Supraclavicular Brachial Plexus Block: Comparison of Varying Doses of Dexmedetomidine with Ropivacaine

Background Alpha-2 adrenergic receptor agonists have been the focus of interest nowadays as an adjuvant to local anesthesia due to its excellent sedative, analgesic, antihypertensive, anesthetic sparing and hemodynamic stabilizing properties. The ideal dose of dexmedetomidine for brachial plexus block is matter of debate. Objective To find the appropriate minimal dose of dexmedetomidine with desired clinical effects and minimal side-effects, we compared different doses (25 mcg, 50 mcg, 75 mcg and 100 mcg) of dexmedetomidine as an adjuvant to ropivacaine. Method One hundred fifty patients of ASA I and II, aged (18-60) years, weighing (50-60) kilograms undergoing upper limb surgeries under brachial plexus block were enrolled in this prospective, double blind, randomized control study. Patients in all group received 19 ml of 0.5% ropivacaine in common. In addition; group RD25, RD50, RD75 and RD100 received 25 mcg, 50 mcg, 75 mcg and 100 mcg of dexmedetomidine diluted in 1 ml of normal saline (NS) respectively whereas group RD00 received only 1 ml of NS. The duration of analgesia was the primary outcome whereas block characteristics, hemodynamic parameters, oxygen saturation, sedation score and adverse effects were taken as secondary outcome. Statistical analysis was done using ANOVA test, Chi-square test and Scheffe's multiple comparison tests. Result The demographic profile and baseline hemodynamic variables were comparable in all five groups. Increasing dose of dexmedetomidine showed significant improvement in block characteristics but associated with increase in sedation and incidence of bradycardia. Conclusion We conclude that dexmedetomidine 50 mcg would be an appropriate dose as adjuvant to local anesthesia in brachial plexus block.

Factors associated with low back pain among construction workers in Nepal: A cross-sectional study

BACKGROUND

Low back pain (LBP) is the commonest cause of disability throughout the world. This study aimed to determine the prevalence and factors associated with LBP among the construction workers in Nepal.

METHODS

A community-based cross-sectional study was conducted among the construction workers working in Banepa and Panauti municipalities of Kavre district, from September 2019 to February 2020. Data was collected purposively by face-to-face interview from 402 eligible participants from the both municipalities using semi-structured questionnaire. Mobile-based data collection was done using KoboCollect. Data were exported to and analysed using R-programming software (R-3.6.2). Univariate and multivariate logistic regressions were performed. All tests were two tailed and performed at 95% confidence interval (CI).

RESULT

One-year prevalence of LBP among construction workers were 52.0% (95%CI: 47.0-57.0). The higher odds of LBP was reported among females [adjusted odds ratio (aOR) = 2.42; 95%CI: 1.12-5.23], those living below poverty-line (aOR = 2.35; 95%CI: 1.32-4.19), participants with more than five years of work experience (aOR = 1.66; 95%CI: 1.01-2.73) and those with intermediate sleep quality (aOR = 2.06; CI: 1.03-4.11). About 80.0% of construction workers with LBP never seek healthcare services due to: a) time constraints (90.9%), b) financial constraints (18.1%) and c) fear of losing wages on seeking healthcare services (40.9%). The majority of the participants (94.8% among those without LBP and 72.3% among those with LBP) did nothing to prevent or manage LBP.

CONCLUSION

The prevalence of LBP in the past one year was high among construction workers where majority of workers never did anything to prevent or manage LBP. Therefore, the public health professionals should set up the health promotion, education, and interventions aimed at increasing awareness on preventive techniques and predisposing factors of LBP.

Novel transdisciplinary methodology for cross-sectional analysis of snakebite epidemiology at national scale

BACKGROUND

Worldwide, it is estimated that snakes bite 4.5-5.4 million people annually, 2.7 million of which are envenomed, and 81,000-138,000 die. The World Health Organization reported these estimates and recognized the scarcity of large-scale, community-based, epidemiological data. In this context, we developed the "Snake-Byte" project that aims at (i) quantifying and mapping the impact of snakebite on human and animal health, and on livelihoods, (ii) developing predictive models for medical, ecological and economic indicators, and (iii) analyzing geographic accessibility to healthcare. This paper exclusively describes the methodology we developed to collect large-scale primary data on snakebite in humans and animals in two hyper-endemic countries, Cameroon and Nepal.

METHODOLOGY/PRINCIPAL FINDINGS

We compared available methods on snakebite epidemiology and on multi-cluster survey development. Then, in line with those findings, we developed an original study methodology based on a multi-cluster random survey, enhanced by geospatial, One Health, and health economics components. Using a minimum hypothesized snakebite national incidence of 100/100,000/year and optimizing design effect, confidence level, and non-response margin, we calculated a sample of 61,000 people per country. This represented 11,700 households in Cameroon and 13,800 in Nepal. The random selection with probability proportional to size generated 250 clusters from all Cameroonian regions and all Nepalese Terai districts. Our household selection methodology combined spatial randomization and selection via high-resolution satellite images. After ethical approval in Switerland (CCER), Nepal (BPKIHS), and Cameroon (CNERSH), and informed written consent, our e-questionnaires included geolocated baseline demographic and socio-economic characteristics, snakebite clinical features and outcomes, healthcare expenditure, animal ownership, animal outcomes, snake identification, and service accessibility.

CONCLUSIONS/SIGNIFICANCE

This novel transdisciplinary survey methodology was subsequently used to collect countrywide snakebite envenoming data in Nepal and Cameroon. District-level incidence data should help health authorities to channel antivenom and healthcare allocation. This methodology, or parts thereof, could be easily adapted to other countries and to other Neglected Tropical Diseases.

Participation of Community in Prevention and Control of Dengue Fever in Dharan Sub Metropolitan City of Province No 1, Nepal

Background: Dengue fever is known as a break-bone fever and its common symptoms are headaches, high grade fever, muscular, bone pains and decrease of platelets count. Community participation involving local government and household participants in controlling breeding areas of dengue mosquitoes is the only cost-effective and sustainable activities of ensuring prevention and control of Dengue fever. This study aimed to assess the perception of the general population regarding community participation in the prevention of dengue and to verify its effectiveness with the control practices observed at the homes in Dharan sub-metropolitan city of Province No 1. Material and Methods: A cross-sectional study was conducted among 250 households at the Dharan sub-metropolitan city of Province no. 1 in Nepal from August to October 2019. The technique of sample collection was done using purposive sampling and data were collected using a pretested close-ended questionnaire and observational checklists. Results: Slightly over half of the respondents 129 (51.6%) reported a positive attitude regarding community practice and almost three out of five 157 (62.8%) houses were observed to have good dengue control practices. The univariate results revealed attitude of households regarding community participation were significantly associated with the control practices observed in their homes (p<0.001). Conclusion: The study concludes that good community participation in collaboration with health volunteers and health institutions can have a positive impact on the dengue control practices at the household level. Hence, the spread of dengue out-break can be controlled by active collaborative community participation.  

Predictors of cardiac self-efficacy among patients diagnosed with coronary artery disease in tertiary hospitals in Nepal

Background: Cardiac self-efficacy determines how people feel, think, motivate themselves and behave with regards to improving their cardiac health subsequently preventing complications of coronary artery disease (CAD). Given almost one-third of global death is contributed by CAD with 10% of disability adjusted life years lost in low- and middle-income countries (including Nepal), it is important to identify factors that can promote cardiac self-efficacy. There are no studies in Nepal focusing on predictors of self-efficacy. Therefore, we aim to determine the predictors of cardiac self-efficacy of CAD patients in Nepal. Design and Methods: This is a cross-sectional study where we recruited 170 patients (≥30 years) diagnosed with CAD from two tertiary level hospitals. Multiple linear regression model was used to identify the predictors of cardiac self-efficacy. Results: The mean age of the participants was 60.45±10.39 years (range, 31-83). Most of the participants were diagnosed as myocardial infarction (91.2%), rest with unstable angina (6.5%) and stable angina (2.4%). The multivariate analysis shows age (p<0.001), health behaviors (p<0.001) and knowledge of the disease (p<0.001) were statistically significant predictors to cardiac self-efficacy. Every 1-year increase in age was associated with 0.23 units increase in cardiac self-efficacy score. Similarly, every unit increase in health behavior score and knowledge of disease score was associated with 0.432 units and 0.475 units increase in cardiac self-efficacy score respectively. Conclusion: Age and health behaviors were the strongest predictors of cardiac self-efficacy followed by knowledge of the disease. We conclude that those with poor health behavior are at a greater risk of poorer cardiac self-efficacy compared to those with relatively good level of self-efficacy. Public health interventions such as awareness raising about cardiac disease and health behavior modification along with early screening, diagnosis and appropriate care are essential to improving self-efficacy and cardiac care outcomes.

Spontaneous Pneumothorax: Follow up Treatment Outcome in a Tertiary Care Center of Eastern Nepal

Background Spontaneous pneumothorax is not an uncommon medical emergency in pulmonary practice. Related data are not available in our setting. In emergency departments, clinical presentation is often confused with other cardiopulmonary problems. Follow up outcome is important for better patient care. Objective To study clinical profile and outcome after non surgical intervention in a tertiary care center. Method This was a prospective observational study carried out in Nobel Medical College, Biratnagar over last 3 years. We enrolled consecutive spontaneous pneumothorax patients over 15 years of age. Each data related to individual patients were collected in predefined proforma. To study follow up outcome of management, we used OPD attendance or if not possible took, at least two telephone numbers from the patients. All patients were followed for recurrences. Data was statistically analyzed using SPSS software. Result Over the last 3 years, we enrolled 65 spontaneous pneumothorax patients. Secondary spontaneous pneumothorax was more common (92.3%). Commonest presentations were acute pleuritic chest pain (92.3%), dyspnea (84.62%) and cough (92.3%). COPD (46.14%), PTB sequelae (15.38%), bronchiectasis (23.07%) and bullous lung disease (23.07%) were common risk factors. Tube thoracostomy (95.38%) with pleurodesis with iodopovidone (84.61%) led to lung expansion in 92.3% cases. During follow up, only 4.61% had recurrences of pneumothorax. There was one mortality. Conclusion Spontaneous pneumothorax is a common pulmonary emergency. Meticulous and careful assessment of the patients may help reach the diagnosis even in primary care setting. Tube thoracostomy followed by pleurodesis with iodo-povidone suffices in most circumstances leading lower future recurrences.

The effect of intraoperative lidocaine infusion on opioid consumption and pain after totally extraperitoneal laparoscopic inguinal hernioplasty: a randomized controlled trial

BACKGROUND

As a component of multimodal analgesia, the administration of systemic lidocaine is a well-known technique. We aimed to evaluate the efficacy of lidocaine infusion on postoperative pain-related outcomes in patients undergoing totally extraperitoneal (TEP) laparoscopies inguinal hernioplasty.

METHODS

In this randomized controlled double-blind study, we recruited 64 patients to receive either lidocaine 2% (intravenous bolus 1.5 mg. kg ^- 1 followed by an infusion of 2 mg. kg^- 1. h^- 1), or an equal volume of normal saline. The infusion was initiated just before the induction of anesthesia and discontinued after tracheal extubation. The primary outcome of the study was postoperative morphine equivalent consumption up to 24 h after surgery. Secondary outcomes included postoperative pain scores, nausea/vomiting (PONV), sedation, quality of recovery (scores based on QoR-40 questionnaire), patient satisfaction, and the incidence of chronic pain.

RESULTS

The median (IQR) cumulative postoperative morphine equivalent consumption in the first 24 h was 0 (0-1) mg in the lidocaine group and 4 [1-8] mg in the saline group (p < 0.001). Postoperative pain intensity at rest and during movement at various time points in the first 24 h were significantly lower in the lidocaine group compared with the saline group (p < 0.05). Fewer patients reported PONV in the lidocaine group than in the saline group (p < 0.05). Median QoR scores at 24 h after surgery were significantly better in the lidocaine group (194 (194-196) than saline group 184 (183-186) (p < 0.001). Patients receiving lidocaine were more satisfied with postoperative analgesia than those receiving saline (p = 0.02). No difference was detected in terms of postoperative sedation and chronic pain after surgery.

CONCLUSIONS

Intraoperative lidocaine infusion for laparoscopic TEP inguinal hernioplasty reduces opioid consumption, pain intensity, PONV and improves the quality of recovery and patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov- NCT02601651. Date of registration: November 10, 2015.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Equity and Coverage in the Continuum of Reproductive, Maternal, Newborn and Child Health Services in Nepal-Projecting the Estimates on Death Averted Using the LiST Tool

Introduction

The third Sustainable Development Goal, focused on health, includes two targets related to the reduction in maternal, newborn and under-five childhood mortality. We found it imperative to examine the equity and coverage of reproductive, maternal, newborn and child health (RMNCH) interventions from 2001 to 2016 in Nepal; and the death aversion that will take place during the SDG period.

Methods

We used the datasets from the Nepal Demographic Health Surveys (NDHS) 2001, 2006, 2011 and 2016. We calculated the coverage and equity for RMNCH interventions and the composite coverage index (CCI). Based on the Annualized Rate of Change (ARC) in the coverage for selected RMNCH indicators, we projected the trend for the RMNCH interventions by 2030. We used the Lives Saved Tools (LiST) tool to estimate the maternal, newborn, under-five childhood deaths and stillbirths averted. We categorised the interventions into four different patterns based on coverage and inequity gap.

Results

Between 2001 and 2016, a significant improvement is seen in the overall RMNCH intervention coverage-CCI increasing from 46 to 75%. The ARC was highest for skilled attendance at birth (11.7%) followed by care seeking for pneumonia (8.2%) between the same period. In 2016, the highest inequity existed for utilization of the skilled birth attendance services (51%), followed by antenatal care (18%). The inequity gap for basic immunization services reduced significantly from 27.4% in 2001 to 5% in 2016. If the current ARC continues, then an additional 3783 maternal deaths, 36,443 neonatal deaths, 66,883 under-five childhood deaths and 24,024 stillbirths is expected to be averted by the year 2030.

Conclusion

Nepal has experienced an improvement in the coverage and equity in RMNCH interventions. Reducing inequities will improve coverage for skilled birth attendants and antenatal care. The current annual rate of change in RMNCH coverage will further reduce the maternal, neonatal, under-five childhood deaths and stillbirths.

Electronic supplementary material

The online version of this article (10.1007/s10995-019-02828-y) contains supplementary material, which is available to authorized users.

The Association of Childhood Pneumonia with Household Air Pollution in Nepal: Evidence from Nepal Demographic Health Surveys

INTRODUCTION

Childhood pneumonia is a major cause of mortality worldwide while household air pollution (HAP) is a major contributor to childhood pneumonia in low and middle-income countries. This paper presents the prevalence trend of childhood pneumonia in Nepal and assesses its association with household air pollution.

METHODS

The study analysed data from the 2006, 2011 and 2016 Nepal Demographic Health Surveys (NDHS). It calculated the prevalence of childhood pneumonia and the factors that cause household air pollution. The association of childhood pneumonia and HAP was assessed using univariate and multi-variate analysis. The population attributable fraction (PAF) of indoor pollution for causing pneumonia was calculated using 2016 NDHS data to assess the burden of pneumonia attributable to HAP factors.

RESULTS

The prevalence of childhood pneumonia decreased in Nepal between 2006 and 2016 and was higher among households using polluting cooking fuels. There was a higher risk of childhood pneumonia among children who lived in households with no separate kitchens in 2011 [Adjusted risk ratio (ARR) 1.40, 95% CI 1.01-1.97] and in 2016 (ARR 1.93, 95% CI 1.14-3.28). In 2016, the risk of children contracting pneumonia in households using polluting fuels was double (ARR 1.98, 95% CI 1.01-3.92) that of children from households using clean fuels. Based on the 2016 data, the PAF for pneumonia was calculated as 30.9% for not having a separate kitchen room and 39.8% for using polluting cooking fuel.

DISCUSSION FOR PRACTICE

Although the occurrence of childhood pneumonia in Nepal has decreased, the level of its association with HAP remained high.

Multi-drug Resistant and Extended Spectrum β-lactamase Producing Salmonella Species Isolated from Fresh Chicken Liver Samples

Background Emergence of antibiotic resistance among microbes contaminating the fresh meat products is a global public health concern as they can be easily transmitted to humans through their consumption and contact. Objective The current study was conducted to determine the distribution of antimicrobial resistance among Salmonella species isolated from fresh chicken liver samples with special emphasis on extended spectrum beta-lactamase (ESBL) production. Method A total of 200 fresh chicken liver samples were cultivated for the isolation of Salmonella and further subcultivated to detect extended spectrum beta-lactamase production among them. Antimicrobial susceptibility testing (AST) was done by disk diffusion method using a panel of 7 antimicrobials. Result Out of 200 samples analyzed, 61 (30.5%) samples harbored Salmonella species out of which 15 (7.5%) samples showed the presence of Salmonella Typhi. A significant association was noted in the incidence of Salmonella with various factors pertaining to the butchers, such as age, sex, literacy rate, practices of washing knives and chopping board, wearing aprons and gloves and type of water used (p < 0.05). Salmonella isolates were highly sensitive to amikacin (82.0%) and least sensitive to tetracycline (3.3%). All the isolates were resistant to colistin. Sixty (98.4%) isolates were identified as multi-drug resistant (MDR). The total number of extended spectrum betalactamase producers reported among Salmonella isolates was 29 (47.5%). Conclusion The results indicate that the fresh chicken liver samples sold in Bharatpur Metropolis are reservoirs of multi-drug resistant Salmonella, including extended spectrum betalactamase producers, that could potentially be transmitted to the humans by direct contact or through inadequate cooking.

2131Pragmatic clinical trials in cardiovascular medicine: trends over time in major medical journals

Background

Pragmatic trials provide results that may be more applicable to the population in which the intervention will be eventually applied and are discussed extensively in the current healthcare environment. The aim of this study was to investigate how pragmatic or explanatory cardiovascular (CV) randomized controlled trials (RCT) are, if this was changing over time, and if they were more or less likely to meet their primary endpoint.

Methods

Using the six top-ranked (based on impact factors) medical and CV journals, all CV-related RCTs that were published during the years of 2000, 2005, 2010 and 2015 were identified, data extracted and reviewed by 2 adjudicators. The PRECIS-2 tool was used to evaluate the level of pragmatism. PRECIS-2 uses a 5-point ordinal scale (ranging from very pragmatic to very explanatory) across 9 domains of trial design, including eligibility, recruitment, setting, organization, intervention delivery, intervention adherence, follow-up, primary outcome, and analysis. A higher score indicates a more pragmatic score on an individual domain, and aggregated scores are a simplified formula across all domains. Cohen's D was used to quantify the mean difference relative to the variation.

Results

There were 616 RCTs, distributed evenly over the 2 decades, and 64% achieved their primary endpoint. The mean (±SD) PRECIS-2 score was 3.26±0.70 among 616 included RCTs. The level of pragmatism increased over time from a score of 3.07±0.74 in 2000 to 3.47±0.67 in 2015 (p<0.0001 for trend; Cohen's D relative effect size 0.57). The increase in pragmatism occurred mainly in the domains of eligibility, setting, intervention delivery, and primary endpoint (Figure). PRECIS-2 score was higher for neutral trials than those with positive results (p=0.0015) and in phase III/IV trials as compared to phase I/II trials (p<0.0001) (Figure). Furthermore, trials that involve more sites, with larger sample sizes, longer follow-ups, and those with mortality as the primary endpoint were found to be more pragmatic. There was no difference in the level of pragmatism between different sources of funding (public, industry, or both; p=0.52).

Study characteristics and pragmatism

Conclusion

The PRECIS-2 tool can be used for appraising trials to assess their placement in the pragmatic-explanatory continuum. The level of pragmatism increased over time in CV trials. Greater focus on the design and delivery of CV trials will be required for the broad application.

Acknowledgement/Funding

Dr. Sepehrvand receives scholarship from Alberta Innovates Health Solutions.

Clinical Profile and Survival Rate of Interstitial Lung Disease in a Tertiary Care Center of Eastern Nepal

Background The clinical profiles of interstitial lung diseases are reported mainly from developed world. There have been no data from Nepal. Objective The objective of this study is to describe clinical profile and survival in Eastern Nepal. Method Prospectively collected clinical, radiological and laboratory data of consecutive patients with Interstitial lung disease from an eastern regional tertiary care center were analyzed. The recommended official criteria for diagnosing different types of interstitial lung diseases were followed accordingly. Result The study revealed that, 68.0% of the patient's age was of above 60 years with male predominance (66.0%). Idiopathic pulmonary fibrosis (79.5%) was the commonest interstitial lung disease followed by connective tissue disease associated interstitial lung disease. Persistent cough (97.7%) and dyspnea (95.5%) were the commonest presentations. Renal impairment, ischemic Heart Disease and anasarca were significant co morbidities contributing to mortality. Survival rate of the patients was found to be maximum at 5 months (95%) and minimum at 24 months (42%) from the diagnosis of the disease. Conclusion Widespread use of High-resolution computed tomography has made early recognition of interstitial lung disease in elderly patients. Well planned large scale multicenter prospective studies are needed to broaden our understanding about this serious pulmonary disorder.

What motivates open defecation? A qualitative study from a rural setting in Nepal

INTRODUCTION

Open defecation is ongoing in Nepal despite the rise in efforts for increasing latrine coverage and its use. Understanding the reasons for open defecation would complement the ongoing efforts to achieve the 'open defecation free' status in Nepal. This study aimed at exploring different motivations of people who practice open defecation in a village in Nepal.

METHODS

This study was conducted among the people from the Hattimudha village in Morang district of eastern Nepal, who practiced open defecation. Maximum variation sampling method was used to recruit participants for 20 in-depth interviews and 2 focus group discussions. We adopted a content analysis approach to analyze the data.

RESULTS

We categorized different reasons for open defecation as motivation by choice and motivation by compulsion. Open defecation by choice as is expressed as a medium for socializing, a habit and an enjoyable outdoor activity that complies with spiritual and religious norms. Open defecation by compulsion include reasons such as not having a latrine at home or having an alternative use for the latrine structures. Despite having a private latrine at home or access to a public latrine, people were compelled to practice open defecation due to constraints of norms restricting latrine use and hygiene issues in general. For women the issues with privacy and issues refraining women to use the same latrine as men compelled women to look for open defecation places.

CONCLUSION

Open defecation is either a voluntary choice or a compulsion. This choice is closely linked with personal preferences, cultural and traditional norms with special concerns for privacy for women and girls in different communities. The ongoing campaigns to promote latrine construction and its use needs to carefully consider these factors in order to reduce the open defecation practices and increase the use of sanitary latrines.

Depression among people living with type 2 diabetes in an urbanizing community of Nepal

BACKGROUND

Diabetes mellitus is a major public health problem which accounts for serious medical and economic consequences. Depression is an important associated condition that upsets the management and complications of diabetes. This study aimed to measure the prevalence of depression among people living with Type 2 Diabetes and to examine the factors linked with it.

METHODS

This community based, cross-sectional study was conducted among 278 people living with type 2 diabetes in Duhabi-Bhaluwa municipality, Nepal. A face to face interview was conducted using a pre-tested semi-structured questionnaire to gain information on socio-demographic characteristics and clinical profile of the participants. Depression was assessed using the Beck Depression Inventory (BDI-II) scale. Variables were categorical and were thus, compared with Pearson's chi-square tests and binary logistic regression models.

RESULTS

The prevalence of depression in this study was 22.7%. Most people indicative of having depression were of older age, females, below secondary level education, with a smaller family size, with low family income, using insulin, without a family history of diabetes and/or having an additional illness. However, multivariate analysis showed that the only significant factors for depression were older age, education below secondary level, homemaker, smaller family size, using insulin and having an additional illness.

CONCLUSION

The prevalence of depression in this study is consistent with that reported by other communities. Factors like older age, lower education level, being a homemaker, living in a small size family, insulin use and additional illness could increase the likelihood of developing Major Depressive disorder among people with type 2 diabetes, hence, psychosocial assessment is necessary along with diabetes management plan in a primary health care setting.

Graded Epidural Anaesthesia for Lower Segment Cesarean in a Parturient with Very Low Ejection Fraction

Dilated cardiomyopathy is characterized by left or biventricular dilatation with impaired ventricular contractility. It is associated with systolic dysfunction with decreased left ventricular ejection fraction and congestive progressive heart failure. Anaesthetic management of such condition is very challenging and requires highest level of expertise, strategy and precaution. We present such a case of dilated cardiomyopathy with a very low ejection fraction of 12% who underwent lower segment cesarean section under epidural anaesthesia with successful outcome.

Development and standardization of tinnitus handicap inventory in Nepali

BACKGROUND

Tinnitus is a frequent but sparsely understood condition of human ear featuring unusual sensation of acoustic energy. A symptom specific inventory forassessment of tinnitus may aid in understanding the severity of the problem and its impact on individuals' life. Initially, English version of THI was the only existing assessment tool available in measuring the impact of tinnitus. Being a self-report inventory, it is vital that the individuals with tinnitus understand the language foradministering instrument. Therefore, the present study aimed at developing and validating self-administering Tinnitus Handicap Inventory (THI) in Nepali language.

METHODS

Standard method of translation-back-translation was utilized where English version of THI was translated and customized by four professors with degree in Nepalilanguage. Later it was administered on 20 native literate Nepali speakers whose first language was Nepali for content validity. Therefore it was administered on 120 patients and total scores under different subscales were measured.

RESULTS

Out of 120 individuals, 20% of them had severe, 20% had moderate, 26% of them had mild and 34% of them had slight tinnitus handicap scores. Nepali version of THI was found to have an alpha value of 0.92. Across three subscales (emotional,functional and catastrophic), Nepali version of THI got the alpha scores of 0.91, 0.91 and 0.80 and Item-total correlation of 0.26-0.74, 0.057-0.90 and 0.54-0.90 respectively.

CONCLUSIONS

Present study confirmed that the THI-Nepali version has good internal consistency and reliability as compare to the original English version and otherestablished versions. Therefore, THI-Nepali version can be used as a robust, easy to use, reliable and valid tool in self-assessment of tinnitus handicap in Nepali speaking individuals with tinnitus in clinical as well as research setting. However, test-retest reliability of the developed questionnaire is essential.

Work Related Injury among Welders Working in Metal Workshops of Dharan Municipality, Nepal

BACKGROUND

Injuries are a problem worldwide in all occupations. Welders are exposed to many hazards at work resulting in a variety of health problems including injuries at work. This study was conducted to find out the prevalence and factors associated with injuries among welders in Dharan city of eastern Nepal.

METHODS

A cross sectional study was conducted among 86 welders in Dharan city. Occurrence of injury in past 2 weeks and past 12 months were recorded. Data regarding sociodemographic along with occupational characteristics was collected using semi structured questionnaire. Data analysis was done using SPSS version 17.

RESULTS

All the welders in this study were male with almost half of the welders under the age of 25 years and about a fifth (21.1%) of the welders having received some form of welding training. In the past 12 months, 21.1% of the welders suffered from work related injuries. More than 95% welders used at least one personal protective equipment in this study. More injuries were seen among welders with age ?35 years, working experience ? 5 years, not received training and not using of PPE at work. However, these factors were not found to be statistically significant.

CONCLUSIONS

Work related injuries are high among welders of Dharan. Further research is required to explore the relationship between age, literacy, training and use of personal protective equipment with the occurrence of injuries among the welders.

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants

BACKGROUND

Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.

METHODS

We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.

RESULTS

In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.

CONCLUSIONS

Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

The Analgesic Effectiveness of Ipsilateral Transversus Abdominis Plane Block in Adult Patients Undergoing Appendectomy: A Prospective Randomized Controlled Trial

Transversus abdominis plane block (TAP) has been shown to produce effective pain relief following lower abdominal surgeries but is yet to be routinized in different type of surgeries including appendectomy. The main risk of visceral injury can be logically avoided when the block is performed with the abdomen open using landmark technique in the absence of ultrasound guidance. Objective To assess the effectiveness of TAP block with bupivacaine for postoperative analgesia using landmark technique (performed with the abdomen open) in adult patients undergoing appendectomy. Method Forty patients undergoing appendectomy were randomized to undergo ipsilateral TAP block with bupivacaine (n=20) versus control (n=20) in addition to standard postoperative analgesia. All patients received standard general anaesthesia. The block was performed using the landmark technique with 20 ml of 0.5% bupivacaine or isotonic saline on ipsilateral side just before abdominal closure. Pain severity was measured using Visual Analogue Scale (VAS). Tramadol 50 mg was administered as rescue analgesic intravenously when VAS was four or more postoperatively. The duration of analgesia and the requirement of tramadol in 24 hours postoperatively were recorded. Result Mean duration of analgesia in the TAP block with bupivacaine was longer as compared with placebo (724.00±299.07 min vs 168.25±55.18 min; p< 0.01). The TAP block with bupivacaine compared with saline significantly reduced postoperative VAS pain scores. Mean tramadol requirement in the first 24 hours was also reduced (42.50±37.25 mg vs 120.00±55.18 mg; p<0.01). There were no significant complications attributable to the TAP block. Conclusion Ipsilateral TAP block with bupivacaine using landmark technique with the abdomen open in appendectomy provides effective postoperative analgesia and opioids sparing effect.

Perception Regarding Swine Flu Among School Teacher in Inaruwa Municipality of Eastern Nepal

Introduction Swine flu is an acute respiratory viral disease, caused by a strain of the influenza type A virus known as H1N1. Currently swine flu is spreading rapidly in India with a regular threat of it being spread to Nepal owing to the open borders.ObjeciveThe objective  of this study was to assess the knowledge, attiude and practice on different aspects of Swine Flu.MethodologyThis is cross-sectional study conducted in Inaruwa municipality of Sunsari district from 1st March to 10th April, 2015. A total  of 31 schools (21 private and 10 public) were identified in the municipality out of which 16 were randomly chosen for the study.ResultsTotal sample size was 260 school teachers. Majority of the respondents belong to the age group 30-39 years, about 72 % were male and 86% thought that it is a preventable disease. It was observed that females had a better attitude towards preventive measures of swine flu as compared to the males (p<0.023), but males had beertter practices as compared to the females (p<0.001).ConclusionThe preventation on practice for swine flu was not adequate. Despite having acceptable knowledge and attitude positive practices needs to be encouraged. The teachers should be well informed about the earliest appearing symptoms of swine flu. So that they can closely monitor the students and can recommend the students for medical checkup on appearance of the symptoms. Birat Journal of Health SciencesVol.2/No.1/Issue 2/ Jan - April 2017, Page: 150-155