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.

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.

Oral Health Care Practice and Circumstances during Covid-19 among Dental Patients in Tertiary Care Hospital in Nepal

Background Patients are hesitant to enter a dental hospital because of the significant danger of cross infection and illness transmission due to rapid spread of corona virus. Objective To assess knowledge regarding Covid-19, oral health practices and circumstances on dental treatment during a pandemic. Method Cross sectional study was conducted among patients visiting dental department of Dhulikhel hospital from September to October 2020. Questionnaires were interviewed following safety protocols regarding the pandemic and descriptive analysis was performed. Both verbal and written consent as well as ethical approval was taken before the study. Result A total 411 patients aged 14 to 75 years old from 14 different districts across Nepal participated in the study. All of the patient were free of Covid-19 symptoms and had strong knowledge and awareness about disease transmission. During the crisis 96% of the people maintain good oral hygiene while 25.8% acquire new dental problems where majority experienced oral discomfort and swelling, 93.2% of them did not attend a dental clinic or hospital in the interim owing to fear and inaccessibility. Majority of the participants were impressed by the safety precautions and preparations during treatment and 99.3% strongly suggest or pledge to visit dental department if necessary during the pandemic. Conclusion Dental patient visiting Dhulikhel hospital is highly aware of current health crisis, possible transmission and preventive measures. Proper safe hospital setup can encourage them to seek dental treatment during crisis. Dental pain and swelling in Endodontic department recorded most common dental emergency during this pandemic.

Slow-release Zn application through Zn-chitosan nanoparticles in wheat to intensify source activity and sink strength

Source activity and sink strength are important aspects to measure growth and yield in wheat. Despite zinc's extended functions in the amendment of plant metabolic activities, critical research findings are missing on mapping the elusive interplays of slow-release zinc (Zn) application from nanoparticles (NPs) in crop plants. The present study reports that slow-releasing Zn application through Zn-chitosan NPs bestows myriad effects on source activity and sink strength in wheat plants. Herein, effects of foliar application of Zn-chitosan NPs (0.04-0.16%; w/v) at booting stage of wheat crop were evaluated to quantify the source sink potential compared to ZnSO₄. Zn-chitosan NPs endowed elevated source activity by up-regulating cellular redox homeostasis by improving the antioxidant status, cellular stability and higher photosynthesis. Cognately, in the field experiment, NPs (0.08-0.16%, w/v) significantly spurred sink strength by up-regulating starch biosynthesis enzymes viz. sucrose synthase (SUS), invertase (INV), ADP-glucose pyrophosphorylase (AGPase), soluble starch synthase (SSS) and accumulated more starch in developing wheat grains. Concomitantly, higher spike lengths without awns, significantly higher number of grains/spike, test weight (24% more than ZnSO₄ treatment), yield (21% more than ZnSO₄ treatment), biological yield and harvest index quantified the higher sink size to further validate the better sink strength in slow-release Zn application via chitosan NPs.

Physio-biochemical responses of wheat plant towards salicylic acid-chitosan nanoparticles

Sustained source-activity is imperative for vigor plant growth and yield. In present study, physio-biochemical responses of wheat plant contributing to source-activity were measured after application of salicylic acid-chitosan nanoparticles (SA-CS NPs). SA-CS NPs slowly release SA for sustained availability to plant. In seedling bioassay, as compared with salicylic acid (SA), SA-CS NPs incurred up to ~1.5 folds increased activities of seed reserve food remobilizing enzymes for substantial mobilization of reserve food to growing seedlings and enhanced seedling vigor index (SVI) by 1.6 folds. At booting stage, foliar application of SA-CS NPs (0.01-0.08%; w/v) enhanced the activities of superoxide dismutase (1.94 folds), catalase (1.33 folds), peroxidase (1.99 folds) and polyphenol oxidase (1.04 folds) in flag leaf. SA-CS NPs further contrived cellular homeostasis by comforting reactive oxygen species (ROS), malondialdehyde (MDA) and proline contents in flag leaf. SA-CS NPs (0.08%; w/v) significantly increased chlorophylls (a-b) contents (1.46 folds), spike length without awns, spike lets per spike and grain weight per pot as compared with SA. Study categorically explicates that slow release of SA from SA-CS NPs could exert significant effect on source-activity by maneuvering various physio-biochemical responses of wheat plant.

Dental caries status and related modifiable factors among Nepali students

OBJECTIVE

This study aimed to assess the dental caries status of Nepali students and describe correlated modifiable factors.

BASIC RESEARCH DESIGN

Cross-sectional analytic study.

PARTICIPANTS

730 grade two to four (6-14 years old) students from 23 different government schools in seven different districts in Nepal from December 2014 to February 2015. The schools were located in areas of low socioeconomic status without access to fluoridated water.

METHOD

A trained, calibrated dentist performed visual examination using WHO criteria. Data on demographic variables, oral health behaviors, the number of shops (including sugary snacks) around each school and the distance from Dhulikhel city (where many medical and dental facilities are available) to each school were collected. Multivariable logistic regression was used to identify factors associated with dental caries.

RESULTS

Of the participants, 53.7% and 14.4% had decayed, missing and filled teeth (dmft) in the primary and permanent dentition, respectively. The mean number of primary decayed teeth (dt) was found to be 1.69, and the permanent DT was 0.22; mean dmft was 1.74 in primary dentition and 0.22 in permanent dentition. The number of markets near a school and the distance to the Dhulikhel city were associated with permanent (odds ratio [OR]: 1.67) and primary dmft (OR: 0.62), respectively, after adjusting for the related covariates.

CONCLUSIONS

Most dental caries remains untreated. Students with more shops near their school and who attended schools closer to the city were more likely to have dental caries.

Selective palladium-catalysed arylation of 2,6-dibromopyridine using N-heterocyclic carbene ligands

A selective palladium-catalysed arylation of 2,6-dibromopyridine has been developed by employing N-heterocyclic carbene ligands. Selective mono-arylation was performed in water/acetonitrile solvent at ambient temperature and low catalyst loading.

Prevalence of Conventional Risk Factors in ST Segment Elevation Myocardial Infarction Patients in Shahid Gangalal National Heart Centre, Nepal

INTRODUCTION

Smoking, diabetes mellitus, hypertension, and dyslipidemia are labelled as conventional risk factors for coronary artery disease. Prevalence of these risk factors varies across populations. This study aimed to assess the prevalence of these conventional risk factors in patients, who were discharged from our hospital, with the diagnosis of ST elevation myocardial infarction.

METHODS

Medical records of 495 ST elevation myocardial infarction patients discharged from our centre in between January 2012 to December 2012 were retrospectively reviewed to evaluate the prevalence of conventional risk factors.

RESULTS

Clear dominance (75%) of male patients was seen. Inferior wall myocardial infarction (29.9%) was the most common diagnosis followed by anterior wall myocardial infarction (25.1%). Hypertension (65%), smoking (57.8%) and dyslipidemia (45.5%) were the most common risk factors. Diabetes (31.1%) was the least common. Prevalence of hypertension, dyslipidemia was similar among male and female. Smoking was statistically common in male (76.8%vs 49.5%),though diabetes was common in female (36.5%vs.29.3%) not statistically significant.

CONCLUSIONS

Conventional risk factors are common among ST elevation myocardial infarction patients. Early detection and treatment of these risk factors play a vital role for the prevention of coronary artery disease. Much more focus should be stressed on preventive programs throughout the country.

Normal Echocardiographic Parameters of Healthy Adult Individuals working in National Heart Centre

Background Studies evaluating potential differences in normal cardiac dimensions and body mass indices of various ethnic populations using 2D echocardiography have reported variations based on gender and ethnicity. Currently, accepted echocardiographic reference values are from US studies, and the limited information is available on Nepalese population. The purpose of this study was to derive population-based reference values for two-dimensional (2D) guided M-mode echocardiographic dimensions and left ventricular mass of adult Nepalese that can be applied in epidemiologic studies, clinical trials and clinical practice. Methods 97 individuals were randomly selected, out of 502 staffs working in our hospital, who were over 18 years of age and were free of cardiovascular disease. Subjects underwent M-mode and 2D echocardiogram with color Doppler study. Reference values were derived for end-diastolic and end-systolic left ventricular internal dimensions, left ventricular wall thickness, left atrial dimension, aorta, LV mass. Measurements were described by mean, standard deviation and 95% reference range. Results Echocardiographic measurements were within standard normal limits. The measurements of aorta, left atrium, inter-ventricular septum, left ventricle in systole and diastole, left posterior wall and left ventricular mass, adjusted or not for body surface area, were significantly higher in males. Several echocardiographic measurements, adjusted or not for anthropometric measurements, had different mean and range than the reference limits in US-based studies. Conclusion The means and range for the measurements of left atrium volume, left ventricular diastolic dimension and left ventricular mass found in this survey were lower than those indicated by the international literature and accepted as normal limits. The results of this study strongly indicate the need for a larger scale study to further establish ethnic-specific and gender-specific echocardiographic reference values for the Nepalese population. DOI: http://dx.doi.org/10.3126/njh.v9i1.8339 Nepalese Heart Journal Vol.9(1) 2012 pp.3-6

Calciphylaxis precipitated by ultraviolet light in a patient with end-stage renal disease secondary to systemic lupus erythematosus

Calciphylaxis is a rare and severe calcification syndrome described mainly in patients with end-stage renal disease (ESRD) undergoing dialysis or with a renal transplant. This life-threatening condition is characterized by the abrupt onset of painful ischemic skin ulcers and necrosis. Secondary local and systemic infection may supervene and, without timely and appropriate interventions, calciphylaxis may be fatal. A precipitant or challenging agent is believed to be necessary to initiate the process. We describe a case of a woman with ESRD receiving continuous ambulatory peritoneal dialysis who developed calciphylaxis in the setting of severe hyperparathyroidism after receiving UV photoradiation therapy. We suggest that the UV light served as the challenging agent in the precipitation of this devastating condition.