Paradigm shift towards emergency cholecystectomy: one site experience of the Chole-QuiC process

INTRODUCTION

Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

METHODS

This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

RESULTS

Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

CONCLUSION

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

Does gender influence retrograde intrarenal surgery (RIRS) outcomes? Data from the Flexible Ureteroscopy Outcomes Registry (FLEXOR)

INTRODUCTION AND OBJECTIVES

As well established flexible ureteroscopy (RIRS). There is still no evidence if gender can have any influence on the outcomes and complication when performing. This study aims to evaluate the role that gender has in performing flexible ureteroscopy from a large series of patients.

METHODS

This study retrospectively analyzed patients who underwent RIRS for renal stones from January 2018 to August 2021 within the multicentric FLEXOR registry. Demographics, stone characteristics, perioperative findings, results and complications were analyzed and compared between gender groups.

RESULTS

A total of 6669 patients were included, 66.1% were male and 33.9% were female. Stone characteristics was comparable between groups. Female patients had significant higher fever and positive urine culture rates (12% vs. 8% and 37% vs. 34%). Also, females had a slight longer hospital stay (3.8 vs. 3.5 days; P < 0.001) and more residual fragments after the procedure (23.03% vs. 20.97 (P = 0.032). Overall complications were slightly significantly higher in women (15.74% vs. 14% (P = 0.042)) mainly at the expense of fever rates (6.9% vs. 5.7%) whereas the risk of sepsis was similar in both groups. A multivariate analysis showed that larger stone size, multiple and lower pole stones seem to have a negative impact in the incidence of residual stones and complications.

CONCLUSION

Our real life global study reflects that female gender may have a correlation with a slightly increased residual fragment rate and overall low grade complications. However, women can safely be treated with RIRS with no increased the rate of sepsis with appropriate care.

Solyx Minisling Surgery for Stress Urinary Incontinence: Dhulikhel Hospital Initiative

Solyx mini-sling surgery is a single-incision procedure that is used to treat stress urinary incontinence (SUI) in women. SUI is a common medical condition characterized by the involuntary leakage of urine with activity such as laughing, coughing, and sneezing. It affects 35% of adult women worldwide. The Solyx sling is a minimally invasive procedure that can be performed through a single vaginal incision. It is a safe and effective treatment for SUI, with a high success rate. The mini-sling is inserted through a small, single incision in the vagina. This makes the procedure less invasive than traditional sling surgery, which requires a larger incision in the abdomen or groin. The Solyx mini sling is also adjustable, which means that the surgeon can make adjustments to the tension of the sling after it is inserted. This helps to ensure that the sling is properly positioned and that the patient experiences optimal results. We have performed Solyx minisling surgery in 182 women and we found it very effective. 96% of women had no leakage of urine while coughing, sneezing after one week of surgery. We have performed this surgery in rural areas of Nepal where there is no facility of cystoscopy.

Pyrexia in Pregnancy and its Maternal and Fetal Outcome

Background Contemporary obstetrics has witnessed improved maternal and fetal outcomes, owing to several advances. Any source of maternal hyperthermia that results in significant core temperature increase (> 38°C), could potentially affect the fetus. Fetus being an integral part of the feto-maternal unit and pregnancy involving numerous physiological changes and adaptations, pyrexia during the pregnancy affects both the mother and her fetus adversely. Objective To find the etiology and prevalence of fever in pregnancy and to know the effect of fever on maternal and fetal outcome. Method Pregnant ladies with fever > 38°C, presenting to Obstetrics and Gynecology, Department of Dhulikhel Hospital were enrolled in the study. A detailed clinical history, thorough general and physical examinations were done. All risk factors were asked and recorded including all baseline investigations and cases were followed up till delivery. Maternal and fetal outcomes were recorded. Data were recorded in Excel and calculated using SPSS 26. Result Eighty patients presented with complaints of fever were included in this study. The mean age of the patient was 25.49± 4.50 years. Out of 80 patients, 46 (57.50%) presented with fever in the third trimester. The most common etiology of fever being urinary tract infection in 21 (26%) cases followed by respiratory tract infection in 20 (25.1%) cases. Twenty two newborns had low birth weight among which 12 (15%) neonates had IUGR. About 14 (17.5%) neonates were admitted in NICU due to various complications and perinatal mortality was in 9 (11.25%) cases. The most common antepartum complication was preterm labor in 16 (20%) cases. Conclusion Fever in pregnancy is still a challenge to obstetrician and the society at large due its problems related to its prevention, diagnosis, management and its feto-maternal outcome. Hence, an evaluation of the effect and outcomes of fever in pregnancy, provides definite knowledge of clinical epidemiology, and facilitates optimum prioritization of efforts and resources.

Coronary Artery Disease in Nepal: Current Perspective, Challenges, Need for National Practice Guidelines, and Potential Solutions

South Asians are estimated to have a 40% increased risk for coronary artery disease as compared to populations from other regions. Nepal, as a South Asian country, should also analyze the burden of coronary artery disease and its risk factors to minimize cardiovascular morbidity and mortality. We reviewed the barriers to cardiovascular care and its services in low- and middle-income countries, including Nepal. The identified barriers included coronary artery disease risk factors, access, cost, adherence to cardiovascular care, awareness, knowledge gaps, and socioeconomic and health system challenges. The possible strategies to reduce coronary artery disease included national, regional, and local perspectives. It also highlighted the involvement of community workers and local leaders, education, patient-centered intervention, easy access to drugs and treatments, rehabilitation and public health measures, innovation within the health care system, and multi-sectoral involvement. This review provides insights into the current situation of coronary artery disease and its possible solutions.

An Anatomical Variation of Median Artery of Forearm and Palm: Cadaveric Study into its Origin and Course

Background The median artery (transitory artery) represents the forearm's embryonic arterial axis. At 8th week of gestation retreats into a little canal that supplies the median nerve. Later, ulnar and radial arteries take its place. Adults may still have it in either a palmar or an antebrachial pattern. The persistent median arteries are a long, angular arterial that extends to the hand's palmar surface. The median artery only partially recedes in the antebrachial type. Objective To identify the median artery distribution in the adult Nepalese population. Method Twenty-five adult human cadavers' left and right upper limbs undergone to descriptive research. The persistent median artery was exposed according to the Cunningham's Manual of Practical Anatomy. Result The forearm and hand arteries in each of the fifty upper limbs from the twentyfive formalin-embalmed human cadavers were studied. Among fifty upper limbs, persistent median arteries were found in six (twelve percent) of them. One percent of a cadaver's right and left limbs had bilateral persisting median arteries (ante brachial). Persistent median artery of the ante brachial type that arises from the anterior interosseous artery in a right upper limb. Persistent median artery emerging from the posterior interosseous arteries were visible in one right upper limb. Conclusion The study showed persistent median artery of ante brachial type. The posterior interosseus artery is the source of the majority of antebrachial type. A median artery piercing the median nerve was discovered.

Clinical Characteristics of Cataract Patients and Outcome of Cataract Surgery in Tertiary Care Hospital in Central Nepal

Background Cataract remains the leading cause of avoidable blindness in low-income countries such as Nepal. Despite the availability of surgical interventions for cataract in leading institutions, still a large number of patients from remote areas delay or have difficulty in getting treatment, present late or with complications. Objective To determine the clinical characteristics and visual outcome of patients undergoing cataract surgery in Tertiary Care Hospital in Central Nepal. Method We retrospectively reviewed the medical records of 138 patients who underwent cataract surgery at a tertiary care hospital from January 2018 to September 2022. R version 4.0.3 was used for the data analysis. Categorical variables are presented as frequency (percentages) and the numerical ones are presented as mean (standard deviation). Result During follow-up visits between one to three weeks, 91.9% out of 135 patients had normal/near normal presenting visual acuity and with best correction it was 96.9% out of 131 patients. About 1.6% out of 124 operated eyes still had moderate visual impairment after best correction when they visited for follow-up at 12 weeks. Conclusion The study findings underline the ongoing gap in increasing access to cataract treatment, given the large proportion of individuals who still presented extremely late.

175 Rare Complications and Management of Port Site Hernias (PSH) Following Robotic-Assisted Radical Prostatectomy (RARP)

Robot-assisted surgery has become increasingly prevalent in surgical practice and is very commonly performed in urological cancers especially of the prostate gland. Robotic surgical techniques are safe and reproducible; however, they have their associated complications. Risk factors such as the nature of cancer, learning curve of the surgery, experience of the surgeon and patient characteristics have been implicated for potential complications. Complications can range from bleeding, infection, bowel injury, ureteric and nerve damage. Port site hernias (PSH) are an infrequent complication with a reported incidence varying from 0.2–4.8%. Although uncommon, they can result in high morbidity due to bowel incarceration and strangulation.

We report two cases of PSH from our large district general hospital, both at the supraumbilical port site after robotic assisted radical prostatectomy (RARP). The first case presented with complete evisceration and strangulation of a segment of small bowel and the second with bowel incarceration and small bowel obstruction. Our cases highlight potentially rare but severe complications of RARP that should be promptly recognised and urgently treated to prevent significant patient morbidity and mortality.

509 Splenosis, an Important Differential for Peritoneal Metastases

Splenosis is defined as the auto-transplantation of splenic tissues in other sites of the body. It is a rare benign condition and can be an incidental finding. However, early diagnosis is essential as the differential diagnosis of splenosis includes peritoneal metastases.

Early identification relies on recognising relevant past medical history including splenic injury and or splenectomy. Splenosis can be confirmed through the usage of a technetium-99m colloid scan. By using nuclear medicine scans, repeated invasive investigations such as biopsy and diagnostic laparoscopies can be avoided.

We present here a case of a 51-year-old woman who was extensively investigated by the gynaecology department and general surgery department, even undergoing a diagnostic laparoscopy following repeated presentations to primary and secondary care with chronic abdominal and pelvic pain. She had a splenectomy 28 years earlier for traumatic splenic injury. CT scan of abdomen and pelvis showed features suspicious of multiple peritoneal metastases and hence she was urgently referred to a colorectal cancer multidisciplinary meeting. A subsequent technetium-99m colloid scan confirmed multiple splenic nodules in the peritoneal cavity. The patient was reassured and discharged.

In conclusion, in a patient with a known history of splenic trauma, splenosis is an important differential diagnosis. A careful past medical history and appropriate investigations will avoid unnecessary referral and invasive investigations.

Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis

OBJECTIVE

To systematically appraise the existing published literature on cervical cancer screening utilization, and associated barriers and facilitators, in Nepal.

STUDY DESIGN

Systematic literature review and meta-analysis.

METHODS

PubMed/MEDLINE, CINAHL, Scopus, Embase, and, Google Scholar were systematically searched using Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. All quantitative and qualitative studies reporting cervical cancer screening (using the Pap smear test or visual inspection with acetic acid or human papillomavirus test) utilization, barriers, and facilitators for screening were identified. A meta-analysis was performed to estimate Nepal's pooled cervical cancer screening utilization proportion.

RESULTS

The search yielded 97 records, of which 17 studies were included. Fifteen studies were quantitative and two were qualitative. Of the 17 studies, six were hospital-based and six were community-based. The pooled cervical cancer screening utilization proportion (using Pap smear test) among Nepalese women was 17% from the studies in the hospital settings, and 16% in the community. Six studies reported barriers to cervical cancer screening, of which four reported embarrassments related to the gynecological examination and a low level of knowledge on cervical cancer. Three (of four) studies reported health personnel, and two studies reported screening services-related facilitators for cervical cancer screening.

CONCLUSION

Our review reported that cervical cancer screening utilization (16%) is more than four times lower than the national target (70%) in Nepal. Multiple barriers such as low levels of knowledge and embarrassment are associated with cervical cancer screening utilization. Health personnel's gender, counseling, and privacy of screening services were commonly reported facilitators. These findings could help to inform future research, and policy efforts to increase cervical cancer screening utilization in Nepal.

A National Equity Initiative to Address Noncommunicable Diseases and Injuries: Findings and Recommendation from the Nepal NCDI Poverty Commission

We aimed to assess the burden of NCDIs across socioeconomic groups, their economic impact, existing health service readiness and availability, current policy frameworks and national investment, and planned programmatic initiatives in Nepal through a comprehensive literature review. Secondary data from Global Burden of Disease estimates from GBD 2015 and National Living Standard Survey 2011 were used to estimate the burden of NCDI and present the relationship of NCDI burden with socioeconomic status. The Commission used these data to define priority NCDI conditions and recommend potential cost-effective, poverty-averting, and equity-promoting health system interventions. NCDIs disproportionately affect the health and well-being of poorer populations in Nepal and cause significant impoverishment. The Commission found a high diversity of NCDIs in Nepal, with approximately 60% of the morbidity and mortality caused by NCDIs without primary quantified behavioral or metabolic risk factors, and nearly half of all NCDI-related DALYs occurring in Nepalese younger than 40 years. The Commission prioritized an expanded set of twenty-five NCDI conditions and recommended introduction or scale-up of twenty-three evidence-based health sector interventions. Implementation of these interventions would avert an estimated 9680 premature deaths per annum by 2030 and would cost approximately $8.76 per capita. The Commission modelled potential financing mechanisms, including increased excise taxation on tobacco, alcohol, and sugar-sweetened beverages, which would provide significant revenue for NCDI-related expenditures. Overall, the Commission's conclusions are expected to be a valuable contribution to equitable NCDI planning in Nepal and similar resource-constrained settings globally.

Human Resources for Cardiovascular Disease Management in Nepal: A National Need Assessment

Background Human resources are the mainstay of the healthcare system. Higher numbers of health workers have better healthcare coverage and outcomes. Availability of trained human resources to address the exponential rise in cardiovascular disease in Nepal is a national concern. Objective To assess the need of human resources for cardiovascular disease management in Nepal. Method We conducted an exploratory sequential mixed-method study. We developed a task force and organized a national workshop to engage stakeholders and collect feedback on the research process. We did a desk review and conducted 24 key informant interviews. We did thematic analysis from the codes generated. Result There is no clear definition and required estimation of health workers for cardiovascular disease management. There is a shortage of health workers with 8.9 doctors, 20.8 nurses, 0.05 cardiologist/cardiac surgeon, 4.2 pharmacist, 10.2 laboratory technicians per 10,000 population. There is a comprehensive human resource plan but it does not provide details of human resources for cardiovascular disease management. There is a lack of public private collaboration for human resource management. However, there is production of human resources for cardiovascular disease management through pre-service specialized courses and inservice training. Conclusion A clear definition and estimation of health workers with stringent human resource plan for cardiovascular disease management is essential. The government can still address these gaps by establishing a well-equipped central health workforce unit and expanding collaboration with private sectors.

Medical Products for Cardiovascular Disease Management in Nepal: a needs assessment study

Background Medical Products and Technologies is a key component of the health system. Quality medicines and efficient management of the medical products can secure effective cardiovascular diseases management. Objective To collate information and identify strengths, weaknesses, opportunities and threats (SWOT) associated with medical products and technology component for cardiovascular disease management in Nepal. Method This study is a part of a larger rapid assessment of Nepal's health system for cardiovascular disease management and based on The Health System Assessment Approach: A How-To Manual (USAID). The authors conducted a desk review of documents related to the WHO "medical product and technology" building block component and key informant interviews using a pre-tested interview protocol. The first eight interviews were transcribed verbatim and analysed inductively to generate a codebook; and the remaining, transcribed and deductively coded based on the codebook. Findings were categorised into relevant topical area and SWOT components. Result Nepal has laws and provisions for medicine regulation, pharmacovigilance, post marketing surveillance, registration and licensing provisions for pharmacy industries/ outlets, essential medicine lists and national formulary. These provisions also apply to medicines used for cardiovascular diseases. The challenge however, is the lack of effective implementation and monitoring, due to shortages of technical workforce and state of art information and technologies. Information on pharmaceutical expenditures for cardiovascular disease management is scarce; there are no standard national level guidelines that are consistently used to manage cardiovascular diseases in health facilities. Conclusion There are limited provisions and information on medical products for cardiovascular disease management in Nepal, and a need to strengthen existing provisions for medicine regulations and surveillance.

Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal

Background A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking. Objective This study attempted to assess Nepal's health system gap on organization and delivery of cardiovascular disease prevention and management services. Method This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery. Result We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking. Conclusion Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverage.

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal

Background Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal. Objective The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes. Method A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using "The Health System Assessment Approach". Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews. Result Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols. Conclusion Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building. KEY WORDS Cardiovascular diseases, Governance, Leadership, Needs assessment, Nepal.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study

Background Health financing is a major domain of health system building blocks. With the epidemiological transition and increasing trend of Cardiovascular diseases (CVDs), it is crucial to assess the status of health financing to address the gap of prevention, control, and treatment of CVDs in Nepal. Objective This paper aims to assess the situation of healthcare financing on Cardiovascular diseases in Nepal. We framed three key functions of health system financing: (a) revenue collection, (b) pooling of resources, and (c) purchasing of services for this study. Method We used sequential explanatory mixed-method research design. We conducted desk reviews, analyzed secondary data on health financing followed by Key-Informant Interviews with five relevant policymakers and experts between February and September 2019. We obtained the Ethical clearance from the Nepal Health Research Council. Result Out of pocket (OOP) expenditure remains the highest source (52%) of total health care expenditure in Nepal, and two third of it is made for NCDs. Out of total current health expenditure on outpatient and inpatient services for fiscal year 2015/16, only 7% of total NCDs was spent on CVDs. Hypertension is the third-most utilized insurance service out of 36 CVD related services provided by the Health Insurance Board. The existing health related social service schemes covers the high costs associated with treatment, and streamlining these services including provider payment mechanisms with the health insurance program could open up opportunities to expand quality CVD services and make it accessible to the marginalized population. Conclusion Health Financing is the integral part of the health system. With the rising burden of cardiovascular diseases and its impact on impoverishment due to high OOP, integrated health care services, budget specification based on the evidence-based burden of disease such as CVD needs to be prioritized by the government.

Burden of Stroke in Nepal: Findings from Global Burden of Disease Dataset 2017

Background Stroke is the second leading cause of death and disability worldwide including Asian countries, surpassing ischemic heart disease. Stroke accounts for 10% of global death, of which more than three fourth occur in low- and middle-income countries. An exact estimate of the burden of stroke in Nepal is not available. Objective To assess the burden of stroke including disability and death over time in Nepal and compare it with other South Asian countries. Method We retrieved data from the Institute of Health Metrics and Evaluation's Global Burden of Diseases database of 2017 on stroke deaths, disability-adjusted life years, incidence, and prevalence rates, for both genders from Nepal, Bangladesh, Pakistan, Bhutan, and India by year. We assessed the trend of deaths and Disability-Adjusted Life Years (DALYs) due to stroke from 1990 to 2017; and the contribution of major risk factors to stroke burden in 2017. Result Stroke contributed 7.6% of total deaths and 3.5% of total DALYs in Nepal, with a higher burden among the male and old age population. Intracerebral hemorrhage was the dominant type of stroke in Nepal with the highest proportion of deaths and DALYs. Among the South Asian countries, incidence, prevalence, and burden of stroke were highest in Bangladesh. Intracerebral hemorrhage contributed the highest DALYs in South Asian countries. High systolic blood pressure was contributing the maximum DALYs due to stroke in Nepal. Conclusion Hemorrhagic stroke causes high mortality and DALYs in Nepal. Most of the burden of stroke is attributed to high blood pressure in Nepal.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study

Background Health information system is an integral component of a country's capacity to integrate, process, report, and use information in improving health services. Objective This study aims to assess the infrastructure and capacity of the national Health information system to address cardiovascular diseases in Nepal. Method We adopted the United States Agency for International Development manual "The Health System Assessment Approach: A How-To Manual", Version 2.0. Three topical areas: input, process and output, were identified. Stepwise approach for Health information system assessment was done. A desk review and key informant interview was performed. Audio recordings were transcribed in Nepali language and intercoder reliability was checked. Result The upgraded District Health Information Software 2.3 provides a comprehensive online data management solution. Sustainable funding to upgrade the system exists. Annual report provides performance of all the components of the health care delivery system. Data were reviewed quarterly. However, no dedicated section for cardiovascular diseases in the Health information system is present. Private health facilities are poorly represented. Strategic planning, management, and evaluation of the Health information system are lacking. Inadequacy of timeliness, completeness, and periodicity of the reporting still exist. Conclusion A separate section of cardiovascular diseases in the Health information system is required. Better reporting of private sectors and its inclusion in databases is of utmost importance. Adaptation in the recently introduced federal structure is key for development of Health information system in the country.

Awareness and Knowledge of Glaucoma and their Associated Factors among Staffs in a Tertiary-level Hospital in Central Nepal

Background Since glaucoma-related blindness may only be prevented with early identification and treatment, finding asymptomatic individuals in the target population is critical. It is thus important to determine the awareness and knowledge on glaucoma. Objective To determine the knowledge and awareness on glaucoma among the staff of a tertiary level hospital in central Nepal. Method This was a cross sectional study among the staffs of Dhulikhel Hospital who participated voluntarily in the study. The data was collected through the administration of semi-structured questionnaires. R version 4.0.3 (2020-10-10) was used for the data analysis. Categorical variables are presented as frequency (percentages) and the numerical ones are presented as mean (standard deviation). Adjusted odds ratio (AOR) with 95% confidence interval were estimated through logistic regression analysis for determining factors associated with awareness and knowledge of glaucoma. Result A total of 107 (89.2%) participants had heard about glaucoma of which 93 (86.9%) had good knowledge and 14(13.1%) had poor knowledge on glaucoma. The mean score of knowledge was 64.1±16.9. Only 47.7% of the participants said that glaucoma also has an asymptomatic course. We could not find an association of awareness and knowledge of glaucoma with any of the selected sociodemographic variables. Conclusion Although there was a fairly good glaucoma related awareness and knowledge among hospital staff, we found lack of understanding on some critical issues on glaucoma, mainly related to its asymptomatic nature. There is thus room for improvement in educating about glaucoma even in healthcare settings. Given the necessity of expanding glaucoma awareness in the public, hospital staff might potentially serve as messengers to the communities.

A Rare Case of Large Hydatidiform Mole Mimicking a Term Pregnancy

Molar pregnancy is a type of abnormal pregnancy that usually presents with amenorrhea, vaginal bleeding and elevated serum ß-hCG levels. We report a rare case of complete hydatidiform mole occurring in a 46-year-old P2L2 lady who presented with a term size uterus and elevated serum ß-hCG level (> 15,00,000 per deciliter, anemia (hemoglobin: 8.1 g/dL), difficulty in breathing and minimal vaginal bleeding. During the course of her evaluation, she had profuse vaginal bleeding, she underwent suction and evacuation, but bleeding was not controlled despite measures to control it. She was given uterotonics and antifibrinolytic agents and uterine artery ligation. But was proceeded with emergency hysterectomy for uncontrolled hemorrhage. The content of suction and evacuation was vesicles with blood clots and histopathology was reported as complete hydatidiform mole. The patient received a total of 4 units of packed red blood cells. She was discharged from hospital on 5th postoperative day and was followed up serial serum ß-hCG level. Therefore, complete mole can present with enlarged uterus, vaginal bleeding and anemia. It is also important to note that intractable bleeding following suction and evacuation not being controlled with uterotonics and antifibrinolytic agents and uterine artery ligation may require hysterectomy to save the patient's life.

Research Capacity for Prevention and Control of Non-communicable Diseases and their Risk Factors in Nepal: Findings of a Needs Assessment Study

Background Despite a high burden, there are limited trainings in non-communicable disease research in Nepal. Objective We conducted a needs assessment to assess existing research training capacity in academic health institutions of Nepal for the prevention and control of noncommunicable diseases, identify gaps in research, and explore the feasibility of developing research training program in Nepal targeting non-communicable diseases. Method We did mixed-method research and reviewed academic institution curricula and scientific articles authored by Nepali researchers. We conducted 14 Focus Group Discussions with bachelor and masters level students of public health and community medicine; 25 In-depth Interviews with department heads and faculties, and government stakeholders. We surveyed medical and public health students on their research knowledge and skills development. Result Research methodology component was addressed differently across academic programs. One-third (33.7%) of students expressed lack of skills for analysis and interpretation of data. They felt that there is a wide scope and career-interest in non-communicable diseases research in Nepal. However, specific objectives in the curriculum and practical aspects regarding non-communicable diseases were lacking. Most of the non-communicable diseases research in Nepal are prevalence studies. Lack of funding, conflicting priorities with curative services, and inadequate training for advanced research tools were reported as major barriers. Conclusion Nepal must strengthen the whole spectrum of research capacity: epidemiological skills, research management, and fund development. Generation of a critical mass of non-communicable disease researchers must go together with improved funding from the government, non-governmental, and external funding organizations.

Awareness and Knowledge of Glaucoma and their Associated Factors among People Visiting a Tertiary Level Hospital in Central Nepal

Background Glaucoma is one of the major causes of irreversible blindness globally. Almost 60 million people globally are affected by glaucoma making it the second leading cause of blindness worldwide. Diagnosis of glaucoma early on is vital for timely management and prevention of blindness. However, it is challenging to diagnose it early because it is asymptomatic in the initial stage, and there is also the dearth of appropriate screening tools. Awareness, knowledge, and beliefs are believed to influence the treatment-seeking behavior of people as well as their uptake of services. Objective To assess the awareness and knowledge about glaucoma among general patients and patient attendants visiting Dhulikhel Hospital. Method We conducted a cross sectional quantitative study among general patients visiting Dhulikhel Hospital. We collected data using face-to-face interviews with semistructured questionnaires. We analyzed data in R version 4.0.3 (2020-10-10). We presented numerical variables as mean and standard deviation whereas categorical variables as frequency and percentage. We determined factors associated with awareness and knowledge of glaucoma using logistic regression analysis and estimated adjusted odds ratio (AOR) with 95% confidence interval. Result Of 379 participants, a total of 214 (56.5%) participants had heard about glaucoma. Out of the participants who heard about glaucoma, the mean knowledge score was 48.3±21.7 and 53.3% had good knowledge on glaucoma. The odds of having heard about glaucoma were two percent lower (AOR=0.98; 95%CI: 0.97-0.99; p-value 0.036) in the older participants compared to one year younger participant, 1.98 (95%CI:1.01-3.86; p-value 0.046) times higher among literates and 2.79 (95%CI: 1.76- 4.41; p-value < 0.001) times among participants with previous ocular examination. The odds of having good knowledge was 1.94 (95%CI: 1.10-3.42; p value 0.021) times among participants with previous ocular examinations. Conclusion The knowledge and awareness regarding glaucoma in a hospital-visiting population in central Nepal was low. Half of the participants were unaware of the disease glaucoma and half of the participants who heard of the glaucoma had poor knowledge on glaucoma.

Oral Solid Dosage form Modification in Community Pharmacies of Kavrepalanchok and Bhaktapur Districts of Nepal

Background People may modify their oral solid dosage form of medicine to deal with problem faced during medicine administration. The modification of dosage form may adversely affect the quality, safety and efficacy of the medicine. Objective To investigate the causes and practices of oral solid dosage form modification among the consumers going to community pharmacies. Method A descriptive, cross-sectional study was conducted in five community pharmacies of Kavrepalanchok and Bhaktapur districts of Nepal. The consumers visiting these pharmacies for their oral solid dosage form of medicine were invited to participate in interview using structured questionnaire. Result Among 419 participants,13.6% of participants reported having problem of taking intact medicine. Most of them (12.4% of total participants) experienced difficulty swallowing the medicine. The swallowing difficulty is significantly associated with age and sex (p < 0.05). Around one third (36.8%) of participant with medicine administration problem modified the dosage form of medicines. One quarter of medicine dosage form modifications (25.0%) were inappropriate. Medicine dosage form modification is associated with age and number of daily medicine intake (p < 0.05). Among participants modifying dosage form of medicines, 66.7% were advised to do so mainly by family and friends; 33.3% were modifying on their own and 76.2% were unaware of possible effects of medicine dosage form modification. About 62.3% of total participants were never asked about any problems on taking medicines by doctor/pharmacists. Conclusion Difficulty swallowing medicines and medicine dosage form modification were prevalent in the Nepalese population. Medicine dosage form modifications also involved inappropriate modifications due to specialized design of such dosage forms. So, it seems important to provide proper counseling while dispensing such dosage forms.

Drug Utilization Study in Outpatient Department of Ophthalmology in Tertiary Care Hospital

Background The advancement in drug development and availability of newer drugs has improved overall health services including decrease in mortality and hospital stay. Along, it has brought negative impacts such as polypharmacy and associated adverse drug reactions and antimicrobial resistance. Drug utilization research is an essential approach to understand the drug use pattern, identify the early signs of such irrational drug use and to improve quality of drug use. Objective To study the drug utilization pattern in the Ophthalmology Outpatient department (OPD) of Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH). Method A descriptive, cross sectional study was conducted from March 2019 to August 2019 in patients attending OPD of Ophthalmology in Dhulikhel Hospital, Kathmandu University Hospital. Prescriptions of 311 patients were analyzed using World Health Organization (WHO) International Network of Rational Use of Drug (INRUD) and additional other indices. The descriptive data was presented in mean and standard deviation. Result The average number of drugs per prescription was 2.10±1.35. Out of total 311 prescriptions, drugs prescribed in generic name were 152 (23.30%). Total antibiotics encountered were 247 (37.90%) and total drugs prescribed from National Essential Medicine List (NEML) were 371 (56.90%). Antibiotics 247 (37.90%) were the most commonly prescribed drugs followed by lubricants 146 (22.40%). Conclusion Practice of polypharmacy was very high. Most of the drugs were prescribed in brand names and antibiotics were the most frequently used drugs.

A case report of transmission and disease caused by Mycobacterium caprae and Mycobacterium bovis in Lima, Peru

BACKGROUND

The Tuberculosis (TB) burden in Peru is significant with respect to both disease morbidity and mortality. Furthermore the recent diversification of farming enterprise to include a wide range of animal species has necessitated the consideration of members of the Mycobacterium Tuberculosis Complex (MTBC) with the potential for zoonotic transmission. M. bovis and M. caprae, a lesser known member of the MTBC exhibit an exceptionally wide host spectrum in animals and are capable of causing disease in humans. M. bovis has a predictable resistance profile which includes resistance to pyrazinamide. Thus, failure to identify M. bovis as the causative agent in reported TB cases leads to higher levels of treatment failure and contributes to the transmission of drug-resistant TB.

CASE PRESENTATION

Reported here are the clinical presentations, investigations and treatment histories of two patients identified from a population level genotyping study in Lima, Peru that were at the time of treatment thought to be M. tuberculosis patients but in retrospect were spectated using whole genome sequencing as M. caprae and M. Bovis.

CONCLUSIONS

The cases reported here constitute convincing evidence that M. caprae and M. bovis are causative agents of TB infection in humans in Peru and underscore the importance of species-level MTBC member identification to effectively control and treat zoonotic TB. Furthermore these cases highlight the challenges of using clinical risk factors to identify cases of zoonotic TB in humans as their clinical presentation and transmission history is often difficult to distinguish from anthroponotic TB.

1354 A Rare Case of Gallstone Ileus Due to Cholecystocolonic Fistula

Introduction

Gallstone Ileus (GI) is an uncommon but potentially lethal complication of cholelithiasis. 50 to 70% of gallstones obstruct in the ileum, the narrowest point of the intestine. More uncommonly the gallstone can travel into the large bowel via an incompetent ileo-caecal valve and impact in the colon at a recto sigmoid junction. GI involving the sigmoid colon is extremely rare cause of large bowel obstruction. The gallstone often enters the large bowel through a fistula formation between the gallbladder and colon, and impacts at a point of narrowing, causing large bowel obstruction.

Case Report

We describe the case of a 72-year-old man who presented with features of bowel obstruction. CT of abdomen pelvis (CTAP) showed a large 5x5cm intraluminal gallstone obstructing at the rectosigmoid area. It showed presence of pneumobilia and incidental finding of abdominal aortic aneurysm (AAA). An emergency laparotomy revealed a cholecystocolonic fistula. The stone was extracted after milking the stone proximally and loop colostomy formed at colotomy site. The patient made an uneventful recovery. Reversal of stoma was postponed pending endovascular repair of enlarging AAA.

Discussion

Presenting symptoms of GI are often non-specific, frequently leading to a delay in diagnosis and treatment. Although no fistula was identified in this patient by imaging, the most common cause of GI in most patients is formation of a cholecystoduodenal fistula.

Conclusions

Compared with biliary enteric fistulae, the occurrence of cholecystocolonic fistulae is remarkably rare. Temporary colostomies can be considered for treating these cases alongside one-stage operations

1470 Consenting for a Bedside Procedure: A Prospective Observational Analysis of Consenting Practice in the Surgical Emergency Admissions Unit of a District General Hospital

Aim

Consent is necessary to enable patient autonomy, and it is vital that it is voluntary, informed and, where possible, the patient has valid mental capacity to give consent. Recent case law has grown around consent and practice guidance has evolved.

This was a prospective observational study investigating the quality of consenting practice for incision and drainage procedures performed within the surgical emergency admissions unit (SEAU) at a district general hospital.

Method

A prospective study was conducted on consent documentation for a study period from August to September 2020, for patients undergoing bedside incision and drainage (I&D) procedures within the SEAU. Documentation was reviewed and data collected for quality of consent. Further data into the quality of this documentation was also collected; including legibility, risk and benefit discussions, local anaesthetic used, operation note documentation and discussion of the procedure. This was compared against GMC standards.

Results

Of 20 cases (n = 20), 1 case had written consent and 15 cases had verbal consent documented. 4 cases had no documentation of consent. No cases had benefit documentation, and 4 out of the 20 cases had risks documented. 4 cases had documentation of procedure discussion. 13 cases had an operation note included.

Conclusions

This study highlights a deviation from recommended practice, and results have been communicated at a departmental level. Recommendations have been offered in an attempt to improve compliance, including the display of posters in the SEAU. We shall re-audit practice within the coming months after these changes have been implemented.

1487 The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

Background

FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment.

Conclusions

This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

Prevalence of Refractive Error and Ocular Pathologies among School Children: Finding from the School Eye Program of Dhulikhel Hospital

Background Childhood blindness and visual impairments could lead to the onset of blindness among children and adolescents. New cases appear particularly between the ages of 6-15 years and if uncorrected, runs a risk of developing Amblyopia, strabismus. There exists a mounting need to strengthen and modify established school eye health programs in Nepal as per the local needs and conditions. Objective To determine the prevalence of refractive error and ocular pathologies among school children in rural Nepal. Method This cross-sectional study was conducted in nine schools of Kavrepalanchowk and Bhaktapur district with 953 students screened from December 2018 to February 2020. The team of optometrist, ophthalmic assistants and ophthalmologist applied a standard protocol for screening of refractive error as a part of the school eye program of Dhulikhel Hospital. Other standard eye examinations were performed to note the ocular pathologies. The association of socio-demographic factors of students having refractive errors with that in emmetropes was identified using logistic regression analysis. Result A total of 953 students were screened in nine study sites, age ranged from 5-19 years. There were 183 students (19.2%) with refractive errors. Blurred vision was the common complaint reported by 2.5% of students. Multivariate logistic regression analysis showed higher age group children (aOR=2.93; 95% CI: 1.62-5.29; P=0.01) and urban area children (aOR=4.37; 95% CI: 0.87-21.98; P=0.07) to have higher odds of refractive error. Conclusion Refractive error is the major eye problem among school children. Despite its high prevalence, there is still a major gap in timely diagnosis and treatment. Regular vision screening and timely treatment is required for better addressing refractive error among school-going children.

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Comparison between Simple and Classical Techniques to Create Closed Pneumoperitoneum

Background Closed method of pneumoperitoneum using Veress needle is an established technique. Classical closed technique is popular. Simple technique is a modified closed technique. Objective To compare the classical and simple techniques of closed pneumoperitoneum. Method This study was conducted in the department of urology, Bir hospital from August 1st 2019 to March 30th 2021. Total 114 patients were randomized into simple and classical technique of creating closed pneumoperitoneum. Time taken for creation of pneumoperitoneum, complications and failure of creating pneumoperitoneum in each group noted and analyzed. Chi square test, Fischer exact test and student t test were used and p < 0.05 considered significant. Result Among 114 patients, 61 in simple and 53 in classical technique allocated. In simple technique, mean age was 42.98±18.21 years, BMI was 21.84±2.57 kg/m2 , mean time for pneumoperitoneum creation was 108.07±21.14 seconds. In classical technique, mean age was 40.15±17.58 years, BMI was 21.94±2.54 (kg/m2 ), mean time for pneumoperitoneum creation was 189.70±32.21 seconds. Mean time was less in simple technique than classical technique (p < 0.001). Complication rate observed was 6% in each technique (p=0.797) with cumulative rate of 10%. Omental injury was seen in 3.2% in simple technique and 5.6% in classical technique (p=0.662). Retroperitoneal insufflation was seen in 6.5% in simple technique and 5.6% in classical technique (p=0.842). No failed pneumoperitoneum was observed in both groups. Conclusion Simple technique is as effective, reproducible and safe method as classical technique of creating closed pneumoperitoneum.

A Rare Case of Large Left Lateral Wall Vaginal Myoma

Vaginal leiomyomas are rare, they are uncommon benign tumor with variable clinical presentation. They usually present as a mass per vaginum or dyspareunia or pressure symptoms on the neighbouring structures. We present a case of 47 years lady with mass per vaginum and difficulty in walking and chronic pelvic pain. Her clinical findings suggested a large mass in the left vaginal wall, the mass was approximately 12 x 10 cm in size hindering the visualization of the cervix. Her ultrasonography showed bulky uterus with mass occupying the cervix. This finding was not correlating with the clinical findings. Magnetic resonance imaging (MRI) was done and it was reported as mass lesion in pelvis separate from the cervix abutting the rectum posteriorly. Ultrasonography (USG) guided biopsy was done which was reported as Leiomyoma. She underwent vaginal myomectomy and was confirmed in histopathology as Leiomyoma. A leiomyoma is a smooth muscle tumor that arises from the muscular part of the uterus and rarely seen in the vaginal wall.

Quality of Life of Patients with Chronic Obstructive Pulmonary Disease Attending a Tertiary Care Hospital, Kavre, Nepal

Background Chronic Obstructive Pulmonary Disease (COPD) is one of the most common chronic health conditions and is increasingly becoming a major public health problem among the elderly population. As the chronic obstructive pulmonary disease is not curable, evaluation of and methods to improve quality of life among such patients is of utmost importance. Objective The objective of the study was to assess the quality of life among patients living with chronic obstructive pulmonary disease. Method This is a cross-sectional carried out in Dhulikhel Hospital, Kathmandu University Hospital, Nepal in 2017-2018. A total of 274 patients aged 40 years and above were selected for this study. The quality of life of participants was assessed through the widely used shorter version ST George's Respiratory Questionnaire (SGRQ-C). Result The mean age of the participants was 68.19 (SD ± 10.36) years, with the age range of 40-94 years. More than half (55.5%) of respondents were females, 55% were from rural areas, 42.7% were illiterate and 53.3% were from joint families. Agriculture (35.4%) and homemakers (32.5%) were the most prevalent occupation. The mean total score for all domains of quality of life was 68.06 (±18.87). The mean quality of life scores for symptom, activity, and impact domains was 70.11 (±22.33), 67.59 (±20.41), 67.64 (±20.41) respectively which suggested marked impairments in quality of life in all SGRQ-C domains. The symptoms and impact domains were most affected during the activity. Among socio-demographic variables, educational status, ethnicity, number of family members, type of family and economic status had a statistically significant effect on the quality of life. Initial health condition, smoking habit, number of cigarettes smoked, and years of smoking had statistically significant effects on quality of life. Conclusion Patients with chronic obstructive pulmonary disease have a low quality of life in three components of symptom, activity, and impact domains. Major factors associated with poor quality of life were low educational status, large family size, poor health condition, and smoking.

Evaluation of Nicotine Dependence in Adult Population of Eastern Nepal

Background Tobacco consumption is a leading cause of premature death in the world. Tobaccorelated deaths are associated with cardiovascular diseases, pulmonary diseases, oral potentially malignant disorders, cancer, others. Moreover there is also associated nicotine dependence which might result to numerous tobacco-associated diseases. Objective This study was conducted to analyze the degree of nicotine dependence considering its potential health risk, in the Eastern region of Nepal. Method A descriptive questionnaire based study was conducted among current tobacco users of six districts of Eastern Nepal. Fagerstrom Test for Nicotine Dependence (FTND) and Fagerstrom Test for Nicotine Dependency for Smokeless Tobacco (FTNDST) questionnaire were used for tobacco smokers and chewers, respectively. Result Of the total participants, 836 were males and 359 females, among whom 736 were active tobacco smokers and 432 chewers, 34.8% had tried to stop consuming tobacco and 306 (25.6%) had oral lesions in white or red forms. Very low nicotine dependence was found among 244 (31.47%) tobacco smokers and 37 (8.56%) chewers whereas 36 (4.71%) smokers and 103 (23.84%) chewers had very high nicotine dependence. The mean score for FTND was 3.73±2.37 and 5.74±2.12 for FTND-ST. A significant difference in duration and age group with FTND score was observed, however not with FTND-ST. Conclusion The information regarding degree of nicotine dependence can be used as baseline information for planning of preventive strategies and implementation of tobacco cessation and control programs.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

81 Integrating A Front Door Frailty Service in the Emergency Department: Results of A Pilot Study

Introduction

Increasing old age and frailty is putting pressure on health services with 5–10% of patients attending the emergency department (ED) and 30% of patients in acute medical units classified as older and frail. National Health Service improvement mandates that by 2020 hospital trusts with type one EDs provide at least 70 hours of acute frailty service each week.

Methodology

A two-week pilot (Monday–Friday 8 am-5 pm) was undertaken, with a “Front Door Frailty Team” comprising a consultant, junior doctor, specialist nurse and pharmacist, with therapy input from the existing ED team. They were based in the ED seeing patients on arrival, referrals from the ED team and patients in the ED observation ward—opposed to the usual pathway of referral from the ED team to medical team. Data was captured using “Cerner” electronic healthcare records. A plan, do, study, act methodology was used throughout with daily debrief and huddle sessions.

Results

95 patients were seen over two weeks. In the over 65 s, average time to be seen was 50 minutes quicker than the ED team over the same period, with reduced admission rate (25.7% vs 46.5%). The wait between decision to admit and departure was shortened by 119 minutes. Overall, this led to patients spending on average 133 minutes less in the ED. 64 patients were discharged, of which 44 had community follow-up (including 37.5% of 64 referred to acute elderly clinic and 25% to rapid response). 47 medications were stopped across 25 patients.

Conclusion

The pilot shows that introduction of an early comprehensive geriatric assessment in the ED can lead to patients being seen sooner, with more timely decisions over their care and reduction in hospital admissions. It allowed for greater provision of acute clinics and community services as well as prompt medication review and real time medication changes.

First Reported Death of a Postpartum Woman Due to Coronavirus Disease 2019 in Nepal: A Lesson Learnt

The first case of coronavirus disease 2019 was reported on December 31, 2019 in Wuhan, China where the average case fatality rate was 6.1 ± 2.9%. There are 453 deaths as of September 24, 2020 in Nepal. We report the first death of a 29-years-old postpartum woman due to COVID-19 in Nepal who was referred from a rural health center to Dhulikhel Hospital. On arrival, she was taken to the acute respiratory zone of the emergency department to provide immediate lifesaving procedures. Despite the repeated resuscitative measures, return of spontaneous circulation could not be achieved. The real time polymerase chain reaction test was positive. Our case report highlights the importance of early clinical suspicion, importance of "safety first" in healthcare settings, and the chain of management in such patients. We consider the fact that a postpartum woman registered as the first case of COVID-19 related death in Nepal to be an area of further study.

Sensitivity and Specificity of Lateral Flow Antigen Test Kits for COVID-19 in Asymptomatic Population of Quarantine Centre of Province 3

Background Nearly after 6 months of the spread of Corona Virus Disease 19, along with the world Nepal is still trying to control the spread and prevent general population from acquiring it. With limited resources in manpower, technology and evidence it has been a difficult battle. But with time and more understanding of the virus new technology to detect the virus are coming up. It is a major breakthrough in the diagnostic field as this helps us in not only detecting the virus but also helps us to mobilize our human resources. This comes in a time where the cases are increasing at an alarming rate. Although numbers of Polymerase Chain Reaction testing have increased but due to the time consuming and the cost wise, we need a faster and equally reliable alternative. Antigen test approved by different countries can be used for point of care, screening and surveillance depending upon the requirements after calculating its sensitivity, specificity and accuracy. Objective To find out sensitivity and specificity of the Antigen test kit for COVID-19. Method Antigen tests were compared with Reverse Transcription Polymerase Chain Reaction as a reference standard in calculated sample size of 113 subjects in a high risk population. Both Reverse Transcription Polymerase Chain Reaction and antigen test were performed in a same subject with in maximum of 2 days' interval. Convenience sampling technique was used to select the subjects. Ethical approval was taken from Nepal Health Research Council before data collection. Study was done from August to September 2020 from Quarantine center of Province 3. Result There were total of 113 test carried out, among those 47 were positive and 66 were negative in Reverse Transcription Polymerase Chain Reaction. After preparing two by two table, Sensitivity and specificity of the tested was calculated which came out to be 85% and 100% respectively, with accuracy of 93.80%. Conclusion Even though the sensitivity and specificity came to be higher, this test should be interpreted cautiously depending upon the prevalence of Corona Virus Disease 19 in that particular community and the clinical and epidemiological context of the person who has been tested. When in doubt by clinical correlation should be confirmed with Reverse Transcription Polymerase Chain Reaction.

Optimal timing of surgery following breast cancer neoadjuvant chemotherapy: A systematic review and meta-analysis

BACKGROUND

Administration of chemotherapy before breast surgery has the potential to reduce the risk of distant recurrence by targeting micrometastasis as well as allowing a more minimalistic approach to surgical intervention. We performed a systematic review to determine the optimum timing of surgery post breast cancer neoadjuvant chemotherapy (NACT).

METHODS

The primary outcome was to determine whether the timing of surgery post NACT impacted overall survival (OS) and disease-free survival (DFS). We compared patient outcomes between those who had surgery within 8 weeks of completion of NACT to those that had surgery after 8 weeks. An outcome comparison between <4 weeks and 4-8 weeks was also performed. Secondary outcome included complete pathological response (pCR) post NACT. A meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Five studies, including 8794 patients were eligible for inclusion. Patients that had surgery within 8 weeks of completion of NACT had a statistically significant improved OS(OR 0.47, 95% c. i 0.34-0.65) and DFS(OR 0.71 (95% c. i 0.52-0.98, P = 0.04). There were no survival advantages associated with having surgery less than 4 weeks post completion of NACT (OR 0.78, 95% c. i 0.46-1.33, P = 0.37). There was no difference in pCR rate between those that had surgery <4 weeks and 4-8 weeks (OR 1.01, 95% c. i 0.80-1.28, P = 0.93).

CONCLUSION

This meta-analysis shows that the optimum timing of surgery post completion of NACT is 4-8 weeks as it is associated with increased OS and DFS.

Dietary Patterns Measured by Principal Component Analysis and its Association with Stunting among Nepalese Schoolchildren in Nepal

Background There is a gap of knowledge on the link of major dietary patterns with stunting among schoolchildren in Nepal. Objective To identify dietary patterns in rural Nepalese households in two districts and assess their association with stunting among schoolchildren. Method This cross-sectional study gathered data from 708 schoolchildren aged 8-16 years participating in the baseline survey in the Districts of Dolakha and Ramechhap, Nepal. We derived major dietary patterns from a principal component analysis of reported intake from a food frequency questionnaire completed through interviews with the caregivers. Statistical analysis was conducted using mixed logistic regression with random intercepts at the level of schools adjusting for socio-demographic and behavioural indicators. Result The diet of surveyed schoolchildren was mainly comprised of starchy staples and legumes. Five dietary patterns score were derived: mixed food, vegetables and lentils, milk and beverages, salty snacks, and processed food. The vegetables and lentils pattern scores were negatively associated with stunting (aOR 0.84; 95% CI: 0.66-1.08, p=0.17) after adjusting for regional differences, demographic and behavioural risk factors. Conclusion Our results suggest that adherence to dietary patterns high in vegetables and animal protein might be associated with reduced odds of being stunted among schoolchildren. Therefore, the promotion of dietary diversification strategies to improve schoolchildren's food consumption is required in the study area.