Prevalence of White Coat Hypertension among the Patients Visiting in a Tertiary Care Center, Kathmandu, Nepal.

Background Hypertension is a major cardiovascular risk factor. White coat hypertension refers to elevated office blood pressure but normal out of office blood pressure. White-coat hypertension has a risk of cardiovascular events more than normotensives. Objective To identify the prevalence of white coat hypertension among patients presented in the cardiology department. Method The descriptive cross-sectional study was conducted among 165 patients who visited the cardiology outpatient department of Kathmandu Medical College and Teaching Hospital from December 2017 to November 2018. Blood pressure was measured at the hospital, and ambulatory blood pressure device was used to monitor 24hrs pattern. Hypertension is classified as per recent guideline. Data were entered and analysed using Statistical Package for social sciences version 20. Result Out of 165 ambulatory blood pressure monitoring conducted patients, 140 participants were enrolled in the study based on inclusion criteria. Among them 55% (77) were male, and 45% (63) were female. Age ranged from 18-78 years with a mean of 43.82 ± 12.31 years. Overall among 140 participants 14.28% had white coat hypertension, however, after excluding twenty-two high normal group, among 118 participants who were hypertensive according to office BP, 16.9% (20) had white coat hypertension, and 33.57% of patients did not have nocturnal dipping of blood pressure. Conclusion The white coat hypertension is prevalent among around one-sixth of hypertensive patients visiting tertiary care centre, and one third have non-dipping which needs to be considered in the management of hypertension.

Determinants of resilience among people who sustained spinal cord injury from the 2015 earthquake in Nepal.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To assess the level of resilience, compare resilience by demographic and injury-related characteristics, and identify significant determinants of resilience in Nepalese people who sustained spinal cord injury (SCI) from the 2015 earthquake. SETTING: Spinal Injury Rehabilitation Center, Kavre and 14 communities in Nepal. METHODS: Eighty-two participants were included using a convenience sampling technique. A demographic and injury-related questionnaire was used to identify the characteristics of the participants. The Connor-Davidson Resilience Scale was used to measure resilience. Linear regression analysis was performed to determine the demographic and injury-related factors that contribute to resilience. RESULTS: Almost 54% of the participants had low level of resilience. Independent samples t-tests and ANOVA showed that participants with higher resilience outcome were more likely to be male, employed, paraplegic level of injury and pain free. The regression analysis revealed that only gender was a unique determinant of resilience (ß=0.38, t=3.40, P=0.001) in Nepalese with earthquake-related SCI. CONCLUSION: More than half of Nepalese who sustained SCI from the 2015 earthquake in Nepal had not achieved a high level of resilience 2 years later. Gender was a significant determinant of resilience. The results highlighted the importance of providing appropriate intervention and allocating continuing support to the Nepalese people with SCI. A further longitudinal study is recommended to determine predictive factors of the dynamic nature of resilience.

Exploring the Diagnosis and Management of Bouveret's Syndrome.

Bouveret's syndrome is an unusual cause of gastric outlet obstruction secondary to gallstone impaction. It is so rare that it is commonly missed in clinical practice if it is not considered in differential diagnoses of intestinal obstruction more specifically in man who does not report the history of gall stone. Furthermore, there are no definitive guidelines on approach and management of this condition. We present a seventy eight year old man who developed acute abdominal symptoms due to impaction of a gallstone in the duodenum. He did not have history of gall stone. The diagnosis was supported via CT abdomen and Endoscopy. The patient was successfully managed by exploratory laparotomy followed by anterior pylorotomy to remove the stone without cholecystectomy and fistula repair.

Comprehensive Diabetes and Non-Communicable Disease Educator in the Low-Resource Settings.

The role of self-management education in diabetes and other major non-communicable diseases is clearly evident. To take care of and educate people with diabetes and other major NCD under the supervision of medical professionals and for education of other health care professionals, Comprehensive Diabetes and NCD Educators are needed in the routine service in peripheral health clinics and hospitals. The areas of training of CDNCD educator should match with the cost-effective interventions for diabetes and other major NCD that are feasible and planned for implementation in primary care in the low resource settings. Most of such interventions are part of diabetes education as required for Diabetes Self-Management Education programmes and traditional Diabetes Educator. The addition of use of inhaled steroids and bronchodilator in chronic respiratory disease and identification of presenting features of cancer, also required for many people with diabetes with various such common co-morbidities, will complete the areas of training of traditional Diabetes Educator as that of CDNCD Educator. Staff nurse and health assistants, who are as such already providing routine clinical service to all patients including with diabetes and major NCD in peripheral health clinics and hospitals, are most appropriate for CDNCD Educator training. The training of CDNCD Educator, like that of traditional Diabetes Educator, requires fulfilment of sufficient hours of practical work experience under supervision and achievement of the essential competencies entailing at least 6 month or more of intensive training schedules to be eligible to appear in its final certifying examination.

Adherence to Antihypertensive Medications: Population Based Follow up in Eastern Nepal.

BACKGROUND: Poor adherence toward antihypertensive drugs is a worldwide problem that results in poor health outcomes and increased health care costs. Community based study related to adherence to antihypertensive medication is limited in context of Nepal. METHODS: This study was conducted to explore the extent of adherence towards prescribed antihypertensive treatment and to identify the factors of non adherence. Community based cross sectional study was conducted in Dharan Municipality of Eastern Region of Nepal from September 2009 to February 2010. Out of 975 hypertensive patients, 154 calculated samples were selected following simple random sampling method. Data was collected by interview method and adherence was measured by using four items Morisky Medicine adherence scale. Data was analyzed using SPSS by descriptive and inferential (Chi square and logistic regression analysis) Statistical method. RESULTS: Among the 154 hypertensive patients, only 56.5% patients were adherent to antihypertensive medication. The important predictors of non adherence by logistic regression analysis at 95% Confidence Interval were illiteracy (OR 5.34, CI= 1.23 -23 , P=0.025), expensive price of medicine (OR 5.14, CI=1.1-23.9, P=0.037), missed medicine due to cost (OR 0.143,CI=0.02-0.78, P= 0.025), no family history of hypertension (OR 4.46,CI= 1.21-16.4, P=0.024), irregular follow up (OR 6.39,CI=1.22-33.3, P=0.028), more than one pills per day ( OR 5.33,CI=1.19-23.7, P= 0.028). CONCLUSIONS: Around half of the population was non adherent towards antihypertensive medications so identified gap need to be addressed to increase adherence level.

Gestational Diabetes Mellitus - A Public Health Concern in Rural Communities of Nepal.

BACKGROUND: Gestational Diabetes Mellitus (GDM) is in increasing trend recently. It is associated with adverse effects on both mother and fetus. Thus, diagnosis of GDM is an important public health issue. This study aimed to determine the frequency of gestational diabetes mellitus in three rural districts of Nepal. METHODS: A hospital based study was conducted in three districts representing mountain, hill and Terai belts of Nepal during the period of July 2009 to June 2010. A total of 564 pregnant women were interviewed and tested for blood glucose as per WHO guideline Results: In Nepal, only 2.5% of pregnant women had GDM according to WHO criteria while it was 6.6% according to IADPSG criteria. Overall mean blood glucose among pregnant women was 72.1 (fasting) and 95.8 (after 2 hrs of 75 gm glucose intake) in which it was 62.8, and 75.1 in Dhading, 78.7 and 88.9 in Dhangadhi, and 98.3 and 99.3 in Solukhumbu districts respectively. Pregnant women with increased age were significantly at high risk of having GDM than those of younger women (p=0.04). There were non-significant differences in GDM by District, Ethnic group and family history of DM. CONCLUSIONS: Gestational diabetes in the rural areas of Nepal is variable with two different criterias (2.5% vs 6.56%). Increasing age was an important influencing factor. Special attention should be given on women with increasing age. There was no significant difference in prevalence of GDM in three ecobelts of Nepal despite of altitude and cultural variability.

Pancreatic Abscess: An Unusual Presentation of Pancreatic Tail Cancer.

Pancreatic abscess usually occurs in the setting of pancreatitis especially if complicated by pseudocysts or pancreatic necrosis. On the other hand, pancreatic body and tail cancer is relatively uncommon cancer and rarely does it present as a pancreatic abscess. We describe a 50-year-old man with sepsis due to underlying pancreatic abscess, who was later diagnosed to have pancreatic tail adenocarcinoma with the help of endoscopic ultrasound guided fine needle aspiration cytology.

Facilitation of free residential training inside the country - The fundamental health service responsibility of the Government and its regulatory body.

For optimum Peripheral Health Service and implementation of various Vertical Public Health Programme Services, network of public Rural and Urban Health Centers with trained Specialists in General Practice (GP) is essential. Later such Specialist GPs will thus fulfill both comprehensive training and experience required for Health Management and Planning Service in the centre. About 40%-50% of all Residential Trainings and Specialists are required in GP. There are further up to 100 to 150 possible specialties in which remaining doctors can be trained for Specialty Health Services. Though free Residential Training has numerous advantages, its shortage inside country is the bottleneck to provide above mentioned Health Services. Planning for health service delivery by at least trainee residents under supervision or appropriately trained specialists guides Residential Training's regulations. Fulfillment of objective training criteria as its core focus is the concept now with the major role of Faculty as supervising residents to provide required service in the specialty and simultaneously updating themselves and their team for Evidence-Based Medicine practice. Similarly the need of Ambulatory Health Service and joint management of in-patients by specialists in hospitals has changed unit and bed divisions and requirements for Residential Training. Residents, already the licensed doctors, are thus providing required hospital service as indispensable part of its functional hierarchy for which they need to be paid. With such changing concepts and trends, there are some essential points in existing situation to facilitate free Residential Training inside country. For Government doctors, relevant amendment in their regulation is accordingly required.

[Attitude of intensive care specialists toward deceased organ donation in Germany. Results of a questionnaire at the 12th Congress of the German Interdisciplinary Association for Intensive and Emergency Medicine]. / Einstellung des intensivmedizinischen Fachpersonals zur postmortalen Organspende in Deutschland. Ergebnisse einer Fragebogenerhebung auf dem 12. Kongress der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin.

BACKGROUND: Organ transplantation is the only treatment option for many patients with end-organ failure. Due to lack of transplantable organs, patients already on the waiting list die every day. The number of organ donors in Germany fell in 2012 by 12.8 %, reaching its lowest level since 2002. The medical and nursing personnel in intensive care units have a key role in the recruitment of potential organ donors; therefore, a survey was conducted on this subject. MATERIALS AND METHODS: At the 12th Congress of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) in December 2012, a point prevalence study using a paper-pencil survey was performed. RESULTS: A total of 1045 questionnaires were analyzed. Of respondents, 81 % favor organ donation in the event of their own brain death. The approval rate in the medical profession was 84 % and 75 % of the nursing profession. Only 45.3 % of the participants (47 % physicians, nursing 44 %) had an organ donor card and nearly half (45 %) had already confided their opinion towards organ donation to their family or friends. The main reasons for a lack of acceptance of organ donation was the concept of brain death (40 %), fear of abuse by organ trade (29 %), and the lack of integrity of the body after death (11 %). The particularly intense discussion about organ donation and transplantation in 2012 resulted in a predominantly negative change of attitude in 45 % of respondents. CONCLUSION: The vast majority of the intensive care personnel supports organ donation, but less than half of the respondents have an organ donor card. The reports of irregularities in the organ allocation were scrutinized, but had apparently no significant impact on the individual and collective fundamental donor decision.

Study of working experience in remote rural areas after medical graduation.

BACKGROUND: Posting of doctors in remote rural areas has always been a priority for Government; however data are scarce in the country about experience of doctors of working in remote areas after medical graduation. OBJECTIVE: A questionnaire survey of doctors was planned to analyze their experience of working after graduation in remote rural areas in various parts of the country. METHOD: The cross-sectional survey was done by convenience sampling method. A one-page questionnaire with one partially closed-end and five open-end type questions was distributed to the doctors who had worked in remote rural areas after graduation under various governments' postings. RESULT: Two-third of participants had their home in urban areas and 89.8% had stayed for 1 to 5 years. About half of the participants had difficulty in getting the posting in the remote areas of their choice. Most participants indicated provision of opportunities for Residential (postgraduate) Training as their reasons of going to remote areas as well as their suggestions to encourage young graduates to go there. Similarly most also suggested appropriate career, salary and incentives to encourage doctors to go to work in remote areas. About 85% of participants pointed out the major problem faced while posted in remote areas as difficulty in handling varied situations with no guidance or seniors available around. CONCLUSION: The notable points indicated by the participants are centered on the opportunity for Residential Training and difficulties faced without such training. Residential Training is a priority to be considered while planning the health policy for optimum health care of people.

Need of the regulation for profit percentage investment by pharmaceutical companies in new drug discovery research from the various local traditional medicinal and plant systems.

In the modern medical systems the active pharmacological ingredients, effective against any disease is identified, purified and studied for its various effects and side-effects whereas it is not so in the traditional systems. Therefore, it is not surprising that safety concerns have often been raised about the traditional medical products. The major issue now, is to make appropriate situation with basic supports to bring all the available experts and resources together for the identification, purification, and study of efficacy and safety of the active molecules of the popular traditional medicines. Government and public sectors in the countries with such rich traditional medicinal and plant systems have related experts, but they also have much hurdle regarding recruitment and retention of expert human resources, getting fund, purchase and maintenance of equipment, bureaucratic formalities and others. The pharmaceutical companies have basic laboratories with related infrastructure and human resources as well as interest about bringing the drug molecules. To bridge the gap, there is a need of the regulation which will make the pharmaceutical companies to invest certain percentage of their profit in the field of research to identify new drug molecules and to study their effects. It is just not an issue of discovering the active molecule but also of creating the concept and culture of research, purity and quality of drugs, safety of people, and future direction of the human society.

PG medical training and accreditation: responsibility of the government for the adequate health service delivery.

On one hand there is obvious inadequate health coverage to the rural population and on the other hand the densely populated urban area is facing the triple burden of increasing non-communicable and communicable health problems and the rising health cost. The postgraduate medical training is closely interrelated with the adequate health service delivery and health economics. In relation to the prevailing situation, the modern medical education trend indicates the five vital issues. These are i). Opportunity needs to be given to all MBBS graduates for General Specialist and Sub-Specialist Training inside the country to complete their medical education, ii). Urgent need for review of PG residential training criteria including appropriate bed and teacher criteria as well as entry criteria and eligibility criteria, iii). Involvement of all available units of hospitals fulfilling the requirements of the residential PG training criteria, iv). PG residential trainings involve doing the required work in the hospitals entitling them full pay and continuation of the service without any training fee or tuition fee, and v). Planning of the proportions of General Specialty and Sub-Specialty Training fields, particularly General Practice (GP) including its career and female participation. With increased number of medical graduates, now it seems possible to plan for optimal health coverage to the populations with appropriate postgraduate medical training. The medical professionals and public health workers must make the Government aware of the vital responsibility and the holistic approach required.

Rigid endoscopic evaluation of conventional curettage adenoidectomy.

OBJECTIVES: To evaluate the results of conventional adenoidectomy, using rigid endoscopy of the nasopharynx, and to establish the role of such evaluation in facilitating complete adenoid removal via the curettage technique. DESIGN: Descriptive rigid endoscopic evaluation of the nasopharynx before and after adenoid curettage, and following subsequent endoscopy-assisted adenoidectomy. SETTING: Tertiary referral centre. PATIENTS: Forty-one consecutive children with symptomatic adenoid hypertrophy scheduled to undergo adenoidectomy. RESULTS: Rigid endoscopic evaluation indicated that conventional curettage, used alone, failed to completely remove adenoid tissue from the superomedial choanae and anterior vault in all cases; incomplete removal was also seen in other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent), the nasopharyngeal roof (61.78 per cent) and the fossa of Rosenmuller (61 per cent). Subsequent rigid endoscopy-assisted adenoidectomy successfully removed the residual adenoid tissue from all nasopharyngeal sites, except the eustachian tube opening in two cases. CONCLUSION: Conventional curettage adenoidectomy misses a substantial amount of adenoid tissue. Rigid endoscopy-assisted adenoidectomy improves this result by enabling localisation of any residual adenoid tissue.

Ten PM note of organophosphate poisoning: successful outcome of a medical audit with complete seven steps.

Medical audit in general consists of seven steps like choosing topic, setting criterion and standard, collecting first data, comparing data with standard, introducing change, collecting second data and reflecting. Its three basic premise are improvement of patient care by using existing knowledge, team work with ongoing educational process and change management and promotion of blame-free culture maintaining confidentiality. Audit mostly relates to a particular practice and is therefore not generalisable. An audit of residents' late evening routine notes of organophosphate poisoning patients is reported here, as the change introduced appears relevant to the situation of developing countries. Organophosphate poisoning patients should be managed in intensive care unit with close monitoring, as inadvertent stoppage or slowing of atropine infusion may occur, particularly at night, leading to reappearance of poisoning manifestations, which may cause respiratory failure and death. If they are managed in wards, residents-on-duty can check the clinical and intravenous drip status in the late evening and communicate with nurses and relatives to be particularly vigilant. In the audit done, such regular ten pm notes of organophosphate poisoning about the clinical and drip status and communication by residents were increased from 15.5% in the first to 81.7% in the second data collection (p < 0.01) after the introduction of the change. The ten pm note is being continued for about two years now. Implementation of ten pm note of organophosphate poisoning patients admitted in medical wards is feasible and appears useful to improve the quality of health care delivery and learning of residents.

"Safety pin"--a question to its safety!

Foreign body ingestion is not an uncommon problem in children. They can ingest various foreign objects and one of such objects is a safety pin. The ingestion of such foreign body is not widely reported in the literature. This case highlights the risk of accidental ingestion of safety pin used on child's clothing to protect him from cold that can result in lethal complications. In a poor developing country like Nepal, this case serves to address all mothers alerting them of their ignorance while using safety pin in infants. In addition, physicians are reminded to obtain a detailed inquiry of suspected foreign body ingestion in every child with the history of dysphagia.

Prospects of jugular venous pulse assessment.

There is no controversy regarding the current clinical method of examination of waveform of jugular vein pulse. However there are limitations of clinical assessment of central venous pressure by jugular vein pressure measurement from the level of sternal angle. There are variations in the reported distances from sternal angle to right atrium as well as to upper limit of JVP. In erect position, anterior end of fourth intercostal space is at about the level of mid-right atrium. In patients with visible JVP at neck in erect position, measurement of CVP can be done more accurately directly from the anterior end of fourth intercostal space. For others, the position of mid-right atrium can be marked in lateral chest wall first in erect position at the mid-point of an anteroposterior line from anterior end of fourth intercostal space to back. Subsequently in reclining position, the vertical height of venous pressure can be measured from the horizontal plane of the midpoint marked at lateral chest wall to visible upper limit of JVP. Such measurement can be done in a more reliable way with venous pressure (VP) manometer with its indicator rod at the horizontal plane of mid-right atrium and with its horizontal surface at upper limit of JVP. The venous pressure manometer can also be used to measure relatively less reliable upper limb venous pressure (ULVP), as indicated by the vertical distance at which veins of upper limb collapse, especially when JVP is not visualized due to subnormal CVP as in hypovolemia.