National Academy of Medical Sciences

Non-alcoholic fatty liver disease (NAFLD) is a potentially serious liver disease that affects approximately one-quarter of the global adult population, causing a substantial burden of ill health with wide-ranging social and economic implications. It is a multisystem disease and is considered the hepatic component of metabolic syndrome. Unlike other highly prevalent conditions, NAFLD has received little attention from the global public health community. Health system and public health responses to NAFLD have been weak and fragmented, and, despite its pervasiveness, NAFLD is largely unknown outside hepatology and gastroenterology. There is only a nascent global public health movement addressing NAFLD, and the disease is absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity. In this global Delphi study, a multidisciplinary group of experts developed consensus statements and recommendations, which a larger group of collaborators reviewed over three rounds until consensus was achieved. The resulting consensus statements and recommendations address a broad range of topics - from epidemiology, awareness, care and treatment to public health policies and leadership - that have general relevance for policy-makers, health-care practitioners, civil society groups, research institutions and affected populations. These recommendations should provide a strong foundation for a comprehensive public health response to NAFLD.

During the twentieth century, inflammatory bowel disease (IBD) was considered a disease of early industrialized regions in North America, Europe and Oceania1. At the turn of the twenty-first century, IBD incidence increased in newly industrialized and emerging regions in Africa, Asia and Latin America, while the prevalence in early industrialized regions continued to grow steadily2–4. Changes in the incidence and prevalence denote the evolution of IBD across four epidemiologic stages: stage 1 (emergence), characterized by low incidence and prevalence; stage 2 (acceleration in incidence), marked by rapidly rising incidence and low prevalence; and stage 3 (compounding prevalence), where the incidence decelerates, plateaus or declines while the prevalence steadily increases. A fourth stage (prevalence equilibrium) has been proposed in which the prevalence slope plateaus due to demographic shifts in an ageing IBD population, but it has not yet been evidenced. To date, these stages have remained theoretical, lacking specific numerical indicators to define transition points. Here, using real-world data from 522 population-based studies encompassing 82 global regions and spanning more than a century (1920–2024), we show spatiotemporal transitions across stages 1–3 and model stage 4 progression. Understanding the evolution of IBD across epidemiologic stages enables healthcare systems to better anticipate the future worldwide burden of IBD. An analysis of data from 522 population-based studies encompassing 82 global regions and spanning more than a century (1920–2024) shows spatiotemporal transitions across epidemiologic stages 1 to 3 of inflammatory bowel disease, and models stage 4 progression.

BACKGROUND: Health care workers exposed to COVID-19 might be at increased risk of developing mental health problems. The study aimed to identify factors associated with anxiety, depression and insomnia among health workers involved in COVID-19 response in Nepal. METHODS: This was a cross-sectional web-based survey conducted between April 26 and May 12, 2020. A total of 475 health workers participated in the study. Anxiety and depression were measured using a 14-item Hospital Anxiety and Depression Scale (HADS: 0-21) and insomnia was measured by using a 7-item Insomnia Severity Index (ISI: 0-28). Multivariable logistic regression analysis was done to determine the risk factors of mental health outcomes. RESULTS: Overall, 41.9% of health workers had symptoms of anxiety, 37.5% had depression symptoms and 33.9% had symptoms of insomnia. Stigma faced by health workers was significantly associated with higher odds of experiencing symptoms of anxiety (AOR: 2.47; 95% CI: 1.62-3.76), depression (AOR: 2.05; 95% CI: 1.34-3.11) and insomnia (AOR: 2.37; 95% CI: 1.46-3.84). History of medication for mental health problems was significantly associated with a higher likelihood of experiencing symptoms of anxiety (AOR: 3.40; 95% CI:1.31-8.81), depression (AOR: 3.83; 95% CI: 1.45-10.14) and insomnia (AOR: 3.82; 95% CI: 1.52-9.62) while inadequate precautionary measures in the workplace was significantly associated with higher odds of exhibiting symptoms of anxiety (AOR: 1.89; 95% CI: 1.12-3.19) and depression (AOR: 1.97; 95% CI: 1.16-3.37). Nurses (AOR: 2.33; 95% CI: 1.21-4.47) were significantly more likely to experience anxiety symptoms than other health workers. CONCLUSION: The study findings revealed a considerate proportion of anxiety, depression and insomnia symptoms among health workers during the early phase of the pandemic in Nepal. Health workers facing stigma, those with history of medication for mental health problems, and those reporting inadequate precautionary measures in their workplace were more at risk of developing mental health outcomes. A focus on improving mental wellbeing of health workers should be immediately initiated with attention to reduction of stigma, ensuring an adequate support system such as personal protective equipments, and family support for those with history of mental health problems.

BACKGROUND & AIMS: The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century. METHODS: We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries. RESULTS: Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence). CONCLUSIONS: Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.

Background and objective The aim of this study was to evaluate the stone-free status (SFS) rate and complications after flexible ureteroscopy (fURS) for treatment of renal stones using a flexible and navigable suction (FANS) ureteral access sheath. Methods Data for adults undergoing fURS in 25 centers worldwide were prospectively collected (August 2023 to January 2024). Exclusion criteria were abnormal renal anatomy and ureteral stones. All patients had computed tomography scans before and within 30 d after fURS with a FANS ureteral access sheath. SFS was defined as follows: grade A, zero fragments; grade B, a single fragment ≤2 mm; grade C, a single fragment 2.1–4 mm; and grade D, single/multiple fragments >4 mm. Data for continuous variables are presented as the median and interquartile range (IQR). Multivariable logistic regression was performed to evaluate predictors of grade A SFS. Key findings and limitations The study enrolled 394 patients (59.1% male) with a median age of 49 yr (IQR 36–61). The median stone volume was 1260 mm 3 (IQR 706–1800). Thulium fiber laser (TFL) was used in 45.9% of cases and holmium laser in the rest. The median lasing time was 18 min (IQR 11–28) and the median operative time was 49 min (IQR 37–70). One patient required a blood transfusion and 3.3% of patients had low-grade fever. No patient developed sepsis. Low-grade ureteral injury occurred in eight patients (2%). The grade A SFS rate was 57.4% and the grade A + B SFS rate was 97.2%, while 2.8% of patients had grade C or D SFS. Eleven patients underwent repeat fURS. Multivariable analysis revealed that a stone volume of 1501–3000 mm 3 (odds ratio 0.50) and of >3000 mm 3 (odds ratio 0.29) were significantly associated with lower probability of grade A SFS, while TFL use was associated with higher SFS probability (odds ratio 1.83). Limitations include the lack of a comparative group. Conclusions and clinical implications fURS using a FANS ureteral access sheath resulted in a high SFS rate with negligible serious adverse event and reintervention rates. Patient summary We looked at 30-day results for patients undergoing telescopic laser treatment for kidney stones using a special type of vacuum-assisted sheath to remove stone fragments. We found a high stone-free rate with minimal complications.

BACKGROUND: To identify potential environmental drivers of Japanese Encephalitis virus (JE) transmission in Nepal, we conducted an ecological study to determine the spatial association between 2005 Nepal JE incidence, and climate, agricultural, and land-cover variables at district level. METHODS: District-level data on JE cases were examined using Local Indicators of Spatial Association (LISA) analysis to identify spatial clusters from 2004 to 2008 and 2005 data was used to fit a spatial lag regression model with climate, agriculture and land-cover variables. RESULTS: Prior to 2006, there was a single large cluster of JE cases located in the Far-West and Mid-West terai regions of Nepal. After 2005, the distribution of JE cases in Nepal shifted with clusters found in the central hill areas. JE incidence during the 2005 epidemic had a stronger association with May mean monthly temperature and April mean monthly total precipitation compared to mean annual temperature and precipitation. A parsimonious spatial lag regression model revealed, 1) a significant negative relationship between JE incidence and April precipitation, 2) a significant positive relationship between JE incidence and percentage of irrigated land 3) a non-significant negative relationship between JE incidence and percentage of grassland cover, and 4) a unimodal non-significant relationship between JE Incidence and pig-to-human ratio. CONCLUSION: JE cases clustered in the terai prior to 2006 where it seemed to shift to the Kathmandu region in subsequent years. The spatial pattern of JE cases during the 2005 epidemic in Nepal was significantly associated with low precipitation and the percentage of irrigated land. Despite the availability of an effective vaccine, it is still important to understand environmental drivers of JEV transmission since the enzootic cycle of JEV transmission is not likely to be totally interrupted. Understanding the spatial dynamics of JE risk factors may be useful in providing important information to the Nepal immunization program.

BACKGROUND: The aim of this study was to determine the knowledge, attitude and practice (KAP) regarding the COVID-19 among frontline healthcare workers (F-HCWs) working at different hospitals in Nepal and to identify the factors significantly associated with KAP. METHODS: We used a web-based survey, and a convenience sampling method was adopted to collect data from 603 F-HCWs working at different hospitals in Nepal during the first week of June 2020. A self-administered questionnaire was utilized to assess the KAP perceived by the F-HCWs. It was divided into 4-parts consisting of 30-items, demographic characteristics (10-items), knowledge (10-items), attitude (5-items), and practice (5-items). It consisted of both multiple-choice questions and Likert scale items questionnaire. RESULTS: Among the participants, 76% reported adequate knowledge, 54.7% reported positive attitude, and 78.9% reported appropriate practice. Statistically significant differences regarding the perceived level of knowledge among F-HCWs were observed among independent variables, including age, gender, level of education, marital status, profession, work experience, source of information, infection prevention and control (IPC) training, and online course(p < 0.05). Similarly, statistically significant differences regarding the attitude among F-HCWs were observed among independent variables, including age, gender, level of education, profession, and online course(p < 0.05). Moreover, only 2-independent variables, including the profession and online course, showed statistically significant differences with practice(p < 0.05). Pearson correlation analysis showed a significant association between knowledge, attitude and practice at the level of p = 0.01. The factors significantly associated with adequate knowledge were male gender, nurse and doctor, websites and IPC training. Similarly, factors significantly associated with positive attitude were online course related to COVID-19 only. Moreover, factors significantly associated with appropriate practice were master's degree or above and online course related to COVID-19. CONCLUSIONS: F-HCWs reported adequate overall knowledge with a positive attitude and adopted the appropriate practice. The experienced F-HCWs with higher education and who received IPC training and online course regarding COVID-19 had better KAP. So, the stakeholders must arrange the educational programs and training for F-HCWs for better preparedness tackling with COVID-19.

Drinking water quality assessment in Kathmandu valley has always been crucial with reference to public health importance. A study was conducted to evaluate the quality of drinking water of the valley. A total of 132 drinking water samples were randomly collected from 49 tube wells, 57 wells, 17 taps and 9 stone spouts in different places of Kathmandu valley. The samples were analyzed for microbiological parameters. Total plate and coliform count revealed that 82.6% and 92.4% of drinking water samples found to cross the WHO guideline value for drinking water. During the study, 238 isolates of enteric bacteria were identified, of which 26.4% were Escherichia coli, 25.6% were Enterobacter spp, 23% were Citrobacter spp, 6.3% were Pseudomonas aeruginosa, 5.4% were Klebsiella spp, 4.0% were Shigella spp, 3.0% were Salmonella typhi, 3.0% were Proteus vulgaris, 3.0% were Serratia spp and 1.0% were Vibrio cholerae . Key words: Drinking water; Public health; Coliform; Bacteria. DOI: 10.3126/sw.v5i5.2667 Scientific World, Vol. 5, No. 5, July 2007 112-114

BACKGROUND: Globally, there is a growing concern over pesticides use, which has been linked to self-harm and suicide. However, there is paucity of research on the epidemiology of pesticides poisoning in Nepal. This study is aimed at assessing epidemiological features of pesticides poisoning among hospital-admitted cases in selected hospitals of Chitwan District of Nepal. METHODS: A hospital-based quantitative study was carried out in four major hospitals of Chitwan District. Information on all pesticides poisoning cases between April 1 and December 31, 2015, was recorded by using a Pesticides Exposure Record (PER) form. RESULTS: A total of 439 acute pesticides poisoning cases from 12 districts including Chitwan and adjoining districts attended the hospitals during the 9-month-long study period. A majority of the poisoned subjects deliberately used pesticides (89.5%) for attempted suicide. The total incidence rate was 62.67/100000 population per year. Higher annual incidence rates were found among young adults (111.66/100000 population), women (77.53/100000 population) and individuals from Dalit ethnic groups (98.22/100000 population). Pesticides responsible for poisoning were mostly insecticides (58.0%) and rodenticides (20.8%). The most used chemicals were organophosphates (37.3%) and pyrethroids (36.7%). Of the total cases, 98.6% were hospitalized, with intensive care required for 41.3%. The case fatality rate among admitted cases was 3.8%. CONCLUSIONS: This study has indicated that young adults, females and socially disadvantaged ethnic groups are at a higher risk of pesticides poisoning. Pesticides are mostly misused intentionally as an easy means for committing suicide. It is recommended that the supply of pesticides be properly regulated to prevent easy accessibility and misuse. A population-based study is warranted to reveal the actual problem of pesticides exposure and intoxication in the community.

Tuberculosis is a common disease and its incidence is in rising tendency in developed world because of AIDSand transglobal migration. Abdominal tuberculosis is more common in immunocompromised populationand manifests as infection of peritoneum, hollow or solid abdominal organs and abdominal lymphatics withmycobacterium tuberculosis organism. The peritoneum and ileo-cecal region are the most likely sites ofinfection and are involved in the majority of cases by hematogenous spread or through swallowing of infectedsputum from primary pulmonary tuberculosis. Pulmonary tuberculosis is evident in less than half of patientseither in active or latent form. Abdominal tuberculosis has a protean manifestation although the mostcommon clinical feature is the triad of abdominal pain, fever and weight loss. The diagnosis is often delayedbecause of non-specific presentation and is usually made through a combination of radiologic, microbiologic,histopathologic, endoscopic and molecular techniques. None of them provide a gold standard by themselves.However, an algorithm of these diagnostic methods leads to considerably higher precision in the diagnosisof abdominal tuberculosis which primarily necessitates a clinical awareness of this serious health problem.Abdominal tuberculosis is a serious condition and if untreated outcome is fatal. Early diagnosis and immediateinitiation of treatment along with dietary support is crucial for better outcome. Antimicrobial treatment isthe same as for pulmonary tuberculosis and management often requires combination of antituberculardrugs and surgery – for diagnosis as well as therapy.Key Words: Tuberculosis; Abdominal Tuberculosis; Extrapulmonary Tuberculosis.

BACKGROUND: Joint-preserving intercalary tumor resection can result in better proprioception and a more normal joint function after reconstruction. However, most reported reconstruction techniques are usually associated with frequent complications. Therefore, the approach of reconstruction following joint-preserving tumor resection warrants further study. METHODS: Between September 2016 and October 2018, 12 patients with metaphyseal malignant bone tumors around the knee joint were treated by joint-preserving intercalary resections with the aid of three-dimensional (3D)-printed osteotomy guide plates and reconstructions using 3D-printed intercalary prostheses. We assessed the accuracy of the resection by comparing the cross sections at the resection plane with 3D-printed matching surface of the prostheses. The functional outcomes, complications and oncological status were also evaluated. RESULTS: All patients were observed for 7 to 32 months with an average follow-up of 22.5 months. The achieved resection was accurate, with accurate matching between the residual bone and prosthesis. The mean MSTS score was 28 (range, 26-30). Superficial infection occurred in two patients. Local recurrence was observed in one patient, while pulmonary metastasis was identified in one patient. CONCLUSIONS: The personalized osteotomy guide plate and prosthesis based on 3D printing technique facilitate joint-preserving tumor resection and functional reconstruction. However, longer follow-up and larger sample size are required to clarify its long-term outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The aim of the study was to correlate between the clinical score described by Peradenya Organophosphorus Poisoning (POP) scale, serum cholinesterase level at presentation and severity of poisoning. Consecutive patients of organophosphorous poisoning attending Bir Hospital from August 2004 to September 2005 were studied. Patients were grouped into mild, moderate and severe poisoning groups according to the POP scale. Fifty patients fulfilled the inclusion criteria. The severity of poisoning directly correlated with serum cholinesterase level (P<0.001). The differences in the mean requirements of atropine on the first day of admission, in the total amount of atropine needed to treat and in the average duration of hospital stay were significant (P<0.05). There were 26% patients in moderate poisoning and only 4% patients in severe poisoning, but a total of 14% of the patients died, indicating that patients with even moderate degree of poisoning had also died. Both the POP scale severity and derangement in serum cholinesterase levels at initial presentation did not correlate with mortality, which could be due to various other co-morbidities and inadvertent stoppage of atropine infusion particularly at night in the wards. The POP scale and serum cholinesterase at presentation appeared useful to assess the severity of poisoning, particularly in terms of higher amount of atropine and prolonged duration of hospital stay. The patients with evidence of moderate and severe degrees of poisoning need close monitoring. Further studies to evaluate the factors likely to cause deaths, particularly by closely monitoring of moderate and severe organophosphorous poisoning in intensive care units, are required to clarify the correlation with mortality.

This study aims to determine the incidence of pre-eclampsia and distribution of risk factors of pre-eclampsia at Paropakar Maternity and Women's Hospital, Kathmandu, Nepal. A retrospective study included 4820 pregnant women from 17 September to 18 December 2017. Data were obtained from the medical records of the hospital's Statistics Department. Associations between the risk factors and pre-eclampsia were determined using logistic regression analysis and expressed as odds ratios. The incidence rate of pre-eclampsia in the study population was 1.8%. Higher incidence of pre-eclampsia was observed for women older than 35 years (Adjusted Odds Ratio, AOR)= 3.27; (Confidence Interval, CI 1.42-7.52) in comparison to mothers aged 20-24 years, primiparous women (AOR = 2.12; CI 1.25-3.60), women with gestational age less than 37 weeks (AOR = 3.68; CI 2.23-6.09), twins pregnancy (AOR = 8.49; CI 2.92-24.72), chronic hypertension (AOR = 13.64; CI 4.45-41.81), urinary tract infection (AOR = 6.89; CI 1.28-36.95) and gestational diabetes (AOR = 11.79; CI 3.20-43.41). Iron and calcium supplementation appear to be protective. Age of the mothers, primiparity, early gestational age, twin pregnancy, chronic hypertension, urinary tract infection and gestational diabetes were the significant risk factors for pre-eclampsia. Iron and calcium supplementation and young aged women were somewhat protective.

Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the "Expert Consensus on the Management of Brain Arteriovenous Malformations".

Abstract Diarrheal disease, still a major cause of childhood illness, is caused by numerous, diverse infectious microorganisms, which are differentially sensitive to environmental conditions. Enteropathogen‐specific impacts of climate remain underexplored. Results from 15 studies that diagnosed enteropathogens in 64,788 stool samples from 20,760 children in 19 countries were combined. Infection status for 10 common enteropathogens—adenovirus, astrovirus, norovirus, rotavirus, sapovirus, Campylobacter , ETEC, Shigella , Cryptosporidium and Giardia —was matched by date with hydrometeorological variables from a global Earth observation dataset—precipitation and runoff volume, humidity, soil moisture, solar radiation, air pressure, temperature, and wind speed. Models were fitted for each pathogen, accounting for lags, nonlinearity, confounders, and threshold effects. Different variables showed complex, non‐linear associations with infection risk varying in magnitude and direction depending on pathogen species. Rotavirus infection decreased markedly following increasing 7‐day average temperatures—a relative risk of 0.76 (95% confidence interval: 0.69–0.85) above 28°C—while ETEC risk increased by almost half, 1.43 (1.36–1.50), in the 20–35°C range. Risk for all pathogens was highest following soil moistures in the upper range. Humidity was associated with increases in bacterial infections and decreases in most viral infections. Several virus species' risk increased following lower‐than‐average rainfall, while rotavirus and ETEC increased with heavier runoff. Temperature, soil moisture, and humidity are particularly influential parameters across all enteropathogens, likely impacting pathogen survival outside the host. Precipitation and runoff have divergent associations with different enteric viruses. These effects may engender shifts in the relative burden of diarrhea‐causing agents as the global climate changes.

Background: Tumor deposits are one of the promising factors among the different edition of Tumor, Node, Metastasis classification. Despite improvement in the treatment of various types of metastatic disease the source and prognostic significance of tumor deposits in staging has not been deliberating the agreeable opinion. We investigated the possibility of tumor deposit as independent prognostic factor and evaluating its prognostic value in colorectal carcinoma patients.

BACKGROUND: Japanese encephalitis (JE) virus (JEV) is a mosquito-borne flavivirus found across Asia that is closely related to West Nile virus. There is no known antiviral treatment for any flavivirus. Results from in vitro studies and animal models suggest intravenous immunoglobulin (IVIG) containing virus-specific neutralizing antibody may be effective in improving outcome in viral encephalitis. IVIG's anti-inflammatory properties may also be beneficial. METHODOLOGY/PRINCIPAL FINDINGS: We performed a pilot feasibility randomized double-blind placebo-controlled trial of IVIG containing anti-JEV neutralizing antibody (ImmunoRel, 400mg/kg/day for 5 days) in children with suspected JE at two sites in Nepal; we also examined the effect on serum neutralizing antibody titre and cytokine profiles. 22 children were recruited, 13 of whom had confirmed JE; 11 received IVIG and 11 placebo, with no protocol violations. One child (IVIG group) died during treatment and two (placebo) subsequently following hospital discharge. Overall, there was no difference in outcome between treatment groups at discharge or follow up. Passive transfer of anti-JEV antibody was seen in JEV negative children. JEV positive children treated with IVIG had JEV-specific neutralizing antibody titres approximately 16 times higher than those treated with placebo (p=0.2), which was more than could be explained by passive transfer alone. IL-4 and IL-6 were higher in the IVIG group. CONCLUSIONS/SIGNIFICANCE: A trial of IVIG for JE in Nepal is feasible. IVIG may augment the development of neutralizing antibodies in JEV positive patients. IVIG appears an appealing option for JE treatment that warrants further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT01856205.

Intervertebral disc (IVD) degeneration is considered to be the primary reason for low back pain. Despite remarkable improvements in both pharmacological and surgical management of IVD degeneration (IVDD), therapeutic effects are still unsatisfactory. It is because of the fact that these therapies are mainly focused on alleviating the symptoms rather than treating the underlying cause or restoring the structure and biomechanical function of the IVD. Accumulating evidence has revealed that the endogenous stem/progenitor cells exist in the IVD, and these cells might be a promising cell source in the regeneration of degenerated IVD. However, the biological characteristics and potential application of IVD-derived stem/progenitor cells (IVDSCs) have yet to be investigated in detail. In this review, the authors aim to perform a review to systematically discuss (1) the isolation, surface markers, classification, and biological characteristics of IVDSCs; (2) the aging- and degeneration-related changes of IVDSCs and the influences of IVD microenvironment on IVDSCs; and (3) the potential for IVDSCs to promote regeneration of degenerated IVD. The authors believe that this review exclusively address the current understanding of IVDSCs and provide a novel approach for the IVD regeneration.

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

The under 5 child mortality rate in Nepal is on track to achieve the target of 54 per 1000 live births by 2015 compared with 158 per 1000 live births in 1991. The maternal mortality rate also looks set to drop to its target of 134 per 100,000 live births by 2015 from 539 per 100,000 live births in 1991. A 3-year interim plan (2008-11) was established to provide free basic health care for all citizens and the safe delivery incentive programme has proved to help progression towards achieving Millennium Development Goals 4 and 5. The development of a policy targeting women, children and vulnerable populations in hard to reach places is a key feature. The principle of a primary healthcare approach is applied in the development and implementation of strategy plans and programmes. The focus is on ensuring that there are functioning facilities for essential obstetric care at health facilities and provision of trained personnel at delivery.