CARCINOMA OF URINARY BLADDER;

Introduction: The most common presentation of carcinoma of urinarybladder is haematuria. Almost 80-90% of patients with carcinoma of bladder present eitherwith microscopic or gross haematuria and it is mostly intermittent rather than constant. Somepatients also complain of irritative voiding symptoms such as frequency, urgency and dysuria.Study Design: Descriptive, case series study. Setting: Department of Urology, DHQ Hospital,Gujranwala, Pakistan. Period: July 2015 to June 2016. Materials & Methods: Total 30 patientsirrespective of age and gender with diagnosis of bladder tumor based on clinical symptomsand supported by laboratory tools like Urine cytology, Ultrasound and IVU were included. Thealready diagnosed patients of bladder tumor that have been treated with different modalitieswere excluded. All the tumors were staged according to TNM classification after TURBT andgraded on the basis of histopathology. Results: Mean age was 53.17+16.07SD years. Maleswere 25(83.3%) and females were 5(16.7%). Male to female ratio is 5:1. Twenty eight (93.3%)patients out of 30 presented with painless haematuria. 23(73.33%) patients out of 30 patientswere smokers. 09 (30%) patients had Ta, in which G1 was found in 2 patients and G2 in 7patients. T1 was found in 10 (33.3%) patients, in which G2 was 5(17.3%) and G3 was 5(17.3%)cases. Muscle invasive T2a was diagnosed in 04 patients amongst them G2 and G3 wasdetected in 2(6.6%) patients each respectively. T2b was present in 3 patients, which had G1 in1(3.3%) and G3 in 2(10%) patients. T3b G2 was found 01 patient and T3b G3 was detected in1(3.3%) patient, T4M1 G3 was present in 2(6.6%) patients. Conclusion: This study concludedthat the bladder tumor is quite common with muscle invasive TCC is more common. Painlesshematuria is the commonest presentation and also smoking has a definite association with CAbladder.

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HEMORRHAGIC STROKE;

The Professional Medical Journal ◽

10.29309/tpmj/2014.21.06.2626 ◽

2014 ◽

Vol 21 (06) ◽

pp. 1204-1208

Author(s):

Faisal Shahab ◽

Irfan Murtaza Shahwani ◽

Shuaib Ansari ◽

Syed Zulfiquar Ali Shah

Keyword(s):

Blood Pressure ◽

Hemorrhagic Stroke ◽

Case Series ◽

Health Sciences ◽

Hypertensive Retinopathy ◽

Age Group ◽

Female Ratio ◽

Case Series Study ◽

Male To Female ◽

Series Study

Objectives: To identify the frequency of risk factors in hemorrhagic stroke at Liaquat university of medical and health sciences. Patient and methods: This Descriptive case series study of six months was carried out in the department of medicine, Liaquat University of Medical and Health Sciences. Patients aged 20-70 years of age with hemorrhagic stroke on CT were enrolled in the study after taking consent from caretaker of patients. Detailed history focusing on hypertension, diabetes and smoking and their duration was taken. Blood pressure was recorded and fundoscopy was done to find out diabetic or hypertensive retinopathy. Thorough neurological examination and fasting / random blood glucose level was evaluated while the data was done was analyzed using SPSS version 16. Results: A total of 100 patients were included in the study during study period. 61% of patients were in > 50 years of age group with mean age of 53.4±11 years. A total of 66 (66%) were male; with male to female ratio was 2:1. Hypertension was present in 63% of cases, Diabetes was found in 24% cases and 44 patients were cigarette smokers. Conclusions: It was concluded that high blood pressure, diabetes mellitus and smoking are associated with hemorrhagic stroke.

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Epidemiology of Skin Diseases among Displaced People in Diyala Province

Journal of the Faculty of Medicine Baghdad ◽

10.32007/jfacmedbagdad.v60i1.45 ◽

2018 ◽

Vol 60 (1) ◽

pp. 52-56

Author(s):

Naseer K. Alwan ◽

Shahab A. Shakir ◽

Hayder H. Waheeb

Keyword(s):

Skin Diseases ◽

Economic Status ◽

Age Groups ◽

Case Series ◽

Female Ratio ◽

Internally Displaced ◽

Case Series Study ◽

Displaced People ◽

Infectious Skin Diseases ◽

Male To Female

Background: Diyala have many internally displaced persons as a consequence of the armed conflict. Those peoples experience serious health problems related to their displacement, including skin disorders.Objective: To determine the prevalence of skin diseases and the use of health care among displaced patients in Diyala.Methods: A case-series study conducted on 246 displaced patients from May to November 2017, who attended Baqubah teaching hospital in Diyala. All patients were diagnosed by dermatologists depending on clinical findings.Results: A total of 246 displaced patient from all age groups mean±SD (21.9±18.59) years, range 1-64) consulate the clinic, of them (29.3%) male and (70.7%) female with male to female ratio (1:2.4). Infectious skin diseases have the highest rate (65.9%), followed by dermatitis (18.4%), acne (5.7%), alopecia (5.3%), and Papulosquamous diseases (4.8%). Parasitic skin infestations (31.7%) and viral infection (24.4%) were the commonest noted infections. Significant associations present between previous consultation and economic status, and between prevalence of skin infections and low economic status. Significant associations between skin diseases and rising crowding index.Conclusion: Infectious skin diseases are common among displaced patients, significantly higher among low economic status. Skin diseases significantly associated with rising crowding index. وبائية الامراض الجلدية بين النازحين في محافظة ديالى د. نصير كريم علوان دائرة صحة ديالى د. شهاب احمد شاكر كلية الطب جامعة ديالى حيدر حميد وهيب دائرة صحة ديالى خلفية الدراسة: نتيجة العنف والنزاع المسلح في ديالى، نزح عدد كبير من الناس فيها. تعاني هذه المجموعات من مشاكل صحية كبيرة تتعلق بنزوحها، بما في ذلك الأمراض الجلدية. هدف الدراسة: هذه الدراسة تهدف الى تحديد انتشار الامراض الجلدية بين النازحين في ديالى ومدى استخدام خدمات الرعاية الصحية لعلاجها. الطريقة: دراسة استطلاعية أجريت على ٢٤٦ نازح من المرضى الذين راجعوا قسم الأمراض الجلدية في مستشفى بعقوبة التعليمي في محافظة ديالى للفترة من ١ مايو إلى ٣٠ نوفمبر ٢٠١٧ واستند التشخيص على الصورة السريرية للمرض. النتائج: خلال فترة الدراسة شُخّص ٢٤٦ نازح بإمراض جلدية مختلفة، تراوحت أعمارهم بين ١-٦٤ سنة، متوسط العمر (٩.٢١) سنة، كانت نسبة الذكور الى الاناث (١: ٢.٤)، ١٧٤ من الإناث (٧٠.٧٪) و٧٢ من الذكور (٢٩.٣٪). وكان المرض الجلدي الأكثر انتشاراً في كل من الذكور والإناث هو الالتهابات الجلدية المعدية (٦٥.٩٪)، يتبعه الأكزيما (١٨.٤٪)، ومن ثم حب الشباب (٥.٧٪) على التوالي. ومثلت الالتهابات الطفيلية أعلى نسب انتشار من بين الالتهابات الجلدية المعدية (٣١.٧٪)، تليها الالتهابات الفيروسية (٢٤.٤٪). أظهرت النتائج علاقة وثيقة بين نسبة انتشار الامراض الجلدية المعدية والحالة الاقتصادية للمرضى، وبين المراجعة لعلاج المرض والحالة الاقتصادية. وجدت الدراسة أيضا علاقة وثيقة بين انتشار الامراض الجلدية المعدية وارتفاع مؤشر ازدحام السكن. الاستنتاج: الأمراض الجلدية المعدية شائعة بين المرضى النازحين، وهي تزداد بين المرضى ذوي الدخل المحدود. الأمراض الجلدية تؤثر على جميع الفئات العمرية، وترتبط بشكل كبير مع ارتفاع مؤشر ازدحام السكن. مفتاح الكلمات: الامراض الجلدية، النازحين، مؤشر الزحام.

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Effects of the COVID-19 Epidemic on Hospital Admissions for Non-Communicable Diseases in a Large Italian University-Hospital: A Descriptive Case-Series Study

Journal of Clinical Medicine ◽

10.3390/jcm10040880 ◽

2021 ◽

Vol 10 (4) ◽

pp. 880

Author(s):

Caterina Caminiti ◽

Giuseppe Maglietta ◽

Tiziana Meschi ◽

Andrea Ticinesi ◽

Mario Silva ◽

...

Keyword(s):

Hospital Admissions ◽

Case Series ◽

Communicable Diseases ◽

University Hospital ◽

Negative Consequences ◽

Non Communicable Diseases ◽

Case Series Study ◽

And Gender ◽

Long Term Impact ◽

Series Study

Background: Concern is growing about the negative consequences that response measures to the COVID-19 epidemic may have on the management of other medical conditions. Methods: A retrospective descriptive case-series study conducted at a large University-hospital in northern Italy, an area severely hit by the epidemic. Results: Between 23 February and 14 May 2020, 4160 (52%) COVID-19 and 3778 (48%) non-COVID-19 patients were hospitalized. COVID-19 admissions peaked in the second half of March, a period characterized by an extremely high mortality rate (27.4%). The number of admissions in 2020 was similar to 2019, but COVID-19 patients gradually occupied all available beds. Comparison between COVID-19 and non-COVID-19 admissions in 2020 revealed significant differences concerning all age classes and gender. Specifically, COVID-19 patients were older, predominantly male, and exhibited more comorbidities. Overall, admissions for non-communicable diseases (NCDs) in 2020 vs. 2019 dropped by approximately one third. Statistically significant reductions were observed for acute myocardial infarction (−78, −33.9%), cerebrovascular disease (−235, −41.5%), and cancer (−368, −31.9%). While the first two appeared equally distributed between COVID-19 and non-COVID-19 patients, chronic NCDs were statistically significantly more frequent in the former, except cancer, which was less frequent in COVID-19 patients. Conclusions: Prevention of collateral damage to patients with other diseases should be an integral part of epidemic response plans. Prospective cohort studies are needed to understand the long-term impact.

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The Epidemiology of Household Rodenticides Poisoning in Hong Kong and its Risk Factors for Developing Coagulopathy

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490791402100601 ◽

2014 ◽

Vol 21 (6) ◽

pp. 339-345 ◽

Cited By ~ 1

Author(s):

N Othman ◽

Ck Chan ◽

Fl Lau

Keyword(s):

Risk Factors ◽

Hong Kong ◽

Emergency Departments ◽

Multiple Logistic Regression Analysis ◽

Case Series ◽

Female Ratio ◽

Intentional Ingestion ◽

Accident And Emergency ◽

Case Series Study ◽

Clinically Significant

Objective To (1) describe the epidemiology of household rodenticides poisoning in Hong Kong, (2) evaluate the proportion of patients who have develop coagulopathy after rodenticide poisoning, (3) identify the risk factors for developing coagulopathy in rodenticide poisoning. Design Case series study. Setting Sixteen accident and emergency departments in Hong Kong. Patients Patients with household rodenticide ingestion who presented to accident and emergency departments during the period from July 2008 to February 2012. Results 110 patients were reported to have rodenticide exposure during the study period. Eighty-seven patients were included in the final analysis. The mean age was 40.1 and the male-to-female ratio was 1.29:1 (49:38). Most patients (91%) took the rodenticide intentionally. Sixty-nine patients (79%) exposed to anticoagulants type of rodenticide based on history or laboratory findings. The ingredient of the rodenticide ingested in 18 patients (21%) was untraceable. The only clinically significant presentation reported after rodenticide exposure was coagulopathy. Thirty-one patients (36%) developed coagulopathy with an international normalised ratio greater or equal to 1.3. Clinical significant bleeding was only observed in one patient. Presence of coagulopathy in rodenticide poisoning was significantly associated with older patient, intentional ingestion, ingestion of warfarin, ingestion of more than one pack and presence of co-ingestion. Multiple logistic regression analysis showed that only two factors were independent predictor of coagulopathy: Ingestion of warfarin rodenticide (p=0.001, odds ratio [OR] = 18.20, 95% confidence interval [CI]=3.44-96.42), and ingestion of more than one pack of rodenticide (p=0.02, OR=10.01, 95% CI=1.43-69.87). Conclusions Clinically significant household rodenticide poisoning in Hong Kong is solely related to ingestion of anticoagulant type of rodenticide. Patients who have ingested warfarin rodenticide and higher ingestion dose are more likely in developing coagulopathy. (Hong Kong j.emerg.med. 2014;21:339-345)

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TO DETERMINE THE FREQUENCY OF VISCERAL LEISHMANIASIS IN PERIPHERAL CYTOPENIC PATIENT IN PATHOLOGY DEPARTMENT HAYATABAD MEDICAL COMPLEX.

Journal of Saidu Medical College, Swat ◽

10.52206/jsmc.2014.4.2.560-566 ◽

1969 ◽

Vol 4 (2) ◽

pp. 560-566

Author(s):

ZARD ALI KHAN ◽

MOHAMMAD SAJJAD ◽

IMRAN UD DIN ◽

MUKAMIL SHAH ◽

SHAH JEHAN

Keyword(s):

Bone Marrow ◽

Visceral Leishmaniasis ◽

Case Series ◽

Bone Marrow Aspiration ◽

Bone Marrow Examination ◽

Total Leukocyte Count ◽

Full Blood Count ◽

Female Ratio ◽

Pathology Department ◽

Case Series Study

BACKGROUND: Visceral Leishmaniasis is a chronic disease and was first described in 1903, byLIESHMAN and DONOVAN. The disease is common in tropical and sub tropical areas of the worldwith various hematological manifestations. It is characterized by fever, visceromegaly, weight loss,pancytopenia and hypergammaglobulenemia. The disease is silent killer, invariably killing almost alluntreated patients, but curable with hematological improvement within 4-6 weeks of treatment.OBJECTIVE: To determine the frequency of Visceral Leishmaniasis in patints with cytopenias .MATERIAL AND METHODS: A descriptive study conducted in Pathology department, HayatabadMedical Complex, Hayatabad from September 1, 2012 to August 31, 2013. This study comprises of 126patients, subjected to complete blood counts. Diagnosis were confirmed by finding Amastigote( L/Dbody) from bonemarrow aspirate. All the patients who were referred to pathology Department of thehospital for bone marrow examination, with the results of peripheral blood using automatedHaematology analyzer, Sysmex KX 21 showing cytopenia were included in the study. Consent wastaken from the patient for bone-marrow aspiration procedure. After consent detailed history, physicalexamination was done.Laboratory investigations i.e. full blood count, which includes hemoglobin estimation, white blood cell,red blood, and platelet count.Bone marrow cytology (Giemsa stain) was recorded on the designed profroma.Posterior superior iliac spine (PSIS) was used as the site for aspiration in adults and children over 2years of ageRESULT: Descriptive case series study of 126 patients of peripheral cytopenia. In which 77 (61.1%)patients were males and 49 (38.9%) were female with male to female ratio of 1.57: 1 It was also foundin this study that visceral leishmaniasis was present in 29 (23%) of cases and the male: female were 1.6:1. Result of the automated hematology analyzer of peripheral cytopenic patients in visceralleishmaniasis show that all of the patients were having total leukocyte count less than 4000/cmm(100%). The hemoglobin level wass less than lOgm/dl in 26 cases (87.7%) and more than lOgm/dl inthree cases (10.3%). In case of platelets count, 27 cases (93.1%) were having platelets count less than150000/cmm.CONCLUSION: Incidence of visceral leishmaniasis is highier in children age group 1-10 years, alsomales are more prone than females. Leukopenia is recorded in all (100%) of the cases, followed bythrombocytopenia (93.1%) and anemia (Hb <10gm %) 87.7% cases.KEY WORD: Visceral Leishmaniasis, Kala Azar, Amastigote (L/D body)

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Operative management of external auditory canal cholesteatoma: case series and literature review

The Journal of Laryngology & Otology ◽

10.1017/s0022215113001850 ◽

2013 ◽

Vol 127 (9) ◽

pp. 859-866 ◽

Cited By ~ 11

Author(s):

M Sayles ◽

H A Kamel ◽

F F Fahmy

Keyword(s):

External Auditory Canal ◽

Case Series ◽

Operative Management ◽

External Ear ◽

Ear Canal ◽

Female Ratio ◽

External Ear Canal ◽

Temporal Bones ◽

External Auditory Canal Cholesteatoma ◽

Male To Female

AbstractObjectives:To describe the clinical features of external auditory canal cholesteatoma, and to assess the outcome following bony meatoplasty with tragal cartilage and perichondrium graft repair.Methods:A retrospective review was carried out, comprising all patients with external auditory canal cholesteatoma who presented between January 2007 and December 2011. Patients underwent pre-operative audiometry and computed tomography imaging of the temporal bones, before undergoing bony meatoplasty via a postauricular incision. Pre- and post-operative comparisons were made of patients' otological symptoms and the otoscopic appearance of the external ear canal.Results and conclusion:Eight patients were included in the analyses. The median age of patients was 46.5 years (range 14–68 years), with a male to female ratio of 1:1. The median length of follow up was 16 months. The most common presenting features were unilateral otalgia and purulent otorrhoea. All patients had relatively advanced disease at presentation, with erosion of the temporal bone. All patients underwent bony meatoplasty via a postauricular approach to eradicate the disease. Bony meatoplasty was successful in the definitive management of external ear canal cholesteatoma.

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Study of hypocalcemia and its risk factors in post thyroidectomy in Al-Karama Teaching Hospital

Journal of the Faculty of Medicine Baghdad ◽

10.32007/jfacmedbagdad.6041052 ◽

2019 ◽

Vol 60 (4) ◽

pp. 185-190

Author(s):

Mohammed H. Surriah ◽

Ahmed N. Hassan ◽

Amine M. Bakkour

Keyword(s):

Risk Factors ◽

Teaching Hospital ◽

Thyroid Surgery ◽

Case Series ◽

Inferior Thyroid Artery ◽

Pathology Report ◽

Surgical Department ◽

Case Series Study ◽

Extent Of Surgery ◽

And Gender

Background: Hypocalcemia is a well-recognized complication of thyroid surgery. The aim of this study was to determine the incidence of hypocalcemia after thyroid surgery and find out the risk factors involved regarding the patient’s age, gender, muscular build, clinical diagnosis, extent of surgery, ligation of the inferior thyroid artery, and pathology report. Patients and Methods: This case series study was carried out on 50 patients who have undergone thyroid surgery for various thyroid diseases at the surgical department of Al-Karama Teaching Hospital for the period between January 2016 and July 2017. Serial serum calcium measurements were recorded as well as details of the operation, patient’s age and gender, whether or not inferior thyroid artery was ligated, and the pathological report. Hypocalcemia was considered transient if it resolved within 6 months and permanent if it persisted after 6 months and the patient was maintained on supplementation therapy of calcium and vitamin D. Results: The study found that the incidence of post-thyroidectomy hypocalcemia was 30% and in the majority of the cases (24%) was transient, while it was permanent in only (6%) of the cases; and had occurred mainly after total thyroidectomy and in cases with ligation of the inferior thyroid artery. Conclusions: It was concluded that post thyroidectomy hypocalcemia is a relatively common complication but it is transient in the majority of the patients. Its incidence is related to the extent of the surgery and can be reduced by the good preparation of the patient preoperatively.

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Central Auditory Nervous System Stimulation through the Cochlear Implant Use and Its Behavioral Impacts: A Longitudinal Study of Case Series

Case Reports in Otolaryngology ◽

10.1155/2021/8888450 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Marina Isabel Cavalcanti ◽

Liliane Aparecida Fagundes Silva ◽

Maria Valéria Schmidt Goffi Gomez ◽

Tsuji Robinson Koji ◽

Ricardo Ferreira Bento ◽

...

Keyword(s):

Cochlear Implant ◽

Oral Language ◽

Auditory Evoked Potentials ◽

Case Series ◽

Behavioral Skills ◽

Case Series Study ◽

And Gender ◽

Clinical Resource ◽

Effective Use ◽

Cortical Maturation

The purpose of this study was to investigate, over a period of five years, the cortical maturation of the central auditory pathways and its impacts on the auditory and oral language development of children with effective use and without effective use of a Cochlear Implant (CI). A case series study was conducted with seven children who were CI users and seven children with normal hearing, with age- and gender-matched to CI users. The assessment was performed by long-latency auditory evoked potentials and auditory and oral language behavioral protocols. The results pronounced P1 latency decrease in all CI users in the first nine months. Over five years, five children with effective CI use presented decrease or stabilization of P1 latency and a gradual development of auditory and oral language skills, although, for most of the children, the electrophysiological and behavior results remained poor than their hearing peers’ results. Two children who stopped the effective use of CI after the first year of activation had worsened auditory and oral language behavioral skills and presented increased P1 latency. A negative correlation was observed between behavioral measures and the P1 latency, the P1 component being considered an important clinical resource capable of measuring the cortical maturation and the behavioral evolution.

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The Level of Vitamin A and Selenium of Cystic Echinococcosis in Aba and Garze Tibetan Autonomous Prefecture , Sichuan, China

10.21203/rs.3.rs-40255/v1 ◽

2020 ◽

Author(s):

Cheng Li ◽

Yongqi Bai ◽

Mingcai Zeng ◽

Yong Luo ◽

Chumu Luorong ◽

...

Keyword(s):

Vitamin A ◽

Cystic Echinococcosis ◽

Serum Levels ◽

Sichuan Province ◽

Healthy Controls ◽

Age And Gender ◽

Female Ratio ◽

Socioeconomic Burden ◽

And Gender ◽

Male To Female

Abstract Background Cystic echinococcus (CE), endemic in Asia, causes disease resulting in a high socioeconomic burden. Methods Eighty-nine echinococcosis patients and 274 controls from the Aba and Garze Tibetan Autonomous Prefecture of Sichuan province in China were recruited. The serum levels of Selenium (Se) and vitamin A (VA) of the cases and controls were detected and stratified by age and gender. Results The results showed that the male to female ratio of the patients was 1:1.97. The echinococcosis patients were mainly adults. It was confirmed that the serum levels of VA and age were correlated. Compared with the healthy controls, the serum levels of Se and VA of the cases significantly declined in both children and adults. Conclusions It was confirmed that the serum levels of Se and VA were interrelated with the prevalence of echinococcosis.

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Spectrum of surgical trauma and associated head injuries at a university hospital in eastern Nepal

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.63092 ◽

2010 ◽

Vol 01 (01) ◽

pp. 02-08 ◽

Cited By ~ 8

Author(s):

A Bajracharya ◽

A Agrawal ◽

B R Yam ◽

C S Agrawal ◽

Owen Lewis

Keyword(s):

Road Traffic ◽

Average Length ◽

Case Series ◽

Operative Management ◽

Health Sciences ◽

University Hospital ◽

Surgical Trauma ◽

Eastern Region ◽

Female Ratio ◽

Case Series Study

ABSTRACT Background: Trauma is one of the common surgical emergencies presenting at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal, a tertiary referral center catering to the needs of the population of Eastern Nepal and nearby districts of India. Objective: The objective of this study is to analyze the magnitude, epidemiological, clinical profile and outcome of trauma at B P Koirala Institute of Health Sciences. Materials and Methods: This descriptive case series study includes all patients with history of trauma coming to BPKIHS emergency and referred to the surgery department. We noted the detailed clinical history and examination, demographics, mechanism of injury, nature of injury, time of reporting in emergency, treatment offered (operative or non operative management) and analyzed details of operative procedure (i.e. laparotomy, thoracotomy, craniotomy etc.), average length of hospital stay, morbidity and outcome (according to Glasgow outcome scale). Collected data were analyzed using EpiInfo 2000 statistical software. Results: There were 1848 patients eligible to be included in the study. The mean age of the patients was 28.9 ± 19.3 years. Majority of the patients (38%) belonged to the age group of 21 - 40 years and the male to female ratio was 2.7:1. Most of the trauma victims were students (30%) followed by laborers (27%) and farmers (22%) respectively. The commonest causes of injury were fall from height (39%), road traffic accident (38%) and physical assault (18%); 78% of the patients were managed conservatively and 22% underwent operative management. Postoperative complications were seen in 18%. Wound infection 7.5%, neurological deficit including cerebrospinal fluid (CSF) otrorrhea was seen in 2.2% patients. Good recovery was seen in 84%, moderate disability in 5.2% patients and severe disability in 1.4% patients. The mortally was 6.3% and most of the deaths were related to traumatic brain injuries. Conclusions: In Nepal, trauma-related injury contributes significantly to morbidity and mortality and is the third leading cause of death. There are very few studies on trauma from this country and hence this study will help in understanding the etiology and outcome particularly in the Eastern region of Nepal.

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