Alarm Fatigue among Nurses Working in Critical Care Setting in a Tertiary Hospital, Nepal

Background Alarm fatigue is a well-recognized patient safety concern in critical care settings. It occurs when nurses become overwhelmed by the total number of alarm signals which can result in alarm desensitization and eventually contributes to missing of serious and important changes in a patient's condition, thus failing to respond properly. Objective To find out alarm fatigue and its associated factors among nurses working in critical care setting. Method A cross-sectional study design with convenient sampling technique was used to select 56 nurses working at different critical care settings in Dhulikhel Hospital. A selfconstructed semi structured questionnaire and nurses alarm fatigue questionnaire was used for the survey. Frequency, percentage, mean and standard deviation were used for descriptive statistics whereas Independent t-test and One-way ANOVA were used for inferential statistics. Result The result shows that more than half of the nurses were less than 25 years, single and more than two-third of the participants worked in Adult Intensive Care Unit. Out of total obtainable score 44, the overall mean score of the Alarm Fatigue was 28.03±12.813. The result showed that there was no significant difference between alarm fatigue and selected socio-demographic and work related characteristics. Conclusion The alarm fatigue among nurses working in critical care settings was found to be higher in this study. Since alarm fatigue is directly related to patients' safety, the effective management of medical device alarms can reduce alarm fatigue and prevent potentially dangerous outcomes.

Speckle tracking echocardiography in patients with systemic sclerosis: a meta-analysis

Background

Myocardial dysfunction is well established in systemic sclerosis (SSc). The utility of standard echocardiography is limited to detect the onset of myocardial dysfunction. Speckle tracking echocardiography (STE) and strain imaging has emerged as a useful technique to quantify left ventricle hemodynamics and myocardial function in early stages of myocardial dysfunction. We aimed to systematically analyze the existing literature on the application of STE and strain analysis in identifying SSc associated myocardial dysfunction

Methods

PubMed, Cochrane, and Google Scholar were queried for studies from the inception of the databases to 2022. Case control studies that used 2D STE for assessment of strain in SSc patients and controls, were included for the analysis. PRISMA guidelines were followed for selections of studies. Two independent reviewers extracted data. Analysis was done using Cochrane Review Manager 5.0.

Results

Total of 19 studies were included in the analysis that compared strain analysis in SSc patient's vs healthy controls. Of the 16 studies that reported left ventricular (LV) global longitudinal strain, we found significantly lower LV global longitudinal strain in SSc patients (mean difference 1.92; 95% CI 0.98–2.87). Six studies reported LV circumferential strain which was noted to be lower in SSc patients compared to healthy controls (mean difference 3.55; 95% CI 1.60–5.51). Five studies reported LV global radial strain with a similar decrease in radial strain among SSc patients compared to controls (mean difference 4.39; 95% CI −6.95 to −1.83). 10 studies reported right ventricular longitudinal strain with a decrease in longitudinal strain in SSc patient's vs controls (mean difference 2.57; 95% CI 2.03–3.12).

Conclusions

SSc patients have lower strain values compared to controls, which is suggestive of an impaired myocardial function in left and right ventricle. Strain analysis by STE could help with early detection of myocardial dysfunction.

Funding Acknowledgement

Type of funding sources: None.

Takotsubo's cardiomyopathy in patients with pre-existing autoimmune diseases: a national inpatient sample analysis

Background

Recent research has suggested a potential role of autoimmunity and inflammation in Takotsubo's cardiomyopathy (TC) [1]. There have been few reports of TC occurring in patients with pre-existing autoimmune diseases (AID). It has also been hypothesised that the low prevalence of TC in patients with AID might be due to attenuating effect on the inflammatory response to catecholamine excess in TC by immunosuppressive medications used in AID patients [2]. On a population-based level, the prevalence of AID in TC patients and its implications remain unknown.

Purpose

Using a large national database, we aimed to describe the prevalence of AID in TC patients and its impact on in-hospital outcomes of TC patients.

Methods

We performed a retrospective analysis using the 2016–2019 National inpatient sample database in the United States, covering over 7 million admissions per year. Using ICD-10 codes, we identified patients with TC and a concomitant diagnosis of any of the AID† depicted in Table 1. We compared TC patients with (AID+) and without AID (AID−) for patient characteristics and in-hospital outcomes. Our primary outcome of interest was mortality. Secondary outcomes are listed in Table 2. Linear regression and multivariate logistic regression analysis were done using STATA 17 to adjust for confounders.

Results

158,230 patients were admitted with TC and of those, 2880 (1.8%) had concomitant AID. Systemic lupus erythematosus (n=1515, 54.1%) was the most common AID followed by Sjogren's syndrome (n=645, 23.02%) Systemic sclerosis (n=440, 14%) and Rheumatoid Arthritis (n=200, 7.1%) in TC population. Compared to TC patients without AID, AID+ patients were relatively younger (mean age of 63 vs 67 years, p<0.0001) and more likely to be females (95% vs 83%, p<0.0001*). 200 (7.1%) and 9459 (6.08%) TC patients with and without AID died during hospitalisation,respectively. TC patients with AID had lower odds of developing acute decompensated heart failure [ADHF] (aOR=0.69 95% CI: 0.56–0.85, p=0.001*) and acute stroke (aOR=0.60, 95% CI: 0.43–0.85, p=0.005*) There was no statistical significance in mortality, rates of acute respiratory failure, cardiogenic shock and healthcare utilisation (Table 2).

Conclusion

Our study notes a substantially higher number of TC patients with pre-existing AID than previously reported in the literature. In addition, these patients have lower odds of developing acute stroke and ADHF, while there was no significant difference for cardiogenic shock and mortality. Further studies are required to decipher the potential link between AID and TC and explore the possible role of immunosuppressants in TC therapy, as suggested in prior studies.

*P-value <0.05 was considered statistically significant. aOR = Adjusted Odds Ratio. †AID included in the study are mentioned in Table 1.

Funding Acknowledgement

Type of funding sources: None.

Estimation of Fluoride concentration in drinking water of Kathmandu Valley

Fluoride has a preventive effect on dental caries. However, excessive/insufficient ingestion of fluoride can lead to the development of dental fluorosis/increased risk for dental caries respectively. The objective of this study was to estimate fluoride concentration in drinking water of Kathmandu valley. It was a community based cross-sectional study in which drinking water samples were collected from municipal water supply and bottled water. Municipal water supply was collected according to eight water schemes in Kathmandu valley and as for bottled water, 35 samples were randomly collected according to different brand names available in the commercial market. The samples were analyzed for fluoride content by SPADNS colorimetric method as per standard procedure set by American Public Health Association (APHA 2012).The results revealed that the fluoride content in drinking water samples was below the permissible limit (<0.5 ppm) as per Nepal’s drinking water quality standards and WHO guidelines. Hence, implementation of water fluoridation program can be initiated for municipal water supply and bottled water for prevention of dental caries to optimize the oral health of people.

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.

4225Effectiveness of a behavioural incentive scheme linked to goal achievement in overweight children: a multicenter cluster randomized controlled trial

Background

The prevalence of childhood overweight and obesity is becoming an increasing concern worldwide and management is vital for primary prevention of cardiovascular disease. Studies in adults have shown that provision of incentives may facilitate behaviour change but there are no similar studies targeting weight management in children.

Purpose

To determine effectiveness of a structured goal setting incentive scheme, delivered within a community program, on health outcomes (with a focus on cardiovascular risk factors) in overweight children at 6 and 18 months.

Methods

Single-blind, multicenter, cluster randomized controlled trial with 10 weeks, 6 and 18 month follow-up. Eligible sites had to be delivering the standard children's weight management program and enrol at least 10 children per term. Eligible children had to be 7–13 years and have a body mass index (BMI) >85th percentile. Recruited sites were randomized to (i) standard weight management program plus incentive scheme (intervention) or (ii) standard program alone (control). The intervention group participated in the standard program plus received milestone based incentives for achievement of goals. Incentives were practical, and healthy in nature such as fun vegetable slicers, sports store vouchers, sport equipment and family zoo passes. Primary outcome was mean BMIz score at 18 months. Secondary outcomes included anthropometric (body weight, waist circumference), behavioural (physical activity, nutrition) and self-esteem (Physical Activity Enjoyment Scale, Rosenberg Self Esteem Scale) measures.

Results

A total of 37 sites (33 urban and 4 regional) and 512 children were recruited. There were no significant differences between the control and intervention groups at any follow-up time-points. There were significantly more participants in the intervention than control group who completed 10 sessions of the weight management program (23% v 13%, p=0.015). Compared to baseline, at 18 month follow-up, the total cohort achieved significant reductions in the mean BMIz score (1.7 v 1.0, p<0.001), median screen time (16.5 v 15.8 hours/week p=0.0414), median number of fast food meals per week (1.0 v 0.7, p<0.001) and significant increases in physical activity (6.0 v 10.0 hours/week, p<0.001) and self-esteem score (20.7 v 22.0, p<0.002).

Conclusions

The incentive scheme, delivered in addition to a standard community weight management program, did not have a significant impact on health outcomes in overweight children. However, the intervention increased program attendance and overall cohort achieved sustained improvements in clinical and lifestyle outcomes. The results of this study suggest that extrinsic rewards may not provide added value to current community weight management programs however, participation in such programs is likely to support primary prevention of cardiovascular disease.

Acknowledgement/Funding

This work was supported by National Heart Foundation (Australia) pilot funding as part of JR's Future Leader Fellowship, in-kind contributions from th

Round Block Technique in Management of Breast Lesions

The basic tenets of oncoplastic surgery essentially includes volume displacement and volume replacement. The round block technique, so-called donut mastopexy or Benelli mastopexy, is frequently used as a volume displacement technique in breast conserving surgery for benign multicentric fibroadenomas and early breast cancers. Such techniques are still underused in Nepal. In this article we present on four cases managed with original round block technique and followed prospectively with their outcome.

Extended Spectrum β-lactamase (ESBL) Producing Multi Drug Resistant (MDR) Urinary Pathogens in a Children Hospital from Nepal

Background Multidrug resistant in clinical bacterial isolates has increasingly been reported through out the world and is associated with high morbidity, mortality and increased health care costs. It is important to determine the status of multidrug resistance pattern to understand the current resistance trend so that appropriate antibiotics can be used in practice. Objective To determine the antibiotic resistant profile and prevalence of extended spectrum β-lactamase producing multidrug resistant strains in pediatric patients of Kanti Children's Hospital, Kathmandu, Nepal. Method Urine sample was cultured by standard microbiological techniques and bacterial isolates were identified using different biochemical tests. Antibiotic susceptibility testing was performed by Kirby Bauer disc diffusion method and extended spectrum β-lactamase detection was carried out using combined disc method as recommended by Clinical Laboratory Standard Institute guidelines. Result All together 65 different bacteria were isolated and subsequently identified. E. coli was the most common isolate with 46 (71%) isolates 63% of these isolates were multidrug resistant. Gram negative isolates were most resistant to nalidixic acid (81.97%) followed by ampicillin (69.35%) and co-trimoxazole (69.35%). The extended spectrum β-lactamase producing isolates were 43% among total isolates. Conclusion Higher rate of Extended Spectrum β-lactamase production among multidrug resistant isolates suggested routine extended spectrum β-lactamase testing in clinical isolates.

Self-Perception of Halitosis among Undergraduate Students of Kathmandu University School of Medical Sciences - A Questionnaire Based Study

Background Halitosis is a frequently reported oral health problem worldwide with a prevalence rate of 10-30% in the general population. It is defined as the disagreeable or foul smelling breath originating consistently from a person's oral cavity. It not only effects the normal daily life activities of the patient but also bring humiliation, reduced self- esteem, ultimately resulting into decreased quality of life. Objective To determine the self-perception of halitosis among undergraduate students of different medical branches of Kathmandu University School of Medical Sciences (KUSMS); Kavre, Nepal. Method A descriptive cross-sectional epidemiological survey was conducted among undergraduate students of Physiotherapy, B.Sc Nursing, Bachelor of Nursing Sciences (BNS), MBBS and BDS program of Kathmandu University School of Medical Sciences, Dhulikhel. A self-administered questionnaire was developed and were distributed among 500 undergraduate students. Result Out of total 500 distributed questionnaires, 406 were completely filled and returned giving an overall response of 81.2%, in which 70 (89.7%) male and 280 (85.4%) female students from different medical branches were aware of the term halitosis. Among them 29 (7.14%) of students think that they suffer from halitosis. Similarly 178 (43.84%) students had severe impact of halitosis on their social life while 153 (37.68%) and 62 (15.27%) students had moderate and mild impact respectively. Conclusion Due to the multifactorial complexity of halitosis, further longitudinal studies including objective assessment of malodor are required to determine its prevalence and to further investigate the association of this problem with other etiological factors in the context of Nepal. Also, curriculum of different fields should be modified to include this simple but very necessary topic.

Effectiveness of a once per week delivery of a family-based childhood obesity intervention: a cluster randomised controlled trial

BACKGROUND

The effectiveness of once per week (OPW) delivery of a family-based childhood obesity programme was compared with twice per week (TPW) delivery in achieving health and behavioural outcomes at a population level and in improving programme attendance. Both programmes were delivered over 10-weeks, and the contact hours in the OPW and TPW programmes were 20 and 35-h, respectively.

METHODS

A cluster-randomised controlled trial with stratification by local health district was conducted. Height, weight and global self esteem of participants and parent-reported diet and physical activity were measured at programme commencement and completion and at 6-month follow-up. Attendance was defined as the proportion of total sessions attended.

RESULTS

There were no differences between the OPW and TPW arms in changes from pre-programme baseline for body mass index (BMI) z-score and other health and behaviourial measures at programme completion and at follow-up, except for the increase in physical activity outside of the programme at programme completion (OPW, 3.5 h/week; TPW, 1.9 h/week; p = 0.03). OPW and TPW participants attended 71.2% and 69.2% of the total sessions, respectively. Attendance was the only contributing factor to a positive BMI z-score outcome (β = -2.45, p < 0.01) with no effects of child age and gender, language spoken at home or highest qualification of mother.

CONCLUSIONS

A family-based childhood obesity programme can be delivered OPW with no compromise to health or behavioural outcomes compared with TPW. Higher attendance, as a proportion of available sessions, leads to better outcomes for children.

Yield of intensified tuberculosis case-finding activities using Xpert(®) MTB/RIF among risk groups in Nepal

SETTING

Twenty-two districts of Nepal, where intensified case-finding (ICF) activities for tuberculosis (TB) were implemented among risk groups under the TB REACH initiative in collaboration with the National TB Programme from July 2013 to November 2015.

OBJECTIVES

To assess the yield of TB screening using an algorithm with smear microscopy followed by Xpert(®) MTB/RIF.

DESIGN

A descriptive study using routinely collected data.

RESULTS

Of 145 679 individuals screened, 28 574 (19.6%) had presumptive TB; 1239 (4.3%) of these were diagnosed with TB and 1195 (96%) were initiated on anti-tuberculosis treatment. The yield of screening was highest among people living with the human immunodeficiency virus (PLHIV) (6.1%), followed by household contacts (3.5%) and urban slum dwellers (0.5%). Among other risk groups, such as prisoners, factory workers, refugees and individuals with diabetes, the yield was less than 0.5%. The number needed to screen to diagnose an active TB case was 17 for PLHIV, 29 for household contacts and 197 for urban slum dwellers. Of 11 525 patients from ICF and the routine programme, 112 (1%) were diagnosed with multidrug-resistant TB.

CONCLUSION

There was a substantial yield of TB cases among risk groups such as PLHIV and household contacts. Although the yield in urban slum dwellers was found to be moderate, some intervention should nonetheless be targeted because of the large population and poor access to care in this group.

Impact of a compulsory final year medical student curriculum on junior doctor prescribing

BACKGROUND

Attendance at face-to-face sessions and completion of online components of the National Prescribing Curriculum was made compulsory for final year medical students at the University of Adelaide in 2010.

AIMS

To determine the impact of a compulsory prescribing curriculum for final year medical students on their prescribing competencies at the start of clinical practice. Graduates' attitudes to their medical school training in prescribing were also surveyed.

METHODS

Two cohorts of medical graduates from the University of Adelaide who commenced medical practice in 2010 and 2011 were required to complete a prescribing task using the National Inpatient Medication Chart (NIMC) at orientation and after 6 months of clinical practice. The main outcome measure was a performance in a scenario-based prescribing test, as determined by test scores and overall safety of prescriptions at orientation and 6 months of clinical practice.

RESULTS

There was a small difference in the average total score for the prescribing task between the 2010 and 2011 cohorts at orientation (P = 0.0007). The 2011 cohort had a higher number of safer charts at commencement of practice. We found no difference between the 2010 and 2011 cohorts in attitudes towards their undergraduate pharmacology education, and new graduates feel poorly prepared.

CONCLUSION

Medical graduates who are required to complete a practically oriented prescribing curriculum in final year perform slightly better on a prescribing assessment at commencement of practice. More work on preparing graduates for this complex task before graduation is needed.

Ecosystem Services and Stakeholder Analysis in Bishajari Lake and Associated Wetland Areas, Chitwan, Nepal

Wetlands as other ecosystems deliver goods and services of enormous value to the human society and are regarded as one of the most productive ecosystems. We assessed the ecosystem services delivered by Bishajari Lake and its associated wetland areas of Chitwan district during June to August, 2012. A household survey consisting 110 households, interviews with key informants, group discussions and stakeholder analysis were carried out for this purpose to document the overall status of ecosystem services, evaluate the provisional services generated by the lakes, understand potentials for payment to ecosystem services, and identify stakeholders involved and their roles and responsibilities. A total of 12 fish species, 17 wild and domestic fruits, 12 timber species, 15 fodder species, 20 wild vegetables species and 31 medicinal plant species were recorded. Moreover 65.5% of respondents were found receiving some sort of income from the wetland area. The majority of respondents felt that the ecosystem is being changed mostly on provisional services. So far with little support from government, the local people have practiced some adaptive responses like biogas plant, afforestation, electric fencing, contract fisheries, ecotourism and other climate-smart measures. It suggest that raising awareness and sharing information among the locals should be done more frequently and effectively to continuously cope with ecosystem change. DOI: http://dx.doi.org/10.3126/ijasbt.v2i4.11552  Int J Appl Sci Biotechnol, Vol. 2(4): 563-569 

Dental caries status and oral health practice among 12-15 year old children in Jorpati, Kathmandu

Oral health is an essential component of health throughout life. There has been a decline in dental caries and periodontal disease in developed countries which can be attributed to the implementation of preventive programmes but in developing countries dental diseases are still on the rise. Therefore this cross sectional study was carried out to assess the prevalence of dental caries and oral hygiene practices among 12 to 15 years old children. Self administered close ended questionnaires were used to assess the oral hygiene practice. The overall dental caries prevalence was 58.3% and the mean DMFT score was 1.2 (± 1.79) and the deft score was 0.6 (± 1.24). Majority of the children (84.1%) presented with the practice of brushing their teeth once everyday using tooth brush and toothpaste. Regular dental check up was very poor (5.6%) but 77.4% reported that they visited a dentist in case of pain or presence of stains in the teeth. Females (63.4%) and children studying in higher secondary class (74.2%) showed a "good" level of oral hygiene practice than males and children in secondary class respectively. Children having "good" practice presented with "low" dental caries severity. The utilization of dental services was poor in the children, therefore highlighting the necessity to implement preventive programmes is important which would help in reducing the incidence of the dental caries as well as aiding in prompt treatment of dental caries at its initial stages.

Using Landsat data for assessing forest cover change and fragmentation in Laljhadi corridor of Kanchanpur district, Nepal

The study, carried out at Laljhadi corridor in Kanchanpur district of Nepal, aimed at assessing forest cover change and fragmentation using multi-temporal Landsat data. Post classifi cation change detection was applied on temporal forest cover class datasets obtained by supervised classifi cation technique with maximum likelihood algorithm. The overall change analysis indicated a decreasing trend in forest cover. Statistics on selected landscape metrics were generated to quantify the change in spatial structure resulting from fragmentation. The analysis of the landscape metrics depicted increase in fragmentation over the analysis time period along with progression of deforestation.DOI: http://dx.doi.org/10.3126/banko.v21i2.9142Banko Janakari Vol. 21, No. 2, 2011 Page: 40-44 Uploaded date: November 11, 2013 

Recurrence of uveal malignant melanoma: a case report

BACKGROUND

Malignant melanoma of uveal tract is a rare ocular malignancy. It is one of the significant causes of ocular morbidity and mortality which is less commonly seen in children.

CASE

We report an unusual case of orbital recurrence of malignant melanoma in a 14-year old boy who had previously undergone enucleation of the left painful blind eye 8 months ago. He was diagnosed to have uveal malignant melanoma elsewhere which was confirmed by histopathology. Orbital recurrence was managed with modified exenteration with adjuvant chemotherapy and radiotherapy.

CONCLUSION

In all treated cases of uveal melanoma, close follow up examination and monitoring is necessary for early diagnosis of the recurrence and to plan for further management.

Results of the Bhaktapur Glaucoma Study, Nepal

Introduction: The Bhaktapur Glaucoma Study is a population-based, cross-sectional and longitudinal study undertaken in one of the districts of Nepal. Objectives: To determine the prevalence of glaucoma in Bhaktapur district, Nepal. Materials and methods: Thirty clusters were randomly selected and a door-to-door census was conducted to identify citizens 40 years of age and older. Four thousand eight hundred individuals fulfilling the eligibility criteria were referred to the base hospital in Kathmandu for a detailed clinical examination. The diagnosis of glaucoma was based upon criteria described by the International Society for Geographic and Epidemiological Ophthalmology (ISGEO). Results: Complete data was available on 3991 subjects (response rate 83.15 %). The mean IOP was 13.3 mm Hg (97.5th and 99.5th percentiles, 18 and 20 mm Hg, respectively) and mean VCDR 0.26 (97.5th and 99.5th percentiles, 0.6 and 0.8 mm Hg, respectively). Seventy-five subjects had glaucoma, an age-sex-standardized prevalence of 1.80 (95 % confidence interval (CI), 1.68 - 1.92). The age-and sex-standardized prevalence of POAG was 1.24 % (CI, 1.14 - 1.34), PACG 0.39 % (CI, 0.34 - 0.45) and secondary glaucoma 0.15 % (CI, 0.07-0.36). The prevalence of glaucoma increased with increase in age and there was no significant difference in gender. Nine eyes were blind and two subjects bilaterally blind from glaucoma. Conclusion: The overall prevalence of glaucoma was 1.9 %. POAG was the most common form of glaucoma. Visual morbidity from PACG, however, was higher. A large majority of the subjects with POAG had not been previously diagnosed and had intraocular pressure within the normal range. Nepal J Ophthalmol 2013; 5(9):81-93 DOI: http://dx.doi.org/10.3126/nepjoph.v5i1.7832

Developing community-based intervention strategies and package to save newborns in Nepal

In Nepal, the proportion of under 5 deaths that are neonatal (0-28 days) has been increasing in the last decade, due to faster declines in infant and child mortality than in neonatal mortality. This trend is likely due to a focus on maternal and child survival programs that did not adequately address newborn health needs. Policy and actions to save newborn lives resulted from increased attention to newborn deaths in 2001, culminating in the endorsement of the National Neonatal Health Strategy in 2004, a milestone that established newborn health and survival as a national priority. Operationalization of the National Neonatal Health Strategy took place in 2007 with the development of the Community-Based Newborn Care Package (CB-NCP). This paper describes how national stakeholders used global, regional and in-country research and policies to develop the CB-NCP, thus outlining key ingredients to make newborn health programming a reality in Nepal. A technical working group was constituted to review existing evidence on interventions to improve newborn survival, develop a tool to prioritize neonatal interventions, and conduct program learning visits to identify key components appropriate to the Nepal context that should be included in the Community Based Integrated Newborn Care Package. The group identified interventions based on the evidence of impact on newborn survival, potential mechanisms within the existing health system to deliver the interventions, and linkages with existing programs and different tiers of the health system. Not only was Nepal one of the first countries in south-east Asia where government adopted a national strategy to reduce neonatal deaths, but it was also one of the first to endorse a package of neonatal interventions for pilot testing and scaling up through existing community-based health systems that provide basic health services throughout the country. CB-NCP was designed to be gradually scaled up throughout the country by integration with Safe Motherhood and Child survival programs that are currently operating at scale. Under Ministry of health and Population leadership, a network of academia, professional bodies and partners developed a common vision for improving newborn health and survival, and launched district-level pilot programs to demonstrate and learn how newborn health interventions could be effectively and efficiently delivered and scaled up in Nepal.

Fitting Community Based Newborn Care Package into the health systems of Nepal

Community-based strategies for delivering effective newborn interventions are an essential step to avert newborn death, in settings where the health facilities are unable to effectively deliver the interventions and reach their population. Effective implementation of community-based interventions as a large scale program and within the existing health system depends on the appropriate design and planning, monitoring and support systems. This article provides an overview of implementation design of Community-Based Newborn Care Package (CB-NCP) program, its setup within the health system, and early results of the implementation from one of the pilot districts. The evaluation of CB-NCP in one of the pilot districts shows significant improvement in antenatal, intrapartum and post natal care. The implementation design of the CB-NCP has six different health system management functions: i) district planning and orientation, ii) training/human resource development, iii) monitoring and evaluation, iv) logistics and supply chain management, v) communication strategy, and vi) pay for performance. The CB-NCP program embraced the existing system of monitoring with some additional components for the pilot phase to test implementation feasibility, and aligns with existing safe motherhood and child health programs. Though CB-NCP interventions are proven independently in different local and global contexts, they are piloted in 10 districts as a "package" within the national health system settings of Nepal.

Verbal autopsy to ascertain causes of neonatal deaths in a community setting: A study from Morang, Nepal

Introduction: Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal. Methods: Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus. Results: The proximate causes of deaths were infections (41 %), birth asphyxia (37.2 %), prematurity (11.5 %), and low birth weight related causes (6.9 %). There was no signifi cant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5 %) than institutional deliveries (34.6 %). More than half of the deaths (58.5 %) occurred within the fi rst three days of life where the predominant cause of death was birth asphyxia (60.7 %). Conclusions: Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the fi rst week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups. Keywords: neonatal deaths, Nepal, newborn, verbal autopsy.

Tear physiology in dry eye associated with chronic GVHD

The purpose of this study was to compare tear physiology characteristics of chronic GVHD (cGVHD)-associated dry eye to dry eye caused by Sjogren's syndrome (SS), a extreme form of aqueous-deficient dry eye, and meibomian gland dysfunction (MGD), the major cause of evaporative dry eye. Tear turnover rate, evaporation and osmolarity along with meibomian gland dropout and lipid layer interferometric patterns were assessed in the right eyes of 12 patients with dry eye associated with cGVHD, 12 age-matched patients with SS and 12 age-sex matched subjects with MGD. In cGVHD, the decrease in tear turnover rate was similar (P=0.33), but the number of non-functioning meibomian glands was significantly higher (P<0.01) than in SS. Tear evaporation rate in cGVHD dry eye was found to be similar to that in MGD (P=0.36) and significantly higher than in SS (P<0.01). The lipid layer was most unstable in cGVHD compared with other groups. There was no variation in tear volume across all groups. Although statistical significance was not detected, the mean tear osmolarity (333.51±14.67mOsm/L) was highest in cGVHD. Major aspects of tear physiology were severely impaired in cGVHD-associated dry eye.

Note: Scalable multiphoton coincidence-counting electronics

We present a multichannel coincidence-counting module for use in quantum optics experiments. The circuit takes up to four transistor-transistor logic pulse inputs and counts either twofold, threefold, or fourfold coincidences, within a user-selected coincidence-time window as short as 12 ns. The module can accurately count eight sets of multichannel coincidences, for input rates of up to 84 MHz. Due to their low cost and small size, multiple modules can easily be combined to count arbitrary M-order coincidences among N inputs.

Verbal autopsy to ascertain causes of neonatal deaths in a community setting: a study from Morang, Nepal

INTRODUCTION

Clinical registration of the cause of death is available for less than one-third of the global newborn deaths, but the need for good quality data on causes of death for public health planning has renewed the interest in the Verbal Autopsy (VA). We aimed to determine the cause of neonatal deaths by VA in Morang district of Nepal.

METHODS

Caretakers of the deceased were interviewed using a semi-structured VA questionnaire by female community health volunteers. The cause of death was assigned by two senior pediatricians independently and disagreements in ascertaining the proximate cause of death were resolved by consensus.

RESULTS

The proximate causes of deaths were infections (41%), birth asphyxia (37.2%), prematurity (11.5%), and low birth weight related causes (6.9%). There was no significant statistical difference in deaths due to infection seen in non-institutional deliveries (43.5%) than institutional deliveries (34.6%). More than half of the deaths (58.5%) occurred within the first three days of life where the predominant cause of death was birth asphyxia (60.7%).

CONCLUSIONS

Analysis of verbal autopsies demonstrates that the major causes of death still are infections and birth asphyxia. The timing of deaths suggests that neonatal interventions should be aimed at the first week of life. There is no comparative advantage between institutional deliveries at below district level institutions and non-institutional deliveries to prevent neonatal infection. Thus, further study on the quality of care at institutes below the district level should be conducted. Disparities still occur in deaths, with most deaths in Morang occurring in non-institutional deliveries and in disadvantaged groups.

Pharmacovigilance: urgent need in midwestern region of Nepal

DOI: 10.3126/kumj.v7i4.2776 Kathmandu University Medical Journal (2009) Vol.7, No.4 Issue 28, 470

A comparative study of outcome of preterm neonate with and without history of preterm premature rupture of membrane

The aim of the study was to find out the neonatal outcome of infants born with history of preterm premature rupture of membrane (PPROM) and to compare with infants born without history of PPROM. It was a retrospective study that included 187 preterm newborn with history of PPROM admitted in neonatal intensive care unit of the third affiliated hospital of Zhengzhou University from January 2008 to December 2008. Another 150 preterm newborns from same department during same period were taken as control. Patient demographics, patient's problem, investigation, management and outcome were recorded from medical record department and compared. Chi square and t test were used for statistical analysis. There was no statistical difference of gestational age, mode of delivery, birth weight and gender between case and control group. Respiratory system related problems like birth asphyxia, respiratory distress syndrome, apnea and pneumonia were common in both group but not statistical significant (p>0.05). However, need of oxygen supply and mechanical ventilation was significantly more (p<0.05) in case group. Neonatal death was more in case group (5.3%) than in control group (0.7%) and was statistically significant (p<0.001). The morbidity of preterm neonate does not entirely depend on history of PPROM than prematurity itself. However severity of disease and death is more with history of PPROM.

Retinal vasculitis

Retinal vasculitis is an idiopathic inflammatory venous occlusion primarily affecting the peripheral retina of otherwise healthy young adults. Eales' disease is recognized as primary vasculitis of unknown etiology occurring in young adults. This article aims at the overall review of the etiopathogenesis, clinical presentations, pathology, management and prognosis of retinal vasculitis.

Relationship between blood group and epistaxis among Nepalese

The relationship between blood group and epistaxis among the patients coming to Tribhuvan University Teaching Hospital, Kathmandu with idiopathic epistaxis was studied. A total of 235 patients coming to the Emergency Department or Department of Otorhinolaryngology with active nose bleeding in were included. ABO blood group was performed. Nearly half (45.5%) of the patients belonged to O-group followed by A-group others. O-group people were also had longer bleeding time compared to other blood groups.

Hyperthermia with magnetic nanowires for inactivating living cells

We describe a method to induce hyperthermia in cells, in-vitro, by remotely heating Ni nanowires (NWs) with radio frequency (RF) electromagnetic fields. Ni NWs were internalized by human embryonic kidney cells (HEK-293). Only cells proximal to NWs or with internalized NWs changed shape on exposure to RF fields indicative of cell death. The cell death occurs as a result of hyperthermia, since the RF field remotely heats the NWs as a result of magnetic hysteresis. This is the first demonstration of hyperthermia induced by NWs; since the NWs have anisotropic and strong magnetic moments, our experiments suggest the possibility of performing hyperthermia at lower field strengths in order to minimize damage to untargeted cells in applications such as the treatment of cancer.

Eliciting knee jerk--a new method of reinforcement

This study was designed to detect the sensitivity of different methods of eliciting knee jerks and to compare the conventional methods with the newly purposed maneuver. Knee jerk (a deep tendon reflex) was elicited in 123 apparently normal population (77 males and 46 females) with three different methods (1) without applying reinforcement, (2) applying Jendrassik maneuver (strong voluntary contraction of upper limbs) and (3) using the new method of reinforcement--that is by dorsiflexion of ankle joint of the same foot voluntarily as strong as possible on which the jerk would be elicitated. The sensitivity of the method without reinforcement was found to be is 87.8%; that with Jendrassik maneuver was 93.5%, whereas the sensitivity of newly proposed maneuver was 99.2%. Results of the present study have served to demonstrate that elicitation of knee jerk with newly proposed reinforcement maneuver is the best among all three methods.

Five-star Doctors for the 21st Century

The term ‘five-star doctor’ has been promoted to denote the model physician for today's society, who should be able to respond to the needs of both individual patients and their community. The B.P. Koirala Institute of Health Sciences (BPKIHS) has adopted integrated, partially problem-based, organ system and community-oriented curriculum for medical graduates. The various field programmes related to community diagnosis, health care delivery system, family health exercise, epidemiology for health management, managerial skills for health services, and learning in fields are incorporated in the MBBS curriculum. Five-month postings during internships in zonal and district hospitals and one month in district public health offices and primary health centres are unique programmes to make it more socially accountable. Such exposure for MBBS students makes them to attain five-star status, that is, caregiver, decision maker, communicator, community leader and manager. Thus, BPKIHS is working as a pioneer in an endeavour to create five-star doctors for the 21st century.

Provisional versus routine coronary stenting. A review

Coronary stenting is the most commonly used coronary revascularization procedure due to the ease of use, safety and evidence that it has predictably better results in several coronary lesion subsets than balloon angioplasty alone. As opposed to routinely stenting all the stentable coronary lesions, in the provisional stenting approach, all the lesions would first be optimally angioplastied and a stent used only in the patients who would not have as good an outcome with balloon angioplasty alone. There are several theoretical advantages to this approach. The two different approaches are compared in this review. Retrospective studies and studies using immediate vessel recoil after optimal balloon angioplasty seemed to suggest that stent-like results after balloon angioplasty had similar target revascularization rates as stenting. However, a prospective randomized study primarily using angiography to guide provisional stenting suggests better outcome in the routine stenting strategy. If provisional stenting were to have similar long-term results as routine stenting, it has to be guided by techniques other than coronary angiography like coronary flow reserve or intravascular ultrasound. Even then, over half of the balloon angioplasty group will need stenting. Besides, based on prospective randomized studies, this strategy is not economically more attractive than the routine stenting strategy. Therefore routine stenting strategy is justifiable for most operators who use coronary angiography to guide their interventions. With further advancement in the stent technology like drug coating routine stenting may be even further attractive.

Large atherosclerotic left main coronary aneurysm--a case report and review of the literature

Coronary artery aneurysm (CAA) is a rare disorder, characterized by an abnormal dilatation of a localized portion of the coronary artery. It is usually diagnosed incidentally by coronary angiography. Over 50% of coronary artery aneurysms are of atherosclerotic origin. The natural history of coronary aneurysms is not well understood. Their presence is not always considered to be an operative indication; rather, the severity of the associated coronary artery disease (CAD) is what dictates a surgical approach. In the absence of obstructive CAD, the definitive treatment for this condition is unclear. The authors present the case of an isolated saccular left main coronary aneurysm with no associated flow-limiting CAD. The patient was treated medically with antiplatelet and anticoagulant medication with no adverse events at 3, 6, 9, and 12 months of follow-up.

Immediate and long-term results comparing coronary versus biliary tubular-slotted stents to treat old obstructed saphenous vein grafts

Stenting of old obstructed saphenous vein grafts improves immediate angiographic results and long-term clinical outcome compared to standard balloon angioplasty. Comparison of results and long-term clinical outcome between different types of stents in the treatment of vein graft disease is scarce. The authors studied two matched groups of 33 patients each, receiving either coronary or biliary tubular-slotted stents in old vein graft lesions to compare immediate results and long-term clinical outcome. Patients in the two groups were matched for age and left ventricular function. Baseline angiographic characteristics, the minimal luminal diameter (MLD) (0.68 +/- 0.56 mm vs 0.61 +/- 0.51 mm, p = 0.9), and diameter stenosis (DS) (81 +/- 14% vs 82 +/- 15%) were similar between the groups. After stenting, the MLD (3.15 +/- 0.65 mm vs 3.37 +/- 0.63 mm, p = 0.9) and residual stenosis (-7 +/- 19% vs -11 +/- 21%) were also similar. The in-hospital major complications (myocardial infarction and death) (one vs eight, p = 0.01) and the combination of major and minor (bleeding and vascular) complications (eight vs 17, p = 0.02) were higher in the biliary stent group. At long-term follow-up, both groups of patients had high but comparable rates of major cardiovascular events (39% vs 45%, p = 0.62). Kaplan-Meier event-free survival analysis did not show any statistically significant difference in event-free survival (log-rank statistic 0.98). The authors conclude that patients receiving biliary stents had higher rates of immediate minor and major complications, but at long-term follow up, major cardiovascular event rates were comparable between the two groups of patients.

Right coronary artery occlusion as a complication of accessory pathway ablation in a 12-year-old treated with stenting

We describe a complication of radiofrequency ablation of a posteroseptal pathway that resulted in acute occlusion of a distal right coronary artery in a pediatric patient. The complication was treated with coronary stenting after unsuccessful angioplasty.

Effect of gender and left ventricular dysfunction on the incidence of hypotension induced by dobutamine stress echocardiography

BACKGROUND

Of patients who undergo dobutamine stress echocardiography (DSE), 14% to 38% experience hypotension that sometimes requires termination of the test before an adequate cardiac work-load is reached. The mechanisms of hypotension reportedly are related to peripheral vasodilation, a decrease in cardiac output, and left ventricular (LV) cavity obliteration. DSE is performed increasingly in women and in patients with LV dysfunction. However, the impact of gender and LV dysfunction on DSE-induced hypotension has not been elucidated.

METHODS AND RESULTS

Clinical, hemodynamic, and echocardiographic characteristics were studied in 412 patients undergoing DSE, 82 patients with an LV ejection fraction of 40% or less, and 147 women. Hypotension, defined as a decrease in systolic blood pressure of at least 20 mm Hg, occurred in 117 (28%) patients. Hypotension was more common in women than men (36% vs 24%, P = .01). Hypotension was also more common in older adults (P = .004), persons taking diuretics (P = .025) or angiotensin-converting enzyme inhibitors (P = .01), and persons with higher baseline blood pressures (P < .0001). Hypotension was not related to the use of beta blockers, calcium channel blockers, digoxin, nitrates, LV dimensions, or ejection fraction.

CONCLUSIONS

The incidence of DSE-induced hypotension is related to gender but not to the level of LV systolic function. It also is associated significantly with higher age, and use of angiotensin-converting enzyme inhibitors or diuretics.

Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function

We investigated 568 consecutive patients undergoing dobutamine stress echocardiography to elucidate the mechanism of left ventricular (LV) obliteration. Baseline clinical and echocardiographic variables were related to dobutamine-induced LV cavity obliteration defined as approximation of LV endocardium associated with an intracavitary flow acceleration of at least 2 m/s in the absence of a distal residual cavity. The LV cavity obliteration was observed in 89 (16%) of the 568 patients and was more frequent in women and those with smaller LV dimensions, increased LV wall thickness, and higher resting ejection fractions. Despite similar peak stress levels, the cavity obliterators were less likely to have chest pain and detectable stress-induced wall motion abnormalities. We conclude that LV cavity obliteration during dobutamine stress is common and is associated with female sex, smaller LV size, presence of LV hypertrophy, and higher LV ejection fraction. Despite similar stress levels, chest pain and reversible wall motion abnormalities are observed less frequently in patients with cavity obliteration, raising the possibility of lower prevalence of coronary artery disease or masking of ischemia in this patient population.

Effect of dobutamine stress on left ventricular systolic and diastolic functions in patients with moderate to severe left ventricular dysfunction

Dobutamine stress echocardiography (DSE) is increasingly used in patients with moderate and severe left ventricular (LV) dysfunction. However, its effect on central and peripheral hemodynamics and LV function in this patient population is not known. This study investigates the effect of dobutamine stress on LV systolic and diastolic performance and peripheral hemodynamics in 177 consecutive patients undergoing DSE. Sixty-five patients with an LV ejection fraction (EF) of < or =40% were compared with 112 patients with an EF of >40%. Compared with those with EF > 40%, patients with EF < or =40% had a faster heart rate(76 +/- 13 vs 70 +/- 13 bpm, p < 0.001), lower systolic blood pressure (127 +/- 18 vs 133 +/- 20 mm Hg, p < 0.05), lower stroke volume (60 +/- 20 vs 74 +/- 36, p = 0.01), longer LV isovolumic relaxation time (118 +/- 37 vs 108 +/- 25 msec, p < 0.05) and larger LV end-diastolic (57 +/- 9.6 vs 49 +/- 7 mm, p < 0.0001) and end-systolic (46 +/- 10 vs 32 +/- 7.9 mm, p < 0.0001) diameters. They also had a lesser increment in cardiac output (1.5 +/- 1.6 vs 3.2 +/- 4.8 L/min, p = 0.02), a smaller reduction of systolic LV size (-5.3 +/- 4.1 vs -7.0 +/- 4.3 mm, p < 0.05) and a lower propensity to LV cavity obliteration with dobutamine infusion. In conclusion, patients with an EF < or =40% have lower baseline stroke volume, systolic blood pressure, higher heart rate, and longer LV isovolumic relaxation time. They also have a smaller increase in cardiac output, a smaller reduction of LV size, and a lower propensity to LV cavity obliteration with dobutamine stress.

Change assessment of forest cover in Ghodaghodi lake area in Kailali district of Nepal

Ghodaghodi Lake in Far-West Nepal has been listed as a Ramsar Site due to its significance as a habitat for several endangered species of flora and fauna. The wetland and its surrounding area is facing deforestation, forest degradation and encroachment. In this case study, unsupervised and finally supervised classification of multi-temporal Landsat imagery covering the wetland area was applied. A post-classification comparison approach was used to derive forest cover change maps. The results depicted the loss of forest cover over a thirty- one year period, in three time slices. The highest rate of loss was observed in the 1990 to1999 time slice. Keywords: Change detection; forest cover; Ghodaghodi lake; Landsat DOI: 10.3126/banko.v19i2.2980 Banko Janakari, Vol. 19, No.2 2009 pp.15-19