Work-related Respiratory Symptoms and Associated Factors among Cement Factory Workers in Rupandehi District, Nepal

Background Cement factory workers are exposed to cement dust at workplace. It leads to a greater prevalence of chronic respiratory signs and symptoms. Objective To identify the prevalence of Work-related respiratory symptoms, its association with various risk factors, and to assess the outcomes like hospitalization and sickness absenteeism. Method Cross-sectional study was conducted in the Argakhanchi Cement factory among 190 workers with minimum work experience of 1 year. Census method was used for data collection. To assess the respiratory symptoms, sputum samples were collected; smears prepared by pick and smear method, and later stained by Leishman and pap stain. Smears devoid of alveolar macrophages were considered unsatisfactory for evaluation. Result The mean age of respondents with standard deviation was 35.56±11.45 years. The prevalence of Work-related respiratory symptoms was 31.6%. Age, no. of years worked, working in the raw materials department, burner and clinker department, cleaning department and wearing mask were the significant risk factors. On cytological analysis of the sputum sample, mild inflammatory cell noticed in 71.6%, moderate inflammation in 23.7%, and dense inflammation in 4.2%. Fungal spores were seen in 3.7%, fungal pseudohyphae in 0.5%, and bacterial colonies in 27% of the sputum samples. Out of 190 participants, 8(4.2%) of them had to be hospitalized and 17(8.9%) were on sick leave due to respiratory symptoms. Conclusion Pre-employment and periodic medical examination, frequent work shift, training on occupational health and safety, use of appropriate personnel protective equipment is recommended to reduce respiratory symptoms.

Addressing challenges for clinical research responses to emerging epidemics and pandemics: a scoping review

BACKGROUND

Major infectious disease outbreaks are a constant threat to human health. Clinical research responses to outbreaks generate evidence to improve outcomes and outbreak control. Experiences from previous epidemics have identified multiple challenges to undertaking timely clinical research responses. This scoping review is a systematic appraisal of political, economic, administrative, regulatory, logistical, ethical and social (PEARLES) challenges to clinical research responses to emergency epidemics and solutions identified to address these.

METHODS

A scoping review. We searched six databases (MEDLINE, Embase, Global Health, PsycINFO, Scopus and Epistemonikos) for articles published from 2008 to July 2018. We included publications reporting PEARLES challenges to clinical research responses to emerging epidemics and pandemics and solutions identified to address these. Two reviewers screened articles for inclusion, extracted and analysed the data.

RESULTS

Of 2678 articles screened, 76 were included. Most presented data relating to the 2014-2016 Ebola virus outbreak or the H1N1 outbreak in 2009. The articles related to clinical research responses in Africa (n = 37), Europe (n = 8), North America (n = 5), Latin America and the Caribbean (n = 3) and Asia (n = 1) and/or globally (n = 22). A wide range of solutions to PEARLES challenges was presented, including a need to strengthen global collaborations and coordination at all levels and develop pre-approved protocols and equitable frameworks, protocols and standards for emergencies. Clinical trial networks and expedited funding and approvals were some solutions implemented. National ownership and community engagement from the outset were a key enabler for delivery. Despite the wide range of recommended solutions, none had been formally evaluated.

CONCLUSIONS

To strengthen global preparedness and response to the COVID-19 pandemic and future epidemics, identified solutions for rapid clinical research deployment, delivery, and dissemination must be implemented. Improvements are urgently needed to strengthen collaborations, funding mechanisms, global and national research capacity and capability, targeting regions vulnerable to epidemics and pandemics. Solutions need to be flexible to allow timely adaptations to context, and research led by governments of affected regions. Research communities globally need to evaluate their activities and incorporate lessons learnt to refine and rehearse collaborative outbreak response plans in between epidemics.

Lessons from the field: Gender roles and researcher reflexivity in smoking cessation in South Asia

Background

In South Asia, dual epidemics of smoking and tuberculosis (TB) have contributed to a high burden of lung disease. To address these health risks, the TB & Tobacco study uses the TB diagnosis as a teachable moment and implements a behaviour support counselling intervention, conducted by TB health workers, for patients in Bangladesh, Nepal and Pakistan. In this region, smoking tobacco is perceived as problematic for women, and being confronted with questions on smoking from a health professional may be uncomfortable for men and women. Anticipating these challenges, we incorporated gender sensitivity into training of health workers.

Methods

During implementation of the cessation support in routine TB care, a process evaluation assessed interactions between participants and the intervention through interviews with health workers and patients with TB participating in the cessation program. This presentation focusses on a retrospective self-reflection on how we conceptualized gender roles based on prior research, and how research findings partially challenged these assumptions.

Findings

While parts of our interview findings point towards smoking as a stigmatized practice for women and some men in South Asia as expected, several male and female respondents across socio-economic and geographical spheres contradicted this assumption. We discovered that health workers’ self-efficacy and perceived smoking stigma among health workers influenced whether they discussed smoking with women or minors. Many patients, on the other hand, told us that they were interested in receiving help to cure their TB and were willing to talk to about smoking with their health workers and their family members.

Conclusions

Patients in this study were more open to talking about smoking than anticipated. When including gender sensitivity into the standard training for health workers, we should be careful not to increase doubts in health workers about addressing smoking with women.

Understanding the mechanisms and drivers of antimicrobial resistance

To combat the threat to human health and biosecurity from antimicrobial resistance, an understanding of its mechanisms and drivers is needed. Emergence of antimicrobial resistance in microorganisms is a natural phenomenon, yet antimicrobial resistance selection has been driven by antimicrobial exposure in health care, agriculture, and the environment. Onward transmission is affected by standards of infection control, sanitation, access to clean water, access to assured quality antimicrobials and diagnostics, travel, and migration. Strategies to reduce antimicrobial resistance by removing antimicrobial selective pressure alone rely upon resistance imparting a fitness cost, an effect not always apparent. Minimising resistance should therefore be considered comprehensively, by resistance mechanism, microorganism, antimicrobial drug, host, and context; parallel to new drug discovery, broad ranging, multidisciplinary research is needed across these five levels, interlinked across the health-care, agriculture, and environment sectors. Intelligent, integrated approaches, mindful of potential unintended results, are needed to ensure sustained, worldwide access to effective antimicrobials.

Role of Ultrasound as Compared with ERCP in Patient With Obstructive Jaundice

Background The diagnosis of obstructive jaundice relies on proper history taking, clinical examination, laboratory investigations and different non invasive imaging modalities like Ultrasonography (USG), Cholangio Computed Tomography (CCT), Magnetic resonance Imaging (MRI) with Magnetic Resonance Cholangio Pancreatography (MRCP) and invasive modalities like endoscopic retrograde cholangiography (ERCP) and percutaneous trans hepatic cholangiography (PTC). Objective To compare the role of ultrasound with endoscopic retrograde cholangiography and to determine the major causes of obstructive jaundice in our prospect. Methods This was a prospective, analytical study conducted on 88 patients presenting to Department of Radiodiagnosis and Imaging at Dhulikhel Hospital-Kathmandu University hospital from March 2011 to August 2012 with clinical diagnosis of obstructive jaundice. Sonographic evaluation was performed in Siemens acusion x-150 and x-300. The final diagnosis was made by endoscopic retrograde cholangiography and /or surgery and confirmed histopathologically. Results The most common benign causes of obstructive jaundice were choledocholithiasis (63%), CBD stricture (12.3%), cholangitis (8%) and pancreatitis (6.85%) whereas cholangio carcinoma (6.85%) and carcinoma head of pancreas (4%) comprised of the malignant causes . Ultrasonography had sensitivity of 100% and specificity of 89% in detecting choledocholithiasis. It was found to be 98.78% sensitive and 83.33% specific in cholangiocarcinoma. Similarly in pancreatitis, the sensitivity of ultrasonography was 97.59% and sensitivity was 66.67%. Conclusion Ultrasonography acts as a valuable diagnostic imaging modality in detecting the causes of obstructive jaundice. Due to its easy availability, non invasive nature and cost effectiveness, it can be considered as the first line imaging technique/ tool. ERCP is the invasive imaging tool and can be used for both diagnostic and therapeutic purpose. DOI: http://dx.doi.org/10.3126/kumj.v11i3.12512 Kathmandu Univ Med J 2013; 43(3):237-240

Prostatic cancer with metastasis to the testis – A case report

Metastatic carcinoma to the testis is very rare.The incidence of secondary testicular tumors ranges from 0.02 to 2.5% among autopsies ingeneral. Despite the high incidence of prostatic adenocarcinoma and its ability for wide dissemination, metastatic cancer to the testis is a rare phenomenon of prostate carcinoma with only 80 cases reported in the literature.It is diagnosed in autopsies or incidentally, following therapeutic orchiectomies in moreadvanced stages of the disease.Ours is the very first case of prostatic carcinoma metastasizing to the testis, being reported from our country. We are reporting this case because of the rarity of metastasis of prostatic carcinoma to testis and for stressing the need for keeping in mind the possibility of metastatic carcinoma also while dealing with testicular tumors. In our case, unilateral testicular metastasis was detected incidentally after bilateral orchiectomy for hormonal management of metastatic prostatecarcinoma. The metastatic lesion was not identified in physical examination or in macroscopic dissection of the testis after surgery. Microscopy revealed an adenocarcinoma which, given the history of the patient and a positive immunohistochemical stain for PSA, was identified as metastatic prostatic adenocarcinoma.Journal of Pathology of Nepal (2015) Vol. 5, 784-786

Nuchal translucency in normal fetus and its variation with increasing crown rump length (CRL) and gestational age

BACKGROUND

Nuchal translucency (NT) is the fluid collection behind the fetal neck which can be measured by ultrasound at 11-14 weeks of gestation. Increase in the nuchal translucency thickness is associated with various congenital anomalies.

OBJECTIVE

To study the relationship between nuchal translucency thickness, crown rump length and gestational age in normal fetus.

METHODS

Prospective analytical study conducted on 211 pregnant women from March 2011 to August 2012. Measurement of Nuchal translucency thickness and crown rump length was performed by ultrasound at 11-14 weeks of gestation. The relationship between nuchal translucency thickness, crown rump length and gestational age was studied by using linear regression analysis.

RESULTS

The mean CRL was 63.67+13.48mm (range 41.2-88mm) and mean NT thickness was 1.55+0.35mm (range 0.8-2.7mm), respectively. The median gestational age was 12.9 weeks. The regression equation which shows relation between median NT thickness and CRL was described as follows: expected NT thickness = 0.013CRL+0.725, (R2 = 0.258, p <0.001). There was increase in the incidence of NT thickness more than or equal to 2.5mm; 1.7% in fetus between 12-12.9 weeks of gestation to 15.1% in fetus between 14.0-14.9 weeks.

CONCLUSION

Our study offers normative data of NT thickness in normal fetus, which can be used as reference to screen various chromosomal and congenital abnormalities between 11- 14 weeks of gestation. NT thickness increased with increasing CRL and a false positive rate increases with increasing gestational age.

Poverty-related and neglected diseases - an economic and epidemiological analysis of poverty relatedness and neglect in research and development

Background

Economic growth in low- and middle-income countries (LMIC) has raised interest in how disease burden patterns are related to economic development. Meanwhile, poverty-related diseases are considered to be neglected in terms of research and development (R&D).

Objectives

Developing intuitive and meaningful metrics to measure how different diseases are related to poverty and neglected in the current R&D system.

Design

We measured how diseases are related to economic development with the income relation factor (IRF), defined by the ratio of disability-adjusted life-years (DALYs) per 100,000 inhabitants in LMIC versus that in high-income countries. We calculated the IRF for 291 diseases and injuries and 67 risk factors included in the Global Burden of Disease Study 2010. We measured neglect in R&D with the neglect factor (NF), defined by the ratio of disease burden in DALYs (as percentage of the total global disease burden) and R&D expenditure (as percentage of total global health-related R&D expenditure) for 26 diseases.

Results

The disease burden varies considerably with the level of economic development, shown by the IRF (median: 1.38; interquartile range (IQR): 0.79–6.3). Comparison of IRFs from 1990 to 2010 highlights general patterns of the global epidemiological transition. The 26 poverty-related diseases included in our analysis of neglect in R&D are responsible for 13.8% of the global disease burden, but receive only 1.34% of global health-related R&D expenditure. Within this group, the NF varies considerably (median: 19; IQR: 6–52).

Conclusions

The IRF is an intuitive and meaningful metric to highlight shifts in global disease burden patterns. A large shortfall exists in global R&D spending for poverty-related and neglected diseases, with strong variations between diseases.

Sonography in acute ureteric colic: an experience in Dhulikhel Hospital

BACKGROUND

Computed tomography is considered as an imaging modality of choice in acute ureteric colic. However due to concerns regarding radiation exposure, sonograms are re-emerging as imaging methods in such situations.

OBJECTIVES

To evaluate the role of sonography in detection of calculus in acute ureteric colic.

METHODS

Total 384 patients were enrolled. Hydronephrosis was graded as mild, moderate or severe. Calculus was detected as an intraluminal echogenic focus with distal shadowing with twinkling artifact. Number, size and position of the calculi were assessed. Patients were categorized into four groups:I. ureteric colic only II. ureteric colic with hematuria III. ureteric colic with hydronephrosis and IV. ureteric colic with hematuria and hydronephrosis and then the possibility of detection of calculi has been compared among these groups.

RESULTS

Out of 384 patients, 254 were found to have calculi ranging between 2.7-27 mm. Nineteen had in the pelvis/ pelviureteric junction, 64 in proximal ureter, 125 in distal ureter, 6 at iliac crossing and 40 at vesicoureteric junction. Two hundred forty one had single and 14 had multiple calculi. Calculus detection is easier in category III and IV patients. The sensitivity and specificity of ultrasonography were 87.98% and 93.07%. Degree of hydronephrosis is strongly correlated with the number of calculi but weakly correlated with the size of the calculus.

CONCLUSION

Sonogram can be used in all cases of acute ureteric colic. Hydronephrosis is the most important finding because it paves the way out for the detection of calculus.

Prevalence of Conventional Risk Factors in ST Segment Elevation Myocardial Infarction Patients in Shahid Gangalal National Heart Centre, Nepal

INTRODUCTION

Smoking, diabetes mellitus, hypertension, and dyslipidemia are labelled as conventional risk factors for coronary artery disease. Prevalence of these risk factors varies across populations. This study aimed to assess the prevalence of these conventional risk factors in patients, who were discharged from our hospital, with the diagnosis of ST elevation myocardial infarction.

METHODS

Medical records of 495 ST elevation myocardial infarction patients discharged from our centre in between January 2012 to December 2012 were retrospectively reviewed to evaluate the prevalence of conventional risk factors.

RESULTS

Clear dominance (75%) of male patients was seen. Inferior wall myocardial infarction (29.9%) was the most common diagnosis followed by anterior wall myocardial infarction (25.1%). Hypertension (65%), smoking (57.8%) and dyslipidemia (45.5%) were the most common risk factors. Diabetes (31.1%) was the least common. Prevalence of hypertension, dyslipidemia was similar among male and female. Smoking was statistically common in male (76.8%vs 49.5%),though diabetes was common in female (36.5%vs.29.3%) not statistically significant.

CONCLUSIONS

Conventional risk factors are common among ST elevation myocardial infarction patients. Early detection and treatment of these risk factors play a vital role for the prevention of coronary artery disease. Much more focus should be stressed on preventive programs throughout the country.

Mapping of available health research and development data: what's there, what's missing, and what role is there for a global observatory?

The need to align investments in health research and development (R&D) with public health demands is one of the most pressing global public health challenges. We aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health R&D, and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. Total global investments in health R&D (both public and private sector) in 2009 reached US$240 billion. Of the US$214 billion invested in high-income countries, 60% of health R&D investments came from the business sector, 30% from the public sector, and about 10% from other sources (including private non-profit organisations). Only about 1% of all health R&D investments were allocated to neglected diseases in 2010. Diseases of relevance to high-income countries were investigated in clinical trials seven-to-eight-times more often than were diseases whose burden lies mainly in low-income and middle-income countries. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The establishment of a global observatory on health R&D, which is being discussed at WHO, could address the absence of a comprehensive and sustainable mechanism for regular global monitoring of health R&D.

Breech presentation among nullipara at term: an indication for caesarean section

BACKGROUND

Breech is the commonest malpresentation. Vaginal breech delivery in a nulliparous lady carries higher risk than in multiparous ladies. Poor neonatal outcome following vaginal delivery has made the mode of delivery a matter of controversy.

OBJECTIVE

To evaluate the outcome of planned caesarean section among nullipara ladies with breech presentation.

METHOD

This is a prospective, analytical study conducted in Dhulikhel Hospital Kathmandu University Hospital from January 2008 to June 2012 among 102 nullipara ladies at term gestation with breech presentation. All cases underwent caesarean section either elective or emergency. During section cause of breech presentation was searched for. Neonatal condition was evaluated using APGAR Score, need for resuscitation and admission in NICU. Post partum status was also recorded for evaluation of maternal morbidity and mortality.

RESULTS

These Nullipara ladies often had some reason for breech presentation, the most common being cord around the neck. Perinatal outcome was uneventful in 97(95%) neonates, there were two (2%) still birth and three (3%) needed NICU care. APGAR was good in 92 neonates, average in eight and poor in two. Total 16(15.6%) ladies stayed hospital for more than eight days. Among them 11(10.7%) developed wound infection and five stayed in hospital waiting for baby.

CONCLUSION

Nullipara ladies with breech presentation should have elective caesarean section as a preferred route of delivery.

Fulminant hepatic failure due to dengue

Dengue Fever (DF) is only rarely considered as a cause of acute liver failure even globally and only a few case reports of acute hepatic failure and encephalopathy occurring in DF in adults are available. We report a case of Acute Liver Failure due to Dengue during a major outbreak in 2010 in Chitwan. A 20 year old previously healthy female presented to the emergency department of Chitwan Medical College with fever, jaundice and altered sensorium. She was tested positive for Dengue IgM. Her biochemical and clinical parameters were suggestive of acute liver failure with total billirubin of 10.1 mg/dL, direct billirubin of 5.2 mg/dL, ALT 5760 IU, AST 14100 IU, alkaline phosphatase of 1250 IU, PT INR of 1.76 and platelet count of 30,000/mm3. Other causes for acute hepatic failure like acute viral hepatitis, leptospirosis, malaria, Reyes syndrome were ruled out. The patient was admitted and managed in the ICU with supportive care and platelet transfusion. With treatment she made a significant clinical and biochemical improvement with AST of 105 IU, ALT of 120 IU and platelet count of 150,000/mm3. She was discharged after 11 days of hospital stay.

Ageism and equality

This paper rebuts suggestions made by Littlejohns et al that NICE is not ageist by analysing the concept of ageism. It recognises the constraints that finite resources impose on decision making bodies such as NICE and then makes a number of positive suggestions as to how NICE might more effectively and more justly intervene in the allocation of scarce resources for health.

Best practice in the management of venous leg ulcers

Leg ulcers are wounds or open sores, often chronic in nature (long-lasting and non-healing), which cause damage to the skin. Appropriate management of chronic venous leg ulcers is essential to prevent further deterioration of the wound, improve patients' quality of life and reduce any healthcare costs associated with treating complications of such ulcers, including infection. However, management of leg ulcers can be challenging, particularly in patients who do not adhere to treatment regimens, cannot tolerate compression therapy, or have increased pain and infection. This article aims to identify best practice in the management of venous leg ulcers.

Ear diseases in children presenting at Nepal Medical College Teaching Hospital

Ear diseases are a common presentation in the ENT out-patient department. These diseases can have sequelae if not treated early which may cause increased morbidity, hearing disability and even mortality. Identifying these conditions early and treating them can reduce these unwanted sequelae. A prospective study over a period of three years was undertaken in a tertiary care hospital in Kathmandu. All children presenting with ear diseases consecutively in the ENT out-patients were included and their data was recorded in a pro forma. The data was analysed for frequency and cross-tabulated. The study included 2218 children with ear diseases among which 868 (39.1%) were pre-school and 1350 (60.9%) were school going children. The male to female ratio was 1.5:1. The most common otological problem was wax impaction (40.2%), followed by acute otitis media (AOM) with 24.3%, chronic suppurative otitis media (CSOM) with 17.7% and acute otitis externa (AOE) with 7.5% of the total cases. The other conditions were otitis media with effusion (2.8%), foreign bodies in the ear (2.3%), otomycosis (1.7%), preauricular sinus (1.1%), sensorineural hearing loss (0.8%), trauma to the ear (0.7%), keloids (0.3%), microtia (0.2%) and perichondritis (0.2%).The three year olds had the highest number of otological diseases with 9.2% of the total among the ages studied. It is felt that proper education of health care providers regarding ear diseases and also awareness in the community can prevent and reduce the disability and complications of these conditions.

Safety and efficacy of the supracostal access for percutaneous nephrolithotomy: our initial experience

The aim of this study was to evaluate the safety and efficacy of the supracostal access for percutaneous nephrolithotomy (PCNL). Between July 2007 and June 2010, 122 patients underwent PCNL, of whom 28 (23%) had supracostal access. All procedures were performed in a single sitting under general anesthesia. The data were analysed for indications, stone clearance rates and the complications associated with supracostal puncture. The indications for a supracostal access were staghorn stones (50%), pelvis stones (28.5%), calyceal stones in high-lying kidney (18%) and upper ureter/ureteric stones (3.5%). All tracts were made in the 11th intercostal space. Single tract access was used in 22 cases (78%), but 6 (22%) required a second tract. Additional punctures were required mainly for staghorn stones (4 out of 14). Overall, 82% of the patients were rendered stone free or had clinically insignificant residual stones with PCNL monotherapy, and this increased to 96% with secondary procedures. In patients with staghorn stones, they were completely cleared in 78%. Overall complication rate was 28% and included hydrothorax in 3 (10%) patients, which required insertion of a chest tube. One (3.5%) patient developed haemothorax secondary to injury of the intercostal artery, pelvic perforation in 1 (3.5%), perinephric collection in 1 (3.5%), infection/sepsis in 2 (7%). Except those patients who had complication, all other patient recovered uneventfully. Postoperative hospital stay ranged from 2 to 9 days. In conclusion, supracostal access gives high clearance rate with acceptable complications and should not be avoided for fear of chest complications.

"Safety pin"--a question to its safety!

Foreign body ingestion is not an uncommon problem in children. They can ingest various foreign objects and one of such objects is a safety pin. The ingestion of such foreign body is not widely reported in the literature. This case highlights the risk of accidental ingestion of safety pin used on child's clothing to protect him from cold that can result in lethal complications. In a poor developing country like Nepal, this case serves to address all mothers alerting them of their ignorance while using safety pin in infants. In addition, physicians are reminded to obtain a detailed inquiry of suspected foreign body ingestion in every child with the history of dysphagia.

Need of Improvement in Emergency Medical Service in Urban Cities

Introduction: An effective Emergency Medical Service system does not exist in Nepal. For an effective EMS system to be developed the scale of the problem and the existing facilities need to be studied. Methods: Prospective observational study was carried out on 1964 patients attending Emergency Department at Patan Hospital during one month period of September 2006. The patients were specifically enquired on mode of transport used, place of origin and whether they called for an ambulance or not. Patients triage category at the time of triaging was also noted. Information on ambulance service were collected by direct interview with the service providers and the total number of patients attending Emergency Departments daily were collected from the major hospitals of the urban Lalitpur and Kathmandu. MS Excel and SPSS software were used for data entry, editing and analysis.Results: Total 9.9% patients arrived in ambulance whereas 53.6% came in a Taxi, 11.4% came in private vehicle, 13.5 % came by bus, 5.4% came by bike and the rest 6.2% came by other modes of transportation. Only 13.5% of triage category I patients took the ambulance. There were 31 service providers with 49 ambulances and 720 patients per day attend Emergency Departments in the surveyed area. Conclusions: Very less number of patients use the ambulance service for emergency services. The available ambulances are not properly equipped and do not have trained staff and as such are only a means of transportation to the hospitals of urban Lalitpur and Kathmandu.Key Words: ambulance, emergency medical service, para-medics, triage Need of Improvement in Emergency Medical Service in Urban Cities Gongal R,1Dhungana B,1Regmi S,1Nakarmi M,2Yadav B11Patan Hospital, Lalitpur, Nepal, 2Health Care Foundation, Kathmandu, NepalCorrespondence:Dr. Rajesh GongalDepartment of SurgeryPatan Hospital, Patan, Nepal.Email: rajgongal@yahoo.comORIGINAL ARTICLE J Nepal Med Assoc 2009;48(174):139-43INTRODUCTIONThe sophisticated Emergency Medical Service (EMS) is limited to developed country only. Many developing countries are now slowly developing such system although most services are localized to the urban areas.1-5 Although inadquate ambulance services are available in the capital city of Nepa

Need of improvement in emergency medical service in urban cities

INTRODUCTION

An effective Emergency Medical Service system does not exist in Nepal. For an effective EMS system to be developed the scale of the problem and the existing facilities need to be studied.

METHODS

Prospective observational study was carried out on 1964 patients attending Emergency Department at Patan Hospital during one month period of September 2006. The patients were specifically enquired on mode of transport used, place of origin and whether they called for an ambulance or not. Patients triage category at the time of triaging was also noted. Information on ambulance service were collected by direct interview with the service providers and the total number of patients attending Emergency Departments daily were collected from the major hospitals of the urban Lalitpur and Kathmandu. MS Excel and SPSS software were used for data entry, editing and analysis.

RESULTS

Total 9.9% patients arrived in ambulance whereas 53.6% came in a Taxi, 11.4% came in private vehicle, 13.5 % came by bus, 5.4% came by bike and the rest 6.2% came by other modes of transportation. Only 13.5% of triage category I patients took the ambulance. There were 31 service providers with 49 ambulances and 720 patients per day attend Emergency Departments in the surveyed area.

CONCLUSIONS

Very less number of patients use the ambulance service for emergency services. The available ambulances are not properly equipped and do not have trained staff and as such are only a means of transportation to the hospitals of urban Lalitpur and Kathmandu.

64-slice CT scan in Kathmandu Medical College Teaching Hospital

64-slice CT scan is a versatile newly introduced imaging technology, which is capable of diagnosing various diseases from head to toe. The 64-slice CT coronary angiography has a negative predictive value of 100%. Virtual images of bronchi, stomach and colon can provide definite diagnosis. Coronary artery calcification score which predicts coronary artery disease can be calculated by 64-slice CT scan.

Spirometry in evaluation of respiratory diseases

A hospital based cross-sectional study was conducted from March 2005 to April 2006 to evaluate the distribution of various respiratory diseases by spirometry. A total of 228 consecutive cases referred for spirometry were included of which 65% were male and 35% female. COPD was the commonest referral diagnosis (40%) followed by the diagnosis of shortness of breath (22%). After spirometry the prevalence of COPD was 42%, Asthma 23.5%, Restrictive disease 3.1% and mixed obstructive and restrictive disease 3.5%. 25% of the sample population was smokers and 22% ex-smokers. Hence we conclude that spirometry is a very useful diagnostic tool for preliminary diagnosis of respiratory diseases and should be used more by general practitioners and physicians to make their diagnosis and therapy more scientific.

Evaluation of a urinary antigen-based latex agglutination test in the diagnosis of kala-azar in eastern Nepal

BACKGROUND

We evaluated the diagnostic accuracy as well as the reproducibility of the urine latex agglutination test 'KAtex' in the diagnosis of kala-azar in patients recruited at a tertiary care centre in Dharan, Nepal, between November 2000 and January 2002.

METHODS

All patients presenting with fever of 2 weeks or more and splenomegaly were consecutively enrolled. Bone marrow and--if negative--spleen aspirates were examined for Leishmania donovani. Serum and urine samples were taken in duplicate for the Direct Agglutination Test (DAT) and KAtex. The reference laboratory determined sensitivity and specificity of KAtex. Reproducibility between both laboratories was assessed.

RESULTS

KAtex was performed on urine from 155 parasitologically confirmed kala-azar and 77 non-kala-azar cases (parasitology and DAT-negative). KAtex showed a sensitivity of 47.7% (74/155, 95% CI: 39.7-55.9) and a specificity of 98.7% (76/77, 95% CI: 93.0-100.0). Reproducibility of KAtex showed a kappa of 0.684 (P < 0.001, n = 232).

CONCLUSION

KAtex evaluation showed high specificity, low sensitivity and moderate reproducibility. A urine test for kala-azar could become a real breakthrough in kala-azar management if its reproducibility and sensitivity could be further improved.

A first estimate of ground water ages for the deep aquifer of the Kathmandu Basin, Nepal, using the radioisotope chlorine-36

The Kathmandu Basin in Nepal contains up to 550 m of Pliocene-Quaternary fluvio-lacustrine sediments which have formed a dual aquifer system. The unconfined sand and gravel aquifer is separated by a clay aquitard, up to 200 m thick, from the deeper, confined aquifer, comprised of Pliocene sand and gravel beds, intercalated with clay, peat, and lignite. The confined aquifer currently provides an important water supply to the central urban area but there are increasing concerns about its sustainability due to overexploitation. A limited number of determinations of the radioisotope 36Cl have been made on bore waters in the basin, allowing us to postulate on the age of ground water in the deeper, confined aquifer. Ground water evolution scenarios based on radioisotope decay, gradual dissolution of formational salts as the ground waters move downgradient, and flow velocity estimations produce comparable ground water ages for the deep waters, ranging from 200,000 to 400,000 years. From these ages, we deduce a mean ground water flow velocity of only 45 mm/year from recharge in the northeast to the main extraction region 15 km to the southwest. We thus estimate current recharge at about 5 to 15 mm/year, contributing 40,000 to 1.2 million m3/year to the ground water system. Current ground water extraction is estimated to be 20 times this amount. The low specific discharge confirms that the resource is being mined, and, based on current projections, reserves will be used up within 100 years.

Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal

CONTEXT

Most of the world's refugees are displaced within the developing world. The impact of torture on such refugees is unknown.

OBJECTIVE

To examine the impact of torture on Bhutanese refugees in Nepal.

DESIGN

Case-control survey. Interviews were conducted by local physicians and included demographics, questions related to the torture experienced, a checklist of 40 medical complaints, and measures of posttraumatic stress disorder (PTSD), anxiety, and depression.

SETTING

Bhutanese refugee community in the United Nations refugee camps in the Terai in eastern Nepal.

PARTICIPANTS

A random sample of 526 tortured refugees and a control group of 526 nontortured refugees matched for age and sex.

MAIN OUTCOME MEASURES

The Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for PTSD and the Hopkins Symptom Checklist-25 (HSCL-25) for depression and anxiety.

RESULTS

The 2 groups were similar on most demographic variables. The tortured refugees, as a group, suffered more on 15 of 17 DSM-III-RPTSD symptoms (P<.005) and had higher HSCL-25 anxiety and depression scores (P<.001) than nontortured refugees. Logistic regression analysis showed that history of torture predicted PTSD symptoms (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-8.0), depression symptoms (OR, 1.9; 95% CI, 1.4-2.6), and anxiety symptoms (OR, 1.5; 95% CI, 1.1-1.9). Torture survivors who were Buddhist were less likely to be depressed (OR, 0.5; 95% CI, 0.3-0.9) or anxious (OR, 0.7; 95% CI, 0.4-1.0). Those who were male were less likely to experience anxiety (OR, 0.66; 95% CI, 0.44-1.00). Tortured refugees also presented more musculoskeletal system- and respiratory system-related complaints (P<.001 for both).

CONCLUSION

Torture plays a significant role in the development of PTSD, depression, and anxiety symptoms among refugees from Bhutan living in the developing world.

Tribhuvan University certificate nursing curriculum

Introduction: A Nepalese certificate of nursing curriculum was developed in 1977 and has been used since with a few revisions. There has been open debate about continuing gaps between theory, as expressed in the curriculum, and practice. The purpose of this study was to evaluate this 3-year undergraduate curriculum, and to draw general lessons, which might help to develop appropriate strategies to improve nursing education in Nepal. Methods: A mixed evaluation method was used consisting of reviews of current curriculum theories/ models, and interviews with nursing students (15) and nursing tutors (10). Results: Both students and tutors were generally positive about the curriculum and its intended learning outcomes. While reviewing the existing curriculum, analysis revealed that there was limited use of curriculum theories and models. Conclusions: There is a need to focus more on the development of abilities related to evidence-based learning. Selection of appropriate teaching-learning methodologies in response to the growing needs of students and professionals, development of learning strategies to reduce the gap between educational theories and nursing practice, in line with a humanistic paradigm in nursing education is important. Keywords: Curriculum evaluation, Nepal, nurses, nursing education. DOI: 10.3126/joim.v31i3.2997 Journal of Institute of Medicine, December, 2009; 31(3) 46-55