Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Endoscopic Management of Foreign Body Impaction in the Upper Gastrointestinal Tract in a Tertiary Care Centre of Nepal

Background Ingested foreign body impaction on upper gastrointestinal tract is common incidence among children, older age group, mentally challenged individuals, and people the influence of alcohol. In most cases, the foreign bodies pass spontaneously and uneventfully but when this does not occur; endoscopic management to ensure removal under direct visualization is required. Relief upon removal of foreign body and prevention of complications is essential. Objective To assess the endoscopic management and outcome of foreign body impacted in the upper gastrointestinal tract. Method This is a hospital based observational retrospective cross sectional study involving 165 patients at Endoscopy Department of Dhulikhel Hospital in Nepal between November 2015 and October 2019. The data regarding the demographic profile, clinical characteristics and endoscopic findings were retrieved and analyzed to determine endoscopic interventions performed, complications and outcomes. Result One hundred and sixty five patients presenting with history of ingestion of foreign body were included in the study. The mean age of the patients was 46.8 ± 19.1 years with male predominance (60%). The most common site of foreign body impaction was oesophagus (70%). The most common foreign body encountered was bone (62.2%) among which chicken bones (91.1%) were most frequent. For the retrieval of sharp-pointed foreign bodies, rat forceps and graspers (45.7%) were most commonly used. Total 14 cases required rigid oesophagoscopy as the foreign body could not be retrieved by flexible endoscopy. Conclusion Foreign body ingestion and its impaction in the upper gastrointestinal tract has been found to be common in endoscopic practise. Early detection and timely removal of foreign bodies is of utmost importance to avoid discomfort to the patient as well as to ensure successful removal without complications.

Recovery Pattern in Different Surgical Approaches on Thoracic Enhanced Recovery based Fourteen-Step Protocol in Patients Undergoing Cardio-thoracic Surgery at University Hospital of Nepal

Background Cardio-thoracic surgery involves open and minimally invasive techniques. Enhanced recovery after surgery is used for early recovery from surgery. Enhanced recovery after surgery decreases hospital stay duration. Patients undergoing Enhanced recovery after surgery after video assisted thoracic surgery use less pain killers and have less hospital cost. There has not been any study on outcomes on patient who follow physiotherapy protocol designed in our setting. Objective To find the physiotherapy outcomes in patients undergoing thoracic enhanced recovery after surgery (T-ERAS) based 14 step protocol locally designed at Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH). Method This is a retrospective cross sectional observational study. All the cases who underwent cardiothoracic surgery were classified based on the approach of chest surgery performed into groups Sternotomy, Thoracotomy and Video Assisted Thoracic Surgery (VATS) groups. Patients were advised for Thoracic Enhanced recovery after surgery based on the protocol that has been devised at Dhulikhel Hospital. The recovery of patients based on activities they could perform was noted and analyzed. Result Both ICU stay and hospital stay in number of days were highest in thoracotomy (6.04 days) group while that was lowest in video assisted thoracic surgery group (1.67 days). There is a similar recovery until step 5, i.e. 2 days and rapid progression in further steps in video assisted thoracic surgery group while it is much slower in both sternotomy and thoracotomy groups. Conclusion Postoperative mobilization and physiotherapy enhance early healing and decrease hospital stay. Mean hospital stay and ICU stay were shorter for video assisted thoracic surgery cases compared to Thoracotomy and Sternotomy groups and the mean days to achieve different steps varied within the protocol between groups compared.

Lipid metabolic differences in cows producing small or large milk fat globules: Fatty acid origin and degree of saturation

This study compared cows that consistently produce milk with small (volume-weighted mean diameter of 2.92-3.83 µm, with an average diameter of 3.29 µm) or large (volume-weighted mean diameter of 4.58-5.67 µm, with an average diameter of 4.92 µm) milk fat globule (MFG) size distributions in terms of the fatty acid (FA) composition of the MFG core. Selected cows fell into the respective size group over at least 3 independent measurements, including an observation period before the experiment. Further selection criteria were similar milk production traits between cows (milk yield, fat yield, fat/protein ratio) and established lactation (>50 d in milk). However, the selected groups differed in parity (parity 1-3 and 3-5 in the small and large MFG groups, respectively), and the small MFG group was an average of 25 d in milk later in their lactation period. All cows were under the same nutritional management and environmental conditions. Here, we show that cows with the small or large MFG phenotype differed in their lipid metabolism in terms of the FA composition of the MFG core. Our results indicate that cows with the small MFG phenotype produced milk with higher concentrations of unsaturated FA despite being fed the same diet. We suggest that this characteristic of the small MFG phenotype is the result of increased uptake of long-chain FA from the blood circulation. A relationship between the degree of unsaturation and MFG size was also identified in preliminary studies across other species-namely, camels, sheep, and goats. These findings show the potential for on-farm selection of cows (and potentially other dairy species) based on MFG size to produce milk with improved nutrient composition. This could lead to purpose-specific separation of milk based on MFG size and FA profile, both known to alter the technological properties of milk.

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal

BACKGROUND

Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP).

METHOD

Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment.

RESULTS

Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, β = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, β = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82).

CONCLUSION

Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone.

Study Of Depression in Elderly: Prevalence and Factors Associated

Introduction: Ageing is a normal phenomenon. Various studies shows that there is a sharp rise in the elderly population in the last few years. Prevalence of depression in elderly is found to around 13% in the community sample in various countries. There is a dearth of study related to psychiatric illness in elderly in Nepal. This study was aimed to find the prevalence of depression in elderly and see for various factors associated with elderly depression. Material And Method: This was a cross-sectional study conducted at Siddharthnagar Municipality, Bhairahawa, Rupandehi. 316 elderly were selected by using systematic random sampling technique. A Semi- structured interview schedule was developed to collect Socio-demographic data. The Short Form Geriatric Depression Scale (SF-GDS) was used to find out the prevalence of depression among elderly people. Ethical Approval was obtained from the Institutional Review Committee, Chitwan Medical College and permission was obtained from Siddharthnagar Municipality, Bhairahawa, Rupandehi. The collected data was entered in Epidata 3.1 and the data was exported and analyzed in IBM SPSS 20. Results: There were a total of 316 samples in this study. The mean age of respondents was 68.47 years of age. Majority of the respondents (54.1%) were female and living in joint Family (72.2%). Almost 45.9% respondents were from upper caste groups, 90.5% of respondents were Hindus. Among the married (100%) respondents, 54.6% of respondents were living with spouse and 3.2% were divorced and separated from spouse. Depression was present in 49.4% of respondents were depressed. Among depressed respondents, 46.7% of respondents were having mild depression, 39.2% moderate depression and 14.1% severe depression. Conclusion: The finding of this study concluded that depression among elderly people was a substantial problem in Siddharthnagar Municipality, Bhairahawa, Rupandehi.

Deep Brain Stimulation in Parkinsons Disease in Nepal

Background Parkinsons disease is a central nervous system degenerative disorder affecting motor system and characterized by progressive tremor, rigidity, gait abnormalities. Surgical treatment of Parkinsons disease is based on the changes in the basal gangliothalamocortical circuits which is altered in Parkinsons disease. Currently pallidotomy and Deep Brain Stimulation are available modes of surgical treatment of Parkinsons disease. Objective To know efficacy of deep brain stimulation in Parkinsons Disease in Nepal. Method All patients of idiopathic Parkinsons disease who underwent Deep Brain Stimulation in Annapurna Neurological Institute and Allied sciences since 2014 were included. The standard functional coordinates for Subthalamic nucleus and Globus pallidus internus was used. We used Zamarano-Dujovny (ZD) Fisher Frame with its software. Patients' Unified Parkinsons disease rating score, Modified Hoehn and Yahr Staging and Schwab and England Activities of daily living Scale were evaluated preoperativelyv as well as postoperatively. Result Ten patients underwent Deep Brain Stimulation. The male is to female ratio was 2:1. The mean age was 55.4±8.9 years and duration of illness was 5.5±2 years. There was a significant improvement in the scores for the main motor manifestations of the disease between the preoperative off-dopa and postoperative off-dopa/on-stim conditions. There was a significant improvement in Schwab and England Activities of daily living scale scores in the off-dopa condition between the preoperative score and the postoperative M6 score. Conclusion Our result of Deep Brain Stimulation is quite promising. However, it is very expensive and requires frequent follow-up for neuromodulation.

Pattern and Prevalence of Refractive Error and Secondary Visual Impairment in Patients Attending a Tertiary Hospital in Dhulikhel, Nepal

Background Uncorrected refractive error is one of the most important causes of visual impairment worldwide. Objective To ascertain the pattern and prevalence of refractive error and secondary visual impairment in subjects attending Ophthalmology department. Method A prospective hospital-based study was designed where presenting visual acuity, age of presentation, refractive status, best corrected visual acuity and status of visual impairment were assessed in participants, ages ranging from 3-39 years presenting to the Ophthalmology department of Dhulikhel Hospital, Kathmandu University Hospital. History of use of spectacle was noted and participants were categorized into different visual impairment categories as per their presenting visual acuity. Result Out of a total of 4500 total clients examined during the study period, 388 (8.62%) had refractive error where 219 (56.44%) were females and 169 (43.56%) were males. Mean age at presentation was 22.70±7.69 years (range, 3-39 years). Astigmatism was the most common subtype seen in 373 eyes (48.06%), followed by myopia (366 eyes, 47.16%) and hypermetropia (31 eyes, 4.0%). Only 40.50% subjects who required refractive correction were using spectacle. 62.37% (242 clients) had some of visual impairment during their presentation. There was statistically significant improvement in visual acuity after refractive correction (p=0.00). Conclusion Uncorrected refractive error is one of the most important causes of visual impairment. Lack of awareness, infrequent ocular examination and lack of community or preschool vision screening were the main causes for the late presentation and significant visual impairment associated with the condition. Social stigma, economical limitation and negative counseling and attitudes about spectacle wear were primary factors behind the unsatisfactory spectacle use.

Febrile illness in Asia: gaps in epidemiology, diagnosis and management for informing health policy

BACKGROUND

Increasing evidence is becoming available on the aetiology and management of fevers in Asia; the importance of these fevers has increased with the decline in the incidence of malaria.

AIMS

To conduct a narrative review of the epidemiology and management of fevers in South and South-East Asia and to highlight gaps in our knowledge that impair evidence-based health policy decisions.

SOURCES

A narrative review of papers published since 2012 on developments in fever epidemiology, diagnosis and treatment in South and South-East Asia. The papers that the authors felt were pivotal, from their personal perspectives, are discussed.

CONTENT

We identified 100 studies. Among the 30 studies (30%)-including both children and adults-that investigated three or more pathogens, the most frequently reported fever aetiology was dengue (reported by 15, 50%), followed by leptospirosis (eight, 27%), scrub typhus (seven, 23%) and Salmonella serovar Typhi (six, 20%). Among four studies investigating three or more pathogens in children, dengue and Staphylococcus aureus were the most frequent, followed by non-typhoidal Salmonella spp, Streptococcus pneumoniae, Salmonella serovar Typhi, and Orientia tsutsugamushi. Increased awareness is needed that rickettsial pathogens are common but do not respond to cephalosporins, and that alternative therapies, such as tetracyclines, are required.

IMPLICATIONS

Many key gaps remain, and consensus guidelines for study design are needed to aid comparative understanding of the epidemiology of fevers. More investment in developing accurate and affordable diagnostic tests for rural Asia and independent evaluation of those already on the market are needed. Treatment algorithms, including simple biomarker assays, appropriate for empirical therapy of fevers in different areas of rural Asia should be a major aim of fever research. Enhanced antimicrobial resistance (AMR) surveillance and openly accessible databases of geography-specific AMR data would inform policy on empirical and specific therapy. More investment in innovative strategies facilitating infectious disease surveillance in remote rural communities would be an important component of poverty reduction and improving public health.

Perceptions and Attitudes towards Evidence Based Practice among Nurses and Nursing Students in Nepal

Background As the evidence based practice (EBP) movement expands, there is a need for health leaders and educators in each country to assess the extent to which health professional students and practitioners are prepared to locate, evaluate, and apply evidence to guide their practice. Objective The study objective was to explore nurses' and nursing students' perceptions and attitudes towards EBP. Method This was a descriptive cross-sectional survey administered to all 273 nurses and nursing students from Nepal who attended an EBP conference. The survey instrument that was used by Majid in Singapore was adapted for use in this study with permission from the author. Result In total, 121 nurses participated in the study. The majority (93%) of respondents reported that they had no previous training in EBP. The respondents' perceptions of their EBP knowledge and skills were variable, but most of them demonstrated positive attitudes toward EBP. Respondents identified a number of barriers that limit the implementation of EBP in Nepal. The greatest barriers were lack of time and resources, difficulty understanding research articles and translating the findings to practice, and limited autonomy to change practice based on evidence. Conclusion Although respondents had positive attitudes towards EBP, their knowledge and skills were limited and barriers to implementation existed. Nursing faculty can use the findings to guide implementation of EBP into curricula, and nursing administrators and clinicians can use the findings to guide practice to promote EBP.

Knowledge of Pressure Ulcer Management among Nurses

Background: Pressure ulcer (PU) development remains a significant complication among at-risk patients. It is considered “never events” because they are preventable and should “never” happen. It has been associated with increased morbidity, mortality, hospital cost and length of stay in the hospital. Prevention of pressure ulcers is considered a nurse-sensitive indicator hence nurses should have adequate knowledge about current evidence-based prevention and management of pressure ulcer. However, non adherence to these guidelines is frequent and lack of knowledge may act as barriers to using guidelines in clinical practice.Objectives: The objectives of the study were to 1. assess the knowledge of pressure ulcer management among nurses 2. determine the level of knowledge of pressure ulcer management among nurses 3. assess the association of knowledge of nurses and baseline variables.Methods: A descriptive cross sectional study was conducted, using pretested self administered questionnaire to assess the knowledge on pressure ulcer management among purposively selected 100 nurses working in Gandaki Medical College Teaching Hospital in 2015. Descriptive statistics as frequency and percentage were used and inferential statistics (Chi-square test) was done to find out association between knowledge and selected baseline variables.Results: The study revealed that 59% of the respondents had adequate knowledge where as 41% of nurse’s knowledge was found to be inadequate. Significant association was not found between age, working ward, experience, education, training, duration and knowledge of pressure ulcer management among Nurses.Conclusion: This result indicates that more than half of the nurses had the adequate knowledge but there is still need of education and training related pressure ulcer management.Journal of Gandaki Medical CollegeVolume, 09, Number 2, July December  2016, Page: 47-51

Effect of Lung Transplantation on Health-Related Quality of Life in the Era of the Lung Allocation Score: A U.S. Prospective Cohort Study

Under the U.S. Lung Allocation Score (LAS) system, older and sicker patients are prioritized for lung transplantation (LT). The impact of these changes on health-related quality of life (HRQL) after transplant has not been determined. In a single-center prospective cohort study from 2010 to 2016, we assessed HRQL before and repeatedly after LT for up to 3 years using the SF12-Physical and Mental Health, the respiratory-specific Airway Questionnaire 20-Revised, and the Euroqol 5D/Visual Analog Scale utility measures by multivariate linear mixed models jointly modeled with death. We also tested changes in LT-Valued Life Activities disability, BMI, allograft function, and 6-min walk test exercise capacity as predictors of HRQL change. Among 211 initial participants (92% of those eligible), LT improved HRQL by all 5 measures (p < 0.05) and all but SF12-Mental Health improved by threefold or greater than the minimally clinically important difference. Compared to younger participants, those aged ≥65 improved less in SF12-Physical and Mental Health (p < 0.01). Improvements in disability accounted for much of the HRQL improvement. In the LAS era, LT affords meaningful and durable HRQL improvements, mediated by amelioration of disability. Identifying factors limiting HRQL improvement in selected subgroups, especially those aged ≥65, are needed to maximize the net benefits of LT.