Left internal jugular vein thrombosis secondary to pacemaker insertion

Venous thrombosis associated with pacemaker implant is a known phenomenon. We present a clinical video emphasizing on an important physical examination finding suggesting propagation of thrombus in internal jugular vein secondary to pacemaker insertion, which would be educational and help readers visualize the sign on physical examination.

Resilience and its association with post-traumatic stress disorder, anxiety, and depression symptomatology in the aftermath of trauma: a cross-sectional study from Nepal

Introduction

Resilience is a multidimensional construct. Despite being quoted as protective against mental disorders, it remains largely unexplored in our context.

Objectives

We attempted to explore the role of resilience in the development of various psychiatric symptoms as depression, anxiety and post-traumatic stress disorder following trauma in clinical population in a psychiatry outpatient of a university hospital.

Methods

We interviewed one hundred patients who sought treatment in psychiatry outpatient in a university hospital in Kathmandu, Nepal. We collected sociodemographic and trauma related information using semi-structured interview format. Other instruments used were the World Health Organization Composite International Diagnostic Interview version 2.1 for trauma categorization, the Post-Traumatic Stress Disorder Checklist-Civilian version to measure the post-traumatic stress disorder symptoms, and the 25-item Hopkins Symptom Checklist-25 to assess the level of depression and anxiety symptoms. We used Nepali adapted resilience scale derived from the original Wagnild and Young Resilience scale to measure resilience. We explored the associations between resilience scores and the scores on depression, anxiety and posttraumatic stress disorder using bivariate and multivariate analysis.

Results

Resilience had negative correlations with depression, anxiety, and post-traumatic stress disorder symptoms after adjusting for other variables such as gender, marital status, employment status, socioeconomic status and trauma types which were observed to have significant association in the bivariate analysis.

Conclusions

There was inverse correlation between resilience scores and depression, anxiety, and post-traumatic stress symptoms. Resilience should be considered in studies involving trauma population.

Disclosure

No significant relationships.

Clinical and epidemiological features of COVID-19 deaths in Nepal

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has taken more than 1 million lives globally. This study, based on the official media releases of the Government of Nepal, analyses the clinical and epidemiological features of the individuals who died as a result of COVID-19 in Nepal from 23 January to 10 August 2020. We found that nearly half of the deaths were among people less than 50 years of age and being female increased the risk of death. The majority of deaths were associated with co-morbidities, the most common being cardiovascular diseases and diabetes followed by respiratory diseases. With the approaching festive season and relaxed lockdown, both government and citizens need to be more cautious about the severity of COVID-19 and take appropriate action.

COVID-19: the current situation in Nepal

The recent global pandemic of novel coronavirus disease 2019 (COVID-19) is increasingly alarming. As of 21 June 2020, there are more than 8.7 million cases worldwide, with 460 000 deaths. Nepal is not an exception to COVID-19 and is currently facing a challenge to prevent the spread of infection. The analysis of the detected cases, severity and outcomes of the cases within a country is important to have a clear picture of where the pandemic is heading and what measures should be taken to curb the infection before it becomes uncontrollable. We collected data regarding all the cases, recoveries and deaths attributed to COVID-19 in Nepal starting from the first case on 23 January to 21 June 2020. At present, COVID-19 has spread all over Nepal, with a rapid increase in the number of new cases and deaths, which is alarming in a low-income country with an inadequate healthcare system like Nepal. Although the government implemented early school closure and lockdown, the management to contain COVID-19 does not appear to be adequate. Understanding the current situation regarding COVID-19 in Nepal is important for providing a direction towards proper management of the disease.

Neuropsychiatric manifestations in General Paralysis of Insane (GPI)

General paralysis of insane is a form of neurosyphilis which brings parenchymatous changes in the central nervous system. Its manifestations include a variety of neuropsychiatric symptoms ranging from cognitive impairment to overt psychosis. Clinicians face difficulties in proper diagnosis as variety of symptoms changes from one form to other within a short period of time. Rarity of the disease at this modern era of penicillin is also another factor in timely diagnosis and management of such cases. Here we present a case of general paralysis of insane who presented with variety of neuropsychiatric symptoms and have had great difficulties to reach into the diagnosis.

An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study

BACKGROUND

In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs.

METHODS

A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels.

DISCUSSION

This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Role of the general practitioner in improving rural healthcare access: a case from Nepal

BACKGROUND

There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital.

CASE PRESENTATION

We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital's catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.

CONCLUSIONS

GPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal's maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal's public sector.

Statins in the treatment of COPD and asthma-where do we stand?

Asthma and chronic obstructive pulmonary disease (COPD) are the two most prevalent obstructive lung diseases that account for tremendous morbidity and mortality throughout the world. These diseases have strong inflammatory components, with multiple prior studies showing elevated levels of various inflammatory markers and cells in those with COPD and asthma. Therefore, efforts to target inflammation in management of these diseases are of great interest. Statins, which define a class of drugs that are HMG-CoA inhibitors, are used to decrease cholesterol levels and have also been described to have many pleotropic effects that include anti-inflammatory and anti-oxidative properties. These properties have led to multiple studies looking at the potential use of statins in decreasing inflammation in many diseases, including COPD and asthma. This review aims to address the current evidence behind the potential use of statins in the treatment of asthma and COPD.

Spotlight on glycopyrronium/formoterol fumarate inhalation aerosol in the management of COPD: design, development, and place in therapy

Long-acting bronchodilators are the mainstay of the treatment of COPD. With the advent of several combination inhalers with long-acting antimuscarinic agents (LAMAs) and long-acting beta agonists (LABAs), the choice of therapy in the treatment of COPD has been ever expanding. With the focus of COPD management shifting from FEV₁-based treatment escalation to symptoms and risk-based treatment, we are seeing a paradigm shift in COPD treatment with early introduction of LAMA-LABA combination as a single inhaler. Glycopyrronium/formoterol fumarate fixed-dose combination formulated in a familiar metered-dose inhaler format using proprietary co-suspension technology is a new option on the market. We purport to discuss the evidence behind the approval of the drug combination and its place in therapy.

Association of thyroid dysfunction with depression in a teaching hospital

BACKGROUND

Thyroid dysfunction is common in patients with depression and depression is also common in patients with thyroid dysfunction. The purpose of this study was to estimate the prevalence of thyroid dysfunction in newly diagnosed depressed patients attending Psychiatry outpatient department of Tribhuvan University Teaching Hospital, Nepal and to find the correlation between the two.

METHODS

The study population comprised of 70 patients aged more than 15 years selected by simple random sampling technique who attended the Psychiatry OPD of Tribhuvan University Teaching Hospital, Kathmandu, Nepal and were diagnosed with first episode depression. A self- designed semi structured proforma was devised to obtain the socio- demographic characteristics of the study population. These patients were diagnosed as depression as per the ICD-10 DCR Criteria and HDRS scale was used at the same interview to verify it objectively.

RESULTS

Fifteen patients (21%) were found to have thyroid dysfunction, the most common being sub-clinical hypothyroidism, seen in 8 (11%). Thyroid dysfunction also showed positive correlation with depression severity. The diagnosis of depression by ICD- 10 DCR Criteria had positive correlation with HDRS grading of depression, though no significant association was found between different socio- demographic variables and depression.

CONCLUSIONS

This study concluded that thyroid dysfunction is common in depressed patients and larger studies are required in this field before TFTs are considered as an integral part of evaluation of these patients.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a condition which affects predominantly overweight women and is characterized by raised intracranial pressure without any identifiable pathology in the brain and with normal cerebrospinal fluid (CSF) composition. The cause of IIH is unclear and as such it remains a diagnosis of exclusion. Although the pathophysiology of IIH remains elusive, some observations have recently been added to our understanding of this, including the presence of transverse sinus stenosis on many patients and the possible role of leptin and inflammation in the disease pathogenesis. Headache is the most common symptom and papilloedema is the major clinical finding. Choices of medical treatment are limited to the use of diuretics particularly acetazolamide and encouragement of weight loss. Surgical therapies such as CSF diversion procedures and fenestration of the optic nerve may be necessary in some cases with persistent symptoms or progressive visual deterioration. While not life-threatening, IIH has a significant morbidity with up to 25% of patients developing visual impairment from optic atrophy. Visual surveillance is therefore vital. Long-term follow-up is recommended as the disease may worsen after an initial period of stability.

Fe(III) coordination properties of two new saccharide-based enterobactin analogues: methyl 2,3,4-tris-O-[N-[2,3-di(hydroxy)benzoyl-glycyl]-aminopropyl]-alpha-D-glucopyranoside and methyl 2,3,4-tris-O-[N-[2,3-di-(hydroxy)-benzoyl]-aminopropyl]-alpha-D-glucopyranoside

The synthesis of two saccharide-based enterobactin analogues, methyl 2,3,4-tris-O[-N[2,3-di(hydroxy)benzoyl-glycyl]-aminopropyl]-alpha-D-glucopyranoside (H(6)L(A)) and methyl 2,3,4-tris-O-[N-[2,3-di(hydroxy)benzoyl]-aminopropyl]-alpha-D-glucopyranoside (H(6)L(B)), are reported along with their pK(a) values, Fe(III) binding constants, and aqueous solution speciation as determined by spectrophotometric and potentiometric titration techniques. Use of a saccharide platform to synthesize a hexadentate triscatechol chelator provides some advantages over other approaches to enterobactin models, including significant water solubility, resistance to hydrolysis, and backbone chirality which may provide favorable recognition and availability to cells. The protonation constants for the catechol ligand hydroxyl moieties were determined for both ligands and found to be significantly different, which is attributed to the differences in the spacer chain of the two triscatechols. Proton dependent Fe(III)-ligand equilibrium constants were determined using a model involving the sequential protonation of the Fe(III)-ligand complex. These results were used to calculate the formation constants, log beta(110) = 41.38 for Fe(III)-H(6)L(A) and log beta(110) = 46.38 for Fe(III)-H(6)L(B). The calculated pM values of 28.6 for H(6)L(A) and 28.3 for H(6)L(B) indicate that these ligands possess Fe(III) affinities comparable to or greater than other enterobactin models and are thermodynamically capable of removing Fe(III) from transferrin.

Crystal structure of ferrioxamine B: a comparative analysis and implications for molecular recognition

Ferrioxamine B was successfully co-crystallized with ethanolpentaaquomagnesium(II) and perchlorate ions as counter ions, C27H62Cl3FeMgN6O26, and the crystal structure has been determined by single-crystal X-ray diffraction. The crystals are monoclinic, space group P2(1)/n, four molecules per unit cell with dimensions a=21.1945(7) A, b=10.0034(3) A, c=106.560(1) A, and beta=106.560(1) degrees. The crystal structure contains a racemic mixture of Lambda-N-cis,cis and Delta-N-cis,cis coordination isomers. The structural parameters and the conformational features of ferrioxamine B compare very well with those of ferrioxamines D1 and E, with an exception of the orientation of the pendant protonated amine, which is pointing away from the connecting amide chains and towards the carbonyl face of the inner coordination shell distorted octahedron. This pendant protonated amine, in conjunction with the carbonyl face of the Fe(III) coordination shell, is proposed to play an important role in the recognition and membrane transport processes.