Background Herniorrhaphy is one of the most frequently performed general surgical operations worldwide. However, most low- and middle-income countries (LMICs) are unable to provide this essential surgery to the general public, resulting in considerable morbidity and mortality. This study aimed to estimate the prevalence, barriers to care and disability of untreated hernias in Nepal. Methods Nepal is a low-income country in South Asia with rugged terrain, infrastructure deficiencies and a severely under-resourced healthcare system resulting in substantial unmet surgical need. A cluster randomized, cross-sectional household survey was performed using the validated Surgeons OverSeas Assessment of Surgical (SOSAS) tool. Fifteen randomized clusters consisting of 30 households with two randomly selected respondents each were sampled to estimate surgical need. The prevalence of and disability from groin hernias and barriers to herniorrhaphy were assessed. Results The survey sampled 1,350 households, totaling 2,695 individuals (97% response rate). There were 1,434 males (53%) with 1.5% having a mass or swelling in the groin at time of survey (95% CI 0.8 – 3.0). The age-standardized rate for inguinal hernias in men ranged from 1,144 per 100,000 persons between age 5 and 49 years and 2,941 per 100,000 persons age ≥50 years. Extrapolating nationally, there are nearly 310,000 individuals with groin masses and 66,000 males with soft/reducible groin masses in need of evaluation in Nepal. Twenty-nine respondents were not able to have surgery due to lack of surgical services (31%), fear or mistrust of the surgical system (31%) and inability to afford care (21%). Twenty percent were unable to work as previous or perform self-care due to their hernia. Conclusions Despite the lower than expected prevalence of inguinal hernias, hundreds of thousands of people in Nepal are currently in need of surgical evaluation. Given that essential surgery is a necessary component in health systems, the prevalence of inguinal hernias and the cost-effectiveness of herniorrhaphy, this disease is an important target for LMICs planning surgical capacity improvements.

Background: Autism spectrum disorder (ASD) is a neurological disorder which usually appears before the age of 3. Several genetic or environmental factors may be involved in onset of Autism Spectrum Disorder. Objectives: To fi nd relationship of Autism Spectrum Disorder with different maternal factors and events during pregnancy. Methodology: This is a retrospective case control study with total of 104 children of age 3-15 years as a sample, 52 were cases and 52 were controls. The study unit was selected from the database of Autism Care Nepal (ACN) for cases and questionnaire was designed based on the probable risk factors of Autism Spectrum Disorder from existing literature. Controls were chosen from schools, questionnaire being fi lled by asking questions to the mothers of the child with same age group as the cases, similar socio-economic background and intellectually normal. Results: There were 78.8% males and 21.1% females among cases and 53.8% were male and 46.1% were female among controls which show male predominance among cases. Among various maternal risk factors, the maternal second hand smoking (P value: 0.04) and maternal respiratory tract infection (P value: 0.04) were found to be statistically signifi cant. Regarding neonatal factors, birth asphyxia (P value: 0.003), delayed cry (P value: 0.000) and neonatal jaundice (P value: 0.05) were found to be statistically signifi cant. Conclusion: We found association of maternal second hand smoking, respiratory tract infection and among neonatal factors, birth asphyxia, delayed cry and neonatal jaundice to be associated with Autism Spectrum Disorder.

Background Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world’s population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries (LIC) such as Nepal. The aim of this study is to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. Methods A countrywide survey utilizing the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool was administered from May 25th to June 12th 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding, and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged over 18 were included in this analysis. Results A total of 1350 households and 2,695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1,941 individuals 18 years and older stated they had experienced rectal bleeding (2.0%, 95% CI 1.4% to 2.7%), with a mean age of 45.5 (SD 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Healthcare was sought in 18 participants with current rectal bleeding, with 2 major procedures performed, one an operation for an anal fistula. For those who sought healthcare but did not receive surgical care, reasons included no need (4), not available (6), fear/no trust (5) and no money for healthcare (1). For those with current rectal bleeding who did not seek healthcare, reasons included no need (1), not available (2), fear/no trust (6) and no money for healthcare (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% CI 0.8% to 1.8%). Conclusion The Nepal healthcare system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a healthcare professional, and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in LIC is crucial to avoid emergency surgeries, advanced stage malignancies or fatalities from treatable conditions.