI, decline in CD4 count, and advancing WHO clinical stages as risk factors can be helpful in preventing under nutrition from developing. Longitudinal research is necessary to further explicate associations between nutritional status and QoL.

BACKGROUND: Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE. METHODS: This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment. RESULTS: Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease. CONCLUSION: Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.

BACKGROUND: Edinburgh Postnatal Depression Scale (EPDS) is considered well accepted screening tool for postpartum depression (PPD). The objective of the study was to validate the EPDS as a screening tool for postpartum depression in Kathmandu, Nepal. METHODS: A hospital based cross sectional study using EPDS was conducted among 346 mothers between 4 and 14 weeks of postpartum period. All the participants were examined by psychiatrist for possible clinical PPD diagnosis using International Classification of Disease tenth revision (ICD-10). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for validation of EPDS. The best cut off point for Nepalese version of EPDS was identified and area of the receiver operating characteristics curve was calculated. RESULTS: The overall prevalence of PPD was 17.1 %.The sensitivity, specificity, positive predictive value and negative predictive value of the Nepalese version EPDS was found to be 92, 95.6, 77 and 99.3 % respectively. The best cut-off point of EPDS for screening of PPD was found to be 12/13 and the area of the curve was 0.98 (95 % CI 0.970-0.994, p = 0.001). CONCLUSIONS: The prevalence of PPD is not that far from the previous studies of Nepal. Nepali version of EPDS was acceptable and the study demonstrates good validity, thus EPDS can be used as valid screening tool for PPD for early detection, prompt treatment and to prevent possible consequences.