Self-Efficacy in Nepali Adults With Musculoskeletal Pain: Measurement Properties of Hard-Copy and Online Versions of the Pain Self-Efficacy Questionnaire

The Pain Self-Efficacy Questionnaire (PSEQ) is commonly used in pain self-efficacy research. Yet its Nepali translation is unavailable, limiting the ability to conduct cross-cultural research on the role of self-efficacy in musculoskeletal pain and its management. This study aimed to 1) translate and culturally adapt the 10-item (PSEQ-10) and 2-item (PSEQ-2) versions of the PSEQ into Nepali, 2) evaluate their measurement properties in Nepali adults with musculoskeletal pain, and 3) evaluate whether the type of administration (ie, hard-copy vs online) affected their measurement properties. The measurement properties of different administrations of the Nepali PSEQ-10 and PSEQ-2 were evaluated in 180 Nepali adults (120 hard-copy and 60 online administrations) with musculoskeletal pain. We conducted confirmatory factor analyses and estimated the measures' internal consistencies, test-retest reliabilities, and smallest detectable changes using standard error of measurement. We planned to conclude that the measures were valid if ≥ 75% of the validity hypotheses were supported. The results supported unidimensionality for the Nepali PSEQ-10. The Nepali PSEQ-2 and PSEQ-10 evidenced excellent internal consistencies (Cronbach alphas = .90-.95) and good to excellent test-retest reliabilities (intraclass correlation coefficient = .61-.85) for both administrations. Construct validity (r's ≥ .20) and concurrent validity (r's ≥ .83) were supported, as hypothesized. Both hard-copy and online administrations of the Nepali PSEQ-2 and PSEQ-10 are similar, reliable, and valid ways to assess self-efficacy in Nepali adults with musculoskeletal pain. The findings should facilitate telehealth and cross-cultural research on pain self-efficacy in Nepal. PERSPECTIVE: This is the first Nepali adaptation of a self-efficacy scale with testing of measurement properties for hard-copy and online administrations. It will facilitate the assessment of pain self-efficacy in clinical practice and research and facilitate a deeper cross-cultural understanding of the role of self-efficacy in musculoskeletal pain.

Barriers and facilitators to implementation of outcome measures among physiotherapists in Nepal: A mixed-methods study

BACKGROUND

Standardised outcome measures are essential to evidence-based practice but their implementation remains a significant challenge in low- and middle-income countries. The barriers and enablers for implementation of outcome measures are likely different in these settings.

OBJECTIVES

We sought to understand barriers and facilitators to use of standardised outcome measures (e.g. patient-reported, performance-based, clinician-reported) in clinical practice among physiotherapists in Nepal.

DESIGN

Exploratory sequential mixed-method study.

METHODS

We conducted focus groups with physiotherapists in Nepal to understand factors contributing to standardised outcome measure use/non-use in depth and thematically analysed the data using Consolidated Framework for Implementation Research (CFIR). To triangulate the findings, we used an online survey which was distributed to practicing physiotherapists in Nepal using social media.

RESULTS

We interviewed 26 physiotherapists for the qualitative phase and 125 physiotherapists responded to our online survey. The most endorsed facilitator was mandating outcome measure use through regulations at organisational or national level, for example, submission of patient-level outcome measures to an insurance system. Major barriers were lack of time, lack of outcome measures in local languages, inability to follow-up with patients and perceived inability of patients to understand outcome measures. Challenges that had not yet been identified in previous studies were inability to follow-up with patients and organisational culture (e.g., cultural hierarchy within an institution).

CONCLUSION

The findings of our study provide an understanding of the contextual needs, and potential way forward for implementation of outcome measures in developing countries like Nepal. Future studies should focus on establishing consensus on which measures to use, the cross-cultural adaptation of these measures, and developing pathways for regulation.

ICARUS at the Fermilab Short-Baseline Neutrino program: initial operation

The ICARUS collaboration employed the 760-ton T600 detector in a successful 3-year physics run at the underground LNGS laboratory, performing a sensitive search for LSND-like anomalous ν e appearance in the CERN Neutrino to Gran Sasso beam, which contributed to the constraints on the allowed neutrino oscillation parameters to a narrow region around 1 eV2 . After a significant overhaul at CERN, the T600 detector has been installed at Fermilab. In 2020 the cryogenic commissioning began with detector cool down, liquid argon filling and recirculation. ICARUS then started its operations collecting the first neutrino events from the booster neutrino beam (BNB) and the Neutrinos at the Main Injector (NuMI) beam off-axis, which were used to test the ICARUS event selection, reconstruction and analysis algorithms. ICARUS successfully completed its commissioning phase in June 2022. The first goal of the ICARUS data taking will be a study to either confirm or refute the claim by Neutrino-4 short-baseline reactor experiment. ICARUS will also perform measurement of neutrino cross sections with the NuMI beam and several Beyond Standard Model searches. After the first year of operations, ICARUS will search for evidence of sterile neutrinos jointly with the Short-Baseline Near Detector, within the Short-Baseline Neutrino program. In this paper, the main activities carried out during the overhauling and installation phases are highlighted. Preliminary technical results from the ICARUS commissioning data with the BNB and NuMI beams are presented both in terms of performance of all ICARUS subsystems and of capability to select and reconstruct neutrino events.

Asian migrants navigating New Zealand primary care: a qualitative study

Introduction Information on the responsiveness of the New Zealand (NZ) health system to Asians to enable navigation of healthcare services is currently lacking. Barriers experienced by Asian patients to enable optimal navigation of, and engagement with, healthcare services are also sparse. Aim This research aimed to: (1) document and analyse resources available on the websites of general practices that aid in optimal health care navigation for NZ Asians; and (2) explore the barriers perceived by Asian migrants to navigating the NZ Health System, particularly primary care. Methods This study involved qualitative document analysis of existing resources on general practice websites. Information on perceived barriers and experiences of navigating the health system was collected through semi-structured interviews (n  = 9). Results Overall, 293 general practice websites were analysed. The themes from content analysis were: availability of basic information, linguistic accessibility, and culturally appropriate support for patients. Relevant and reliable information facilitating effective navigation of the NZ health system by Asians was lacking. Interview data supported the findings about the general practices, with participants reporting significant difficulties navigating and understanding NZ primary care services. Discussion Current navigational resources presume knowledge that Asian migrants do not often possess. Participants felt this lack of accessible information acutely, and it influenced how they perceived and engaged with healthcare services. Increased accessibility through resources in Asian languages, including an overview of how Health NZ functions in providing health care and professional interpreter services, would be critical to increase appropriate engagement with healthcare services and thus contribute to better health outcomes for Asians.

Lessons learnt from the implementation of new models of care delivery through alliance governance in the Southern health region of New Zealand: a qualitative study

OBJECTIVES

To explore the process of implementation of the primary and community care strategy (new models of care delivery) through alliance governance in the Southern health region of New Zealand (NZ).

DESIGN

Qualitative semistructured interviews were undertaken. A framework-guided rapid analysis was conducted, informed by implementation science theory-the Consolidated Framework for Implementation Research.

SETTING

Southern health region of NZ (Otago and Southland).

PARTICIPANTS

Eleven key informants (Alliance Leadership Team members and senior health professionals) who were involved in the development and/or implementation of the strategy.

RESULTS

The large number of strategy action plans and interdependencies of activities made implementation of the strategy complex. In the inner setting, communication and relationships between individuals and organisations were identified as an important factor for joint and integrated working. Key elements of a positive implementation climate were not adequately addressed to better align the interests of health providers, and there were multiple competing priorities for the project leaders. A perceived low level of commitment from the leadership of both organisations to joint working and resourcing indicated poor organisational readiness. Gaps in the implementation process included no detailed implementation plan (reflected in poor execution), ambitious targets, the lack of a clear performance measurement framework and an inadequate feedback mechanism.

CONCLUSIONS

This study identified factors for the successful implementation of the PCSS using an alliancing approach in Southern NZ. A key enabler is the presence of a stable and committed senior leadership team working through high trust relationships and open communication across all partner organisations. With alliances, partnerships and networks increasingly held up as models for integration, this evaluation identifies important lessons for policy makers, managers and services providers both in NZ and internationally.

321 Surgery Induction Guidebook – an Aid to a Successful Transition

Aim

There is a 4–12% increase in mortality following the August change over in the National Health Service (NHS) UK. A well-structured induction programme is mandatory to improve both the competency and confidence of new junior doctors. This activity was designed to evaluate and improve the induction process in Pilgrim Hospital by introducing an induction guidebook. It aimed to provide a sustainable and reliable source of information to junior doctors.

Method

An initial survey in the department assessed the needs and identified the information required for the guidebook. An induction guidebook was designed and circulated during the changeover. A feedback survey was conducted after the six months of the initial Induction guidebook release, to know the usefulness of components of the induction guidebook and identify any gaps to improve the guidebook.

Results

A total of 15 participants completed the feedback survey. 47% (7) found the induction guidebook beneficial and 53.3 % (8) found it ‘slightly beneficial'. Similarly, only 1 participant (6.7%) rated the guidebook to be “of minor importance”, while 53% (8) rating it “very important” part of induction. The feedback for the contents of the book was also encouraging with suggestions.

Conclusions

The guidebook proved to be a valuable source in helping new doctors during times of transition to adjust to the local system and improve the induction process. It provided information about local guidelines, job overview, team structure, IT, useful contacts, and other relevant information. We recommend the departmental guidebook as a vital part of local departmental induction during the changeover.

Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review

Background

Actively involving patients and communities in health decisions can improve both peoples’ health and the health system. One key strategy is Patient-Public Engagement (PPE). This scoping review aims to identify and describe PPE research in Sub-Saharan Africa; systematically map research to theories of PPE; and identify knowledge gaps to inform future research and PPE development.

Methods

The review followed guidelines for conducting and reporting scoping reviews. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 was conducted on Scopus, Medline (Ovid), CINAHL and Embase databases. Independent full text screening by three reviewers followed title and abstract screening. Using a thematic framework synthesis, eligible studies were mapped onto an engagement continuum and health system level matrix to assess the current focus of PPE in Sub-Saharan Africa.

Results

Initially 1948 articles were identified, but 18 from 10 Sub-Saharan African countries were eligible for the final synthesis. Five PPE strategies implemented were: 1) traditional leadership support, 2) community advisory boards, 3) community education and sensitisation, 4) community health volunteers/workers, and 5) embedding PPE within existing community structures. PPE initiatives were located at either the ‘involvement’ or ‘consultation’ stages of the engagement continuum, rather than higher-level engagement. Most PPE studies were at the ‘service design’ level of the health system or were focused on engagement in health research. No identified studies reported investigating PPE at the ‘individual treatment’ or ‘macro policy/strategic’ level.

Conclusion

This review has successfully identified and evaluated key PPE strategies and their focus on improving health systems in Sub-Saharan Africa. PPE in Sub-Saharan Africa was characterised by tokenism rather than participation. PPE implementation activities are currently concentrated at the ‘service design’ or health research levels. Investigation of PPE at all the health system levels is required, including prioritising patient/community preferences for health system improvement.

287 COVID-19 and Surgical Specialties – Lessons Learnt: A Rural DGH Perspective

Introduction

The COVID-19 pandemic has seen the restructuring of surgical services worldwide. We aimed to evaluate pre-operative planning and post-operative outcomes in expedited colorectal surgery (ECRS), emergency general surgery (EGS), and emergency orthopaedic surgery (EOS) during the COVID-19 era at our rural hospital.

Method

This was a prospective observational cohort study. Electronic hospital systems identified adult patients who underwent ECRS, major EGS or EOS at our site, from the start of the UK lockdown.

Results

Following exclusion criteria, 98 patients were included in data analysis. Post-operative respiratory complications were seen in 27.8% of ECRS patients, 13.3% of EGS patients and 4% of EOS patients. 2 patients were diagnosed with COVID-19, with 1 COVID-19 associated mortality. Length of hospital stay was reduced for EOS in the COVID-19 setting and this was found to be statistically significant (p value <0.001).

Conclusions

When compared to the literature, COVID-19 related complications in surgical patients were found to be lower at our rural hospital. This could be due to regional variation in the prevalence of COVID-19. If there were to be a second surge, we suggest NHS Trusts should be given the autonomy to make local decisions on modifying their elective caseload, rather than following a national ‘one-size-fits-all’ guideline.

Comparison of Outcome of Borderline and Normal Amniotic Fluid Index in Term Pregnancy

Background Determination of Amniotic Fluid Index (AFI) is an important component of antepartum assessment of all normal pregnancies. Objective To compare the obstetric interventions and neonatal outcomes in term pregnancies with borderline Amniotic Fluid Index versus normal Amniotic Fluid Index. Method This hospital based prospective study was conducted at Tribhuwan University Teaching Hospital over 1 year between 2017 and 2018 in 128 women having uncomplicated term pregnancy admitted in labor ward. Of the 128 women, 64 women had borderline Amniotic Fluid Index (5.1-8 cm) and 64 normal AFI (8.1 - 24 cm). Parameters studied were induction of labor, cesarean section, instrumental delivery, intrapartum abnormal fetal heart rate, meconium staining of liquor, APGAR score at 5 and 7 minutes, birth weight, neonatal intensive care unit (NICU) admission and neonatal death. Data was analyzed using software OpenEpi. Result Statistically significant difference in result was obtained in the two groups in terms of rate of induction of labor (73.4% vs 35.9%, p = 0.0001, OR = 4.9), rate of cesarean section (42.1% vs 28 .1%, p = 0.04, OR = 1.8), tachypnea (50% vs 11.1%, p = 0.01) and low birth weight (9.1% vs 4.5%, p = 0.04). No statistical significance was found in meconium staining of liquor (33% vs 38.3%, p = 0.3) and APGAR score of <7 at 5 minutes (3.1% vs 1.5%, p = 0.06). There were no neonatal intensive care unit admissions and neonatal mortality in any of the babies. Conclusion Detection of amniotic fluid volume at term is important for timely maternal interventions to improve the overall fetal outcome.

Patient-public engagement interventions for health system improvement in Sub-Saharan Africa: A systematic scoping review protocol

BACKGROUND

Research has found health system improvement cannot be achieved without continuously engaging patients, their families and all stakeholders in the design, management and delivery of health care services. Following the Alma Ata declaration on Primary Health Care in 1978, the focus of health system improvement has tended to shift from physician or hospital-centric approaches to a more democratic vision of engaging the public and/or patients in the commissioning, planning, organisation, operation and control of the health care system. Thus, patient-public engagement (PPE) has become an important tool in health system improvement particularly for countries with poor health outcomes including countries in sub-Saharan Africa which carries an estimated 24% of the global burden of diseases in both human and financial costs. The aim of this scoping review is to describe and systematically map PPE research in sub-Saharan Africa, and then to synthesise this research in relation to key theories of PPE, identify the key drivers and barriers of PPE and to identify the knowledge gaps that may usefully be addressed by future research.

METHODS

This scoping review will follow Arksey and O'Malley's best guidelines for conducting scoping reviews and also follow the standard guidelines for reporting using the Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews checklist. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 will be conducted on four databases: Scopus, CINAHL, Medline (Ovid) and Embase. The initial screening of titles and abstracts will be undertaken independently by two reviewers, followed by full text screening involving three independent reviewers. A thematic framework synthesis will be employed in the analysis of data to identify the various PPE interventions, and outcomes mapped to a framework of engagement continuum to understand its overall effect on health system improvement in sub-Saharan Africa.

DISCUSSION

To our knowledge, this scoping review will be the first to systematically investigate PPE interventions implemented across sub-Saharan Africa, map the outcomes of identified interventions to a framework of engagement continuum and to understand its overall effect on health system improvement. Findings of this review will be published in an open-access peer review journal and disseminated at scientific conferences.

Controlling spin current polarization through non-collinear antiferromagnetism

The interconversion of charge and spin currents via spin-Hall effect is essential for spintronics. Energy-efficient and deterministic switching of magnetization can be achieved when spin polarizations of these spin currents are collinear with the magnetization. However, symmetry conditions generally restrict spin polarizations to be orthogonal to both the charge and spin flows. Spin polarizations can deviate from such direction in nonmagnetic materials only when the crystalline symmetry is reduced. Here, we show control of the spin polarization direction by using a non-collinear antiferromagnet Mn₃GaN, in which the triangular spin structure creates a low magnetic symmetry while maintaining a high crystalline symmetry. We demonstrate that epitaxial Mn₃GaN/permalloy heterostructures can generate unconventional spin-orbit torques at room temperature corresponding to out-of-plane and Dresselhaus-like spin polarizations which are forbidden in any sample with two-fold rotational symmetry. Our results demonstrate an approach based on spin-structure design for controlling spin-orbit torque, enabling high-efficient antiferromagnetic spintronics.

In the typical spin-hall effect, spin-current, charge current, and spin polarisation are all mutually perpendicular, a feature enforced by symmetry. Here, using an anti-ferromagnet with a triangular spin structure, the authors demonstrate a spin-hall effect without a perpendicular spin alignment.

Risk and protective factors for post-traumatic stress among New Zealand military personnel: A cross sectional study

Background

Post-traumatic stress (PTS) is prevalent among military personnel. Knowledge of the risk and protective factors associated with PTS in this population may assist with identifying personnel who would benefit from increased or targeted support.

Aims

To examine factors associated with PTS among New Zealand military personnel.

Methods

For this cross-sectional study, currently serving and retired military personnel were invited to complete a questionnaire. The questionnaire included a measure of PTS (the Military Post-traumatic Stress Disorder Checklist; PCL-M), where scores ≥30 indicate the experience of significant PTS symptoms and scores ≥45 indicate a presumptive clinical diagnosis of post-traumatic stress. Potential risk and protective factors associated with PTS were examined using logistic regression modelling.

Results

1817 military personnel completed the questionnaire. PCL-M scores were ≥30 for 549 (30%) participants and ≥45 for 179 (10%) participants. Factors associated with higher PCL-M scores were trauma exposure, older age, male sex, and Māori ethnicity. Factors associated with lower PCL-M scores were greater length of service, psychological flexibility, and better quality sleep.

Conclusions

PTS was found to be prevalent among New Zealand military personnel. The experience of trauma was strongly associated with PTS. However, factors such as psychological flexibility (the ability to adapt to changes in circumstances) and good sleep were protective, suggesting that these factors could be key targets for interventions designed to reduce PTS among military personnel in New Zealand.

The role and functions of community health councils in New Zealand's health system: a document analysis

BACKGROUND

Community/consumer health councils (CHCs) are a relatively new phenomenon in New Zealand. CHCs are usually established within district health boards (DHBs) to help address gaps in community engagement in the health sector. Little is known about the establishment, structure, roles and functioning of these councils.

AIM

To undertake a literature review, including grey literature, related to the structure, roles and functioning of CHCs in New Zealand.

METHOD

A document analysis of the New Zealand-focused website materials and newspaper articles related to CHCs was conducted. Data were analysed thematically using a qualitative content analysis approach.

RESULTS

The search identified 251 relevant web sources and 118 newspaper articles. The main role of the CHCs appeared to be to advise and make recommendations to their respective DHBs (and DHB governance and management structures) about health service planning, delivery and policy. All CHCs discussed in the identified sources comprised different demographic backgrounds and expertise. Although the CHCs were mainly engaged in information sharing and consultation, their influence on DHB decision-making could not be determined from the sources.

CONCLUSION

This is the first study of CHCs throughout New Zealand investigating their roles, structure and type of engagement. As the concept is evolving and more CHCs are being established, this information may be useful for future CHCs. With increasing longevity of CHCs in New Zealand, future studies could usefully investigate CHCs' potential to represent the health interests of their local communities, and their influence on DHB decision-making.

Child/youth, family and public engagement in paediatric services in high-income countries: A systematic scoping review

Background

Patient and public engagement in paediatric health‐care decision making is under‐researched, and there is a lack of systematically reviewed literature in this area.

Objective

To examine the extent, range and nature of published research investigating the engagement of children/youth, families and the public in paediatric service improvement, to summarize key aspects of the research identified and to identify gaps to help inform future research needs.

Methods

Literature was sought in MEDLINE, EMBASE, PsycINFO and CINAHL. Eligible articles presented research focused on patient, family and public engagement strategies in the paediatric health‐care setting. Two reviewers extracted and charted data and analysed findings using a descriptive numerical summary analysis and a thematic analysis.

Results

From 4331 articles, 21 were eligible. Most were from the United States. The majority of studies were undertaken in hospital settings and used quantitative methods. Various patient and public engagement strategies/interventions were examined, including shared decision‐making tools, questionnaires, youth councils/family advisory groups, patient portals and online networks. Most of the studies examined child/youth/parent satisfaction, with fewer investigating treatment outcomes or service improvement. The majority of studies investigated an engagement strategy at the ‘individual treatment’ level of engagement. Regarding the continuum of engagement, most of the studies were at either the ‘consultation’ or ‘involvement’ stage.

Conclusion

Future research needs to focus on the investigation of engagement strategies delivered in primary care, and the use of more qualitative and mixed methods approaches is recommended. There is a gap in the area of engagement strategies directed towards ‘service design and resources’ and ‘macro/policy’ levels.

Perspectives on preventing musculoskeletal injuries in nurses: A qualitative study

AIMS AND OBJECTIVES

To explore the perspectives of nursing and physiotherapy academics regarding techniques designed to prevent musculoskeletal pain and injury in nurses.

BACKGROUND

High rates of musculoskeletal injuries are evident in nurses, yet there is an absence of research identifying effective interventions to address this problem. Exploring the perspectives of individuals with specialist knowledge in the area could help identify barriers to musculoskeletal injury prevention, and innovative strategies to investigate in future studies.

DESIGN

Cross-sectional qualitative descriptive study.

METHODS

Between October-December 2017, group and individual face-to-face semi-structured interviews were used to collect data. All interviews were audio-recorded. A thematic analysis was performed, with two researchers coding audio files using NVivo software. The Consolidated Criteria for Reporting Qualitative Research Checklist was consulted to ensure complete reporting of all methods and findings.

RESULTS

Nursing and physiotherapy academics (N = 10) were aware of a range of techniques to prevent musculoskeletal injuries in nurses, including education, equipment, health and safety policy and multi-disciplinary collaboration. However, several barriers to using these techniques were identified, including age, knowledge and availability of equipment, personal and contextual factors, staffing and time pressures. Several strategies were recommended for further investigation and implementation in clinical practice, such as the sharing of personal experiences, orthopaedic assessments and changes to workplaces that foster a culture of safety.

CONCLUSIONS

Further research is required to reduce musculoskeletal pain and injury among nurses. This research should account for the barriers to current prevention strategies and consider investigating novel interventions.

RELEVANCE TO CLINICAL PRACTICE

These findings highlight strategies for preventing musculoskeletal injuries among nurses that are likely to be most effective in clinical practice.

Citizen's Charter in a primary health-care setting of Nepal: An accountability tool or a "mere wall poster"?

BACKGROUND

Despite some empirical findings on the usefulness of citizen's charters on awareness of rights and services, there is a dearth of literature about charter implementation and impact on health service delivery in low-income settings.

OBJECTIVE

To gauge the level of awareness of the Charter within Nepal's primary health-care (PHC) system, perceived impact and factors affecting Charter implementation.

METHOD

Using a case study design, a quantitative survey was administered to 400 participants from 22 of 39 PHC facilities in the Dang District to gauge awareness of the Charter. Additionally, qualitative interviews with 39 key informants were conducted to explore the perceived impact of the Charter and factors affecting its implementation.

RESULTS

Few service users (15%) were aware of the existence of the Charter. Among these, a greater proportion were literate, and there were also differences according to ethnicity and occupational group. The Charter was usually not properly displayed and had been implemented with no prior public consultation. It contained information that provided awareness of health facility services, particularly the more educated public, but had limited potential for increasing transparency and holding service providers accountable to citizens. Proper display, consultation with stakeholders, orientation or training and educational factors, follow-up and monitoring, and provision of sanctions were all lacking, negatively influencing the implementation of the Charter.

CONCLUSION

Poor implementation and low public awareness of the Charter limit its usefulness. Provision of sanctions and consultation with citizens in Charter development are needed to expand the scope of Charters from information brochures to tools for accountability.

Air Transfer of Obstetric Emergencies to a Tertiary Care Center in Nepal

Aims: This study was performed to review the places, indications, maternal-perinatal outcomes requiring emergency air transfer to a tertiary level referral center.Methods: A hospital based descriptive study of one year duration, conducted in Tribhuvan University Teaching Hospital (TUTH), over a period of twelve months. All the women who were air transferred for pregnancy complications were enrolled.Results: There were total 19 airlifted obstetric emergencies to TUTH over one year period:  majority (68%) from hilly areas and others (32%) from mountain region. Out of them, referred cases were 11 [district hospital (5), healthpost (4); Primary Health Center (PHC) (2)]; and rest were from home (8). Two cases were abortion related; septic abortion (1) and incomplete abortion (1). There were three antepartum cases: pregnancy with meningoencephalitis (1), eclampsia (1) and bleeding placenta previa (1); maximum, eleven intrapartum cases, obstructed labor (6),labor dystocia (3), breech in labor (1) and undelivered second twin (1). Rest three were postpartum cases, one each of eclampsia, puerperal sepsis and retained placenta. Maternal morbidities were one each case of uterine rupture, acute kidney injury, retained placenta with PPH and vesicovaginal fistula that developed in the case of shoulder dystocia. Maternal mortality occurred in 2 cases, first women with antepartum eclampsia who had intracerebral bleed and second was a case of pregnancy with meningoencephalitis who later developed brain death. Regarding perinatal outcome 12/14 (86%) had live birth and 2/14 (14%) had IUFD upon arrival.Conclusion: Air lift on personal expenditure, despite economic constraints has proven beneficial in our country’s context with difficult geographical terrain and inadequate health services, whereas anticipation of any critical condition right in the beginning and timely transfer however could have been more advantageous.

Changing trends in caesarean deliveries at a tertiary care Centra: a ten year appraisal

Introduction: Over the last few decades, the rise in the rates of Caesarean Sections (CS) has become a global phenomenon. The objective of this study was to follow the CS rates over the last 10 years and to compute the various indications of CS in an attempt to analyze the possible reasons for this changing trend in the institute.Methods: All deliveries that took place between April 13, 2004 to April 14, 2014 (Baisakh 2061 BS and Chaitra 2070 BS) in TUTH were retrospectively collected. Annual total number of deliveries, rates of CS, instrumental deliveries and Vaginal Birth after Caesarian Section (VBAC) along with indications for CS were computed and analyzed.Result: A total of 38,770 deliveries were conducted over ten years with 26,791 (69.10%) vaginal deliveries and 11,979 (24.80%) CS. There was a steep rise in the rates of CS from 21.04% in 2004 to 39.23% in 2014. Rates of instrumental deliveries and VBAC remained low at 0.86% to 3.35% and 0.15% to 0.7 % respectively. Fetal distress was the commonest indication of emergency CS while previous CS was the commonest indication for elective CS.Conclusion: Over the last decade, the global trend of rising CS rates was also found to be mirrored at TUTH. The causes for rise in CS  rates were- increased diagnosis of fetal distress and oligohydramnios, delivery of most breech by Caesarean sections, low rates of VBAC and instrumental deliveries, complicated referrals from all over the country and last but not the least,  threat of malpractice litigations.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

Why service users do not complain or have 'voice': a mixed-methods study from Nepal's rural primary health care system

BACKGROUND

Despite abundant literature on the different aspects of health care complaint management systems in high-income countries, little is known about this area in less developed health care systems and most research to date has been conducted in hospital settings. This article seeks to address this gap by reporting on research into complaint systems in primary health care (PHC) settings in Nepal.

METHODS

Using a mixed-methods design, qualitative interviews were conducted with key informants (n = 39) and six community focus groups (n = 56), in the Dang District of Nepal. In addition, interviewer-administered structured questionnaire interviews were held with 400 service users, health facility operation and management committee (HFMC) members and service providers from 22 of the 39 public health facilities. Qualitative data were transcribed, organized and then analyzed using the framework method in QSR NVivo 10, while quantitative data were analyzed using IBM SPSS 22.

RESULTS

Despite service users having grievances with the health system, they did not complain frequently: 9% (n = 20) reported ever making complaints about the PHC services. Complaints made were about medicines, health facility opening hours, health facility physical environment, and service providers, and were categorized into environment/equipment, accessibility/availability, level of empathy in the care process and care/safety. Generally, complaints were made verbally to health providers or to HFMC members or female community health volunteers. Use of formal channels such as suggestion boxes or written complaints was almost non-existent. Reasons reported for not complaining included: a lack of complaint channels; lack of knowledge of service entitlements; power asymmetry between service providers and service users; lack of opportunity to choose alternative providers, lack of an established culture of complaining, and a perceived lack of responsiveness to complaints.

CONCLUSION

Very few service users made complaints to PHC services in Nepal. Several contextual factors related to the community and the health system were identified as the reasons for not complaining. We recommend continuing efforts to establish proper complaints mechanisms with an increased emphasis on the existing community health system networks. Furthermore, awareness among service users about service entitlements and complaint mechanisms should be increased.

Assessment of Knee Joint Injuries with Low Field Strength Magnetic Resonance Imaging

BACKGROUND

Magnetic Resonance Imaging is an appropriate screening tool before therapeutic arthroscopy, making diagnostic arthroscopy unnecessary in most patients. This study aims to evaluate the MRI findings in knee injuries and diagnostic value of low Strength MRI for assessing Meniscal and cruciate ligament tear.

METHODS

A cross sectional study was conducted on patients undergoing "Magnetic Resonance Imaging of the Knee" for injuries of the knee and excluded patients undergoing MRI for other causes, poor diagnostic quality MRI and post operative MRI. All patients were interviewed for mechanism of injury and followed up for arthroscopic findings. Statistical analysis was doe using IBM SPSS 20.0.

RESULTS

A total of 81 MRIs was included in the study. Arthroscopic finding of only 32 patients could be followed up. Anterior cruciate ligament (ACL) tear was the most common internal ligament tear accounting for 34(42%) of cases followed by medial meniscus tear in 33(40.7%). Twisting 14( 42.4%)was the most common mechanism involved in medial meniscus tear while combined mechanism of injury was most common mechanism for ACL tear 16( 47.05%). The sensitivity of MRI for diagnosis of ACL tear and medial meniscus tear was 96.3% and 94.7% respectively. Specificity for ACL tear was however only 80% and that for medial meniscus tear was 100%.

CONCLUSIONS

The diagnostic value of MRI for diagnosing internal derangement of knee was high even with a low Tesla (0.3 T) MRI thus emphasizing the role of MRI as a non-invasive alternative to diagnostic arthroscopy.

Magnetic Resonance Imaging Findings in Degenerative Disc Disease of Cervical Spine in Symptomatic Patients

BACKGROUND

The pathophysiological findings demonstrated in cervical spine in Magnetic Resonance Imaging (MRI) can explain only partly the occurrence of neck and shoulder pain. This study aims to evaluate the occurrence of cervical degenerative disc pathologies in symptomatic patient with neck pain and radiculopathy.

METHODS

The study was a retrospective and institutional record based descriptive study carried out for the duration of 3yrs in a well-equipped imaging center. Only MRI performed for neck pain with or without radiculopathy with complete clinical form was included in the study. MRI findings were entered in SPSS spread sheet and analyzed using SPSS 19.0.

RESULTS

A total of 750 MRI was reviewed among which 571(76.13%) had cervical degenerative disc pathology. Disc degeneration and disc bulge was the most common finding, followed by neural foramina stenosis, disc herniation and myelopathic changes. Disc degeneration and disc bulge was seen more frequently in patients older than 40 years than those less than 40 years. Disc herniation was rare in extremes of age and noted predominantly in productive population between 3 rd and 6 th decade of life.

CONCLUSIONS

Disc degeneration and global disc bulge were predominant findings in symptomatic patients increasing with the age. Disc herniation and neural foraminal stenosis were common changes seen associated with neck pain with or without radiculopathy and were predominant in productive age group.

Magnetic Resonance Imaging Findings in Lumbar Disc Degeneration in Symptomatic Patients

BACKGROUND

The sequel of disc degeneration is one of the leading causes of functional incapacity that leads to chronic disability. The study aims to evaluate the MRI findings of degenerative changes in symptomatic patients.

METHODS

The study was a retrospective study for the duration of 3 years. Symptomatic patients undergoing MRI of LS spine were included in the study. Patients undergoing MRI for neurological symptoms alone and acute trauma or suspected infection or tumor were excluded from the study. MRI of patients was evaluated for degenerative changes and their sequel. Data was entered in a predesigned proforma and analysis was done with SPSS version 19.0.

RESULTS

A total of 2037 MRIs of LS spine of symptomatic patients were included in the study. Degenerative changes were demonstrated in 1906 (93.8 %) patients, which comprised 1039 (54.5 %) males and 867 (45.4 %) females. Disc bulge along with disc desiccation was the most common degenerative findings noted in 1667 (81.8 %). Disc herniation was seen in 1032(50.6%), neural foraminal stenosis in 1220 (59.8 %), central spinal canal in 1136 (55.8%) and nerve root compression in 650 (31.9%). Disc bulge, neural foraminal stenosis, central spinal canal stenosis was significantly more common in patients older than 40 years. Disc herniation was however significantly more frequent in patients younger than 40 years.

CONCLUSIONS

Degenerative changes are common in symptomatic patients and increase in frequency with aging. Disc herniation is however more common in younger patients.

Governance challenges in the Nepalese primary health care system: time to focus on greater community engagement?

Nepal has seen impressive recent health gains through a successful community-based health program. However, governance challenges remain within the Nepalese primary health care system that include under-staffing and absenteeism, limited health facility opening hours, poor supervision and monitoring, and insufficient financial management. We propose that these be addressed through expanded community engagement and a power shift towards local communities, enhancing skills of community representatives in co-managing health facilities and of service providers to effectively engage the community, increased quality of community participation, and improved documentation of the process and impact of engagement on health outcomes. Copyright © 2015 John Wiley & Sons, Ltd.

Obstetric Hysterectomy and Maternal Survival

Aims: This study was done to analyze the cases of obstetric hysterectomy and maternal complications and survival after that. Methods: A retrospective study was carried out from the review of records   of the near miss, maternal mortality, cesarean audit and operation theater record of the Department of Obstetrics and Gynaecology, Tribhuvan University Teaching Hospital (TUTH), Kathmandu from 2057-2071 BS. Results: Fourteen maternal survival resulted following total of 19 obstetric hysterectomy, subtotal hysterectomy being the procedure of choice in 11 cases, emergency peripartum hysterectomy (EPH) being performed in abundance (18/19) in comparison to an elective peripartum hysterectomy, which was undertaken in a single case of placenta percreta, and inclusive of latter were four cases of morbid placental adhesion, a placenta increta and two placenta accreta. Eight out of 19 cases had vaginal delivery and rest had cesarean section. Among seven cases of cesarean hysterectomy 3 were done for placenta previa with accreta one case each done for abruptio placentae  and placenta accreta and two cases were done for extra placental causes. Among four cases of emergency peripartum hysterectomy (EPH), which were relaparotomy followed by hysterectomy, three cases were done for complication of cesarean section and one done for uterine atonicity. Four cases of spontaneous vaginal deliveries needed peripartum hysterectomy two of them were complicated by morbid placental adhesion placenta increta (1), placental percreta (1), two cases were vaginal birth after cesarean (VBAC). Seven cases of uterine rupture had undergone peripartum hysterectomy.   Conclusions: Obstetric hysterectomy is a lifesaving surgical procedure for maternal survival whenever necessary and mandates a quick decision making process, however in consideration of younger age and low parity or nulliparity, the best obstetric governance and services must foresee not to let mothers meet such situation necessitating organ removal and to enjoy potential reproductive life cycle.DOI: http://dx.doi.org/10.3126/njog.v9i2.11759    

A clinicopathological study of dysfunctional uterine bleeding

Background: Dysfunctional uterine bleeding is a form of abnormal uterine bleeding when there is absence of organic disease of the genital tract. The objective of this study was to find out the clinical and pathological aspect of women presenting with dysfunctional uterine bleeding.Materials and Methods: A descriptive study was conducted over a period of one year from April 14th 2010 to April 13th 2011 in the Department of Obstetrics and Gynaecology and Department of Pathology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A complete history, clinical examination, pelvic scan, hormonal status if required and endometrial biopsy were done to diagnose dysfunctional uterine bleeding.Results: A total of 120 cases were included. The age of the patients diagnosed dysfunctional uterine bleeding were ranging from 24 -63 years. Dysfunctional uterine bleeding was most common in the age group 40-44 yrs (30%) followed by 45-49 yrs (27.5%). Menorrhagia (41.7%) was the most common presenting sign. Majority histopathology of endometrium revealed anovulatory pattern (61.7%) followed by ovulatory (38.3%). Of the cases with an anovulatory pattern 48.6% was proliferative endometrium, 33.8% disordered proliferative endometrium, 6.8%atrophic, 5.4% weakly proliferative and 2.7% each of simple hyperplasia without atypia and complex hyperplasia with atypia. All cases with ovulatory pattern showed secretory endometrium.Conclusion: Dysfunctional uterine bleeding was the most common in the perimenopausal age group and chiefly in the form of an anovulatory endometrium. . Histopathological evaluation of endometrium helps exclude the local causes and establishes the diagnosis of dysfunctional uterine bleeding, its types, and clinical correlation to histopathological findings and finally helps to determine the mode of management.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11500 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 635-638

Use of Misoprostol in the Management of Early Pregnancy Loss

Aims: To evaluate the effectiveness of Misoprostol administered vaginally to assist complete evacuation in early pregnancy losses (incomplete abortion, missed abortion and blighted ovum). Methods: It is a descriptive study conducted in the Department of Ob/Gyn and Emergency Department Tribhuvan University Teaching hospital. All women with clinical/USG diagnosis of incomplete abortion, missed abortion and blighted ovum ≤12 weeks POG either from last menstrual period (LMP) or USG were inserted tab. misoprostol 800 mcg in the posterior fornix. Same dose was repeated when the evacuation was incomplete on day 3 of follow-up. Manual vacuum aspiration (MVA) was offered on day 14 if evacuation was incomplete or any complications like excessive bleeding/severe pain occurred during this period. Results: A hundred and thirty three women with incomplete/missed/blighted ovum were reported, of which 112 (84.3%) were analyzed as 21(15.7%) lost to follow up. Among the 112, 51 (45.5%) were incomplete abortion, 34(30.3%) blighted and 27 (24.1%) missed abortion. Complete evacuation was achieved in 98/112 (87.5%) cases [73 (65%) cases with single dose & 25(22.3%) with double doses]. Evacuation was failed in 14(12.5%) cases [incomplete abortion 6 (42%), blighted 7 (50%) & missed abortion 1 (7.1%)]. Failure for complete evacuation (n=14) related to gestational age: 10-12 weeks 9/14(64%), 7-9 weeks 5 (35%) and none in the ≤6 weeks. Although the plan was to evacuate on day 14 of follow-up for incomplete evacuation which was applicable only in 11(78.5%) cases, 3(21.5%) cases were surgically (MVA) treated beforehand (2 for excessive bleeding, 1 for severe pain). No severe complications and side effects requiring treatment were observed. Conclusions: Vaginal Misoprostol is proved to be effective and safe in cases of incomplete abortion, missed abortion and blighted ovum. In the cases that failed to achieve complete evacuation by medical means using misoprostol were subjected to surgical manual vacuum aspiration (MVA) on day 14 of follow-up. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11133   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 9-13

Crossed Testicular Ectopia

Crossed testicular ectopia also known as transverse testicular ectopia is a rare anomaly of the testis which is ectopically located in contralateral hemiscrotum with absent testis in the ipsilateral hemiscrotum. Most case are incidentally discovered intraopeartively during operation of inguinal hernia and few case reports are available which have reported preoperative diagnosis of crossed testicular ectopia. We report a case of crossed testicular ectopia in 12 year old boy who presented with right undescended testis diagnosed preoperative on Ultrasound and Magnetic Resonance Imaging as crossed testicular ectopia.

Fostering good governance at peripheral public health facilities: an experience from Nepal

CONTEXT

The Nepalese primary healthcare system at sub-district level consists of three different levels of health facility to serve the mostly rural population. The Ministry of Health and Population decentralised health services by handing over 1433 health facilities in 28 districts to Health Facility Operation and Management Committees (HFOMCs), which were formed following a public meeting, and consist of 9 to 13 members, representing the health facility in-charge, elected members of the village development committee, dalit (disadvantaged caste) and women members. The purpose was to make this local committee responsible for managing all affairs of the health facility. However, the handing over of the health facilities to HFOMCs was not matched by an equivalent increase in the managerial capacity of the members, which potentially makes this initiative ineffective.

ISSUE

The Health Facility Management Strengthening Program was implemented in 13 districts to foster good governance in the health facilities by increasing the capacity of HFOMCs. This effort focuses on capacity building of HFOMCs as a continuous process rather than a one-off event. Training, follow-up and promotional activities were conducted. This article focuses on how good governance at the peripheral public health facilities in Nepal can be fostered through the active engagement and capacity building of HFOMCs. This article used baseline and monitoring data collected during technical support visits to HFOMCs and their members between July 2008 and October 2011.

LESSONS LEARNED

The results show that the Health Facility Management Strengthening Program was quite successful in strengthening local health governance in the health facilities. The level of community engagement in governance improved, that is, the number of effective HFOMC meetings increased, the inclusion of dalit/women members in the decision-making process expanded, resource mobilization was facilitated, and community accountability, as measured by health facility opening days, increased. Furthermore, availability of technical staff, supervision and monitoring, and display of the citizen charter increased, and health services became more inclusive. Several lessons emerged. Functioning of HFOMCs is largely dependent on the process of selecting members, the staff and community's support of the HFOMC, and a sense of volunteerism and team spirit among the members. Similarly, to ensure the effective participation of dalit/woman members, the educational and livelihood empowerment of the members is deemed necessary. Furthermore, capacity building of and giving authority to HFOMCs should go hand-in-hand.

CONCLUSION

Local governance of health facilities was fostered through the local people's active engagement in HFOMCs and capacity building of the HFOMC members.

Post Caesarean Caecal Perforation with Fecal Peritonitis

NJOG 2011 Nov-Dec; 6 (2): 58-59 DOI: http://dx.doi.org/10.3126/njog.v6i2.6762

Strengthening national health systems for improving efficiency of health service delivery in Nepal

The success of Nepal's community-based health programmes in promoting maternal and child health has been achieved due to an overall improvement in service delivery facilities and health support systems. This article assesses the progress made by the Government of Nepal in improving health service delivery by introducing three key components: an improved health logistics management, facility-based maternal and neonatal health services, and decentralized health facility management.

Nepal health sector decentralization in limbo: what are the bottlenecks?

Nepal's efforts to decentralize its governance date back to over half a century. These efforts remained incomplete due to different reasons including administrative responses and political development affecting its implementation. The Local Self Governance Act (LSGA), 1999 envisaged, for the first time, to decentralize governance in the health sector through devolution of responsibilities, authority and resources to the local bodies. However, the pace of health sector decentralization in Nepal even after the LSGA was enacted has not progressed satisfactorily due to different reasons. The purpose of this paper is to discuss why health sector decentralization in Nepal has not advanced as expected. This paper identifies many issues--policy related, political, functional, and institutional--as stumbling blocks for health sector decentralization of Nepal. More specifically, the major bottlenecks for progress are lack of a clear cut policy, poor coordination among different sectors, improper handover process, lack of elected bodies, poor selection process of management committees, lack of coherence in the capacity building process of local bodies, ongoing debate about state restructuring including federalism and different political ideologies on decentralization.

Capacity building is not an event but a process: lesson from health sector decentralization of Nepal

Health Facility Operation and Management Committee are supposed to govern all the affairs of local health facilities under decentralization policy. The capacity building of the committee was deemed necessary and thus different stakeholders involved in the capacity building process. All agreed up on the need of capacity building of the committee but there were different school of thoughts on the contents and process of capacity building. Major capacity building inputs included orientations and training to the committee. However the follow up part was not uniform; some organizations conducted periodic reflection meeting, where as many ended up with the training. There were some tangible changes observed by the capacity building inputs. Their priority however was on infrastructure and drug purchase. The changes observed were very short lived and not sustainable. The capacity building was equated with training and an event with low priority on follow up, monitoring and coaching. It was not thought as a process. A concept of complete package of capacity building should have been developed where training component would be only an element of overall capacity building.

Child Health Status of Nepal: Social Exclusion Perspective

Introduction: Nepal has achieved a spectacular success in child health over the last decades but the achievement is not uniform across different social groups. Therefore, there is urgent need to identify the groups who are excluded from access of child health services which would give us population at risk to prioritize and utilize the scarce resources available in health sector more effectively and efficiently. Methods: The study was descriptive type and was based on review of secondary data of different studies done in past. The study used World Bank framework of dimension of exclusion to analyze social exclusion in child health in Nepal. The health differentials in child health across different social groups were analyzed using simple descriptive analysis like percentage and ratios. The trends of the child health disparities over the ten years were done comparing the data of NFHS1996 and NDHS 2006. Results: The study showed there were disparities in child health status by ethnicity, location, wealth status. In most of the cases, the trends of disparities are increasing for mortality indicators and malnutrition status. Interestingly, the gaps in accessibility indicators of child health services are becoming narrowed down. Conclusion: This study showed the discrepancies in child health status in different social groups. The inequality in childhood mortality and malnutrition are increasing over the period for different groups where as it is decreasing for accessibility indicators of childhood health services. Key words: Child health status, inequality, social exclusion, social groups.   doi: 10.3126/jnps.v29i2.2044 J. Nepal Paediatr. Soc. Vol 29, No. 2, pp.79-84

Live birth following treatment of post molar choriocarcinoma

A G3P(1+1) who underwent dilatation and curettage (D and C) for persistent vaginal bleeding after a month of molar evacuation, underwent successful treatment of choriocarcinoma with methotrexate and was able to have normal baby weighing 2800 gms with good Apgar score and normal placenta. This shows that a normal menstruation and uncomplicated term delivery can be expected after complete chemotherapy for gestational trophoblastic neoplasia (GTN).

Simultaneous occurrence of hematometrocolpos and consecutive pregnancies in uterine didelphys : a case report

Hematometrocolpos drained abdominally at laparotomy done, with suspicion of an ovarian torsion in an adolescent with ipsilateral renal agenesis, was eventually rediscovered to have in coexistent uterine didelphys in a 25 year P3+0 at the time repeat caesrean for breech in the event of third parturition, complicated by partum hemorrhage as in all her previous delivery (first vaginal delivery and retained placenta, second caesarean for obstructed labor by non pregnant half of didelphic uterus). This illustrates how simultaneous occurrence of hematometrocolpos can go unnoticed although there was every reason for this condition not to go unrecognized for the simple fact ofhemivaginal obstruction and hematometra with ipsilateral renal agenesis (on the left side) unaffecting the consecutive pregnancy in the other uterus.

Practices on immediate care of newborn in the communities of Kailali district

Immediate proper care of newborn is vitally important for survival, growth and development of a baby. Despite several studies conducted in Nepal about maternal and child health care practices, little is known about factors that determine behaviors related to immediate care of newborn. Identification of behavioral determinants for immediate care of newborn in Kailali district was objective of the study. This formative research was conducted in 6 purposely selected Village Development Committees (VDCs) of Kailali. Altogether 17 Focused Group Discussions (FGDs) were conducted with 106 parents. To triangulate the findings, 58 in-depth interviews were conducted with various individuals. Most people are unaware of importance of immediate care of newborn and many unsafe behavior do exist such as common use of untrained attendants, unsafe cord care, immediate bathing of baby. Most of the existing practices are based on deep-seated traditional beliefs. Some used Clean Home Delivery Kit (CHDK) and a few had used knife to cut the cord. All had tied stump with thread and applied mustard oil to prevent infection. The use of CHDK was high in the Tharu group with surprisingly low among Brahmin/Chetri. Yet! This research showed willingness on the part of the community to learn and change harmful practices. Almost all had similar opinion that survival of a baby is with in their control. As child is the center of love of all and targeting a child many behaviors and practices could be changed. The next step would be to prioritize the behaviors that need to be targeted for change and spread key messages for behavior change.

A study of public health indicators of morang Nepal by lot quality assurance sampling method

This article presents the findings of public health status indicators of Morang District as studied by Lot Quality Assurance Sampling (LQAS) methods 2006. The contraceptive prevalence rate (CPR) and women receiving antenatal service from health workers were 42.0% and 46.0%, respectively. A total of 80.0% mothers were receiving iron tablets whereas 55.0% mothers gave history of taking Vita A during their last pregnancy. Nearly three-fifth (57.0%) of deliveries was conducted by health workers. Thirty-one percent of mothers fed their breast milk within 1 hour during last natal period. These figures were higher compared with previous years.

A simple new technique of performing myomectomy for a predominantly subserosal myoma quickly within few minutes

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

PLACENTA PREVIA ACCRETA

Placenta accreta is defined as any placental implantation in which the placenta isabnormally and firmly adherent to the underlying uterine wall in part or in total. Theprobable cause is defective decidual formation as shown by its occurence in area wherethe endometrium is deficient or damaged.The commonest condition associated with it are placenta previa and previous caesareansection. A case of placenta previa accreta is described herewith in a 2nd gravida whoeventually needed emergency caesarean hysterectomy (total) due to profuse bleeding.Key Words: Placenta accreta, placenta, caesarean hysterectomy.

Analysis of Septic Abortion During Six Year Period(April 1992-1998) in Teaching hospital, Nepal

Abstract

CERVICAL CERCLAGE

ABSTRACT

Closed Mitral Valvotomy During Pregnancy

Abstract