Assessment of quality of essential medicines in public health care facilities of Nepal: Findings of nationwide study.

Essential medicines are those medicines that satisfy the primary health care needs of the citizens. Poor quality of essential medicines can have serious impact on public health. Thus, this study is aimed to assess the quality of essential medicines available in public health care facilities of Nepal. A cross sectional descriptive study was carried out in 62 health facilities across 21 districts, representing all seven provinces of Nepal and selected proportionately from all three ecological regions i.e. Terai, Hill and Mountain using lottery method. Health facilities in selected districts were chosen using random number generator. Face to face interview was taken with health facility in charge using structured questionnaire. All storage conditions information was recorded through observation checklists. Temperature and humidity were measured using a digital instrument. Similarly, 20 different generic medicines were collected for quality testing. The obtained data were entered in Epidata version 3.1, cleaned in Microsoft Excel 2007 and analyzed in SPSS version 16.0. Among 62 health facilities, only 13% of health facilities were found to follow the medicine storage guidelines, with temperature and humidity levels exceeding recommended limits. Out of 244 batches of 20 different generics of essential medicines, 37 batches were found to be substandard. These substandard medicines were- Ciprofloxacin hydrochloride eye/ear drop, Iron supplement tablets, Metformin Hydrochloric tablet, Metronidazole Tablets, Paracetamol Oral suspension, Paracetamol tablet and Povidone Iodine solution. The study recommends the urgent need for the Government of Nepal to prioritize ensuring the quality of essential medicines in the country.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal.

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

The Identical External Reference Point Standardized to the Zero-Reference Level for Measuring Both Central and Jugular Venous Pressures: An Observational Study.

Background: Studies report discrepancies between CVP and JVP measurements. The mid-thoracic plane (MTP) at the anterior fourth intercostal space level indicates the zero-reference level (ZRL) for venous pressure measurement, and the midaxillary line (MAL) at fourth intercostal space is a point near the ZRL in the supine position. JVP is usually measured from the sternal angle (SA) with further addition of 5 cm (JVP-SA + 5) and CVP in the supine position from MAL (CVP-MAL). However, no report has compared CVP measured from MTP (CVP-MTP) with CVP-MAL and with JVP from MTP (JVP-MTP) and JVP-SA + 5. Methods: We measured JVP-MTP and JVP-SA + 5 in appropriate reclining positions and subsequently CVP-MTP and CVP-MAL in the supine position blindly in 150 patients. We compared the pressures by Pearson correlation and Bland-Altman plots. Results: CVP-MTP and CVP-MAL demonstrated similar means (p = 0.129), strong positive linear relationship (r = 0.908), and good agreement (near-zero mean difference) with each other. JVP-MTP was about 1 cm higher than JVP-SA + 5 (p < 0.001). JVP-MTP displayed higher correlation coefficients and better agreements with both CVPs than JVP-SA+5. Correlation coefficients and mean differences of both CVPs with JVP-MTP were almost equal, about 0.83 and 1 cm, and with JVP-SA + 5 also almost equal, about 0.72 and 2 cm, respectively. Conclusions: JVP tallies better with CVP examined in the supine position when both are measured from MTP as the identical external reference point (ERP), and MAL can be used as MTP to measure CVP in the supine position. Our findings indicate the way to explore the matching of CVP and JVP to the full extent possible by standardizing their measurements from other identical ERPs to that from the zero-reference level MTP. Their further study in similar higher reclining positions from identical ERPs, such as MTP, MAL, and SA with the addition of higher numbers instead of 5 cm, is warranted standardizing other measurements to that from MTP.

Clinical Competency Retention after Mid-Level Practicum Training and It's Associated Factors among Health Workers of Nepal.

BACKGROUND: Mid-level health workers are deployed in a large proportion with the expectation of similar patient outcomes as with physicians. Mid-level practitioners are Health Assistants and Auxiliary Health Workers who provide clinical care at remote locations. National Health Training Center has been providing 60 days in-service Mid-level Practicum training since 2009 AD for the mid-level practitioners with the aim to enhance quality of patient care in Nepal. METHODS: An observational study conducted using retrospective data from onsite follow-up assessment of 180 Mid-level Practitioner from 18 districts of Nepal between July 2015 to June 2019. The retention of competency onsite follow-up was calculated as percentage of assessment score at the end of Mid-level Practicum training. Percentage retention of competency and association of retention with factors were analyzed using independent t-test. RESULTS: Majority of participants were male (85.6%), and working in a Health Post (84.4%). Average clinical competency retention in each domain at their work place was 68.79% in knowledge, 73.80% in patient encounter skill, 82.84% in clinical decision-making skill and 87.58% in clinical procedure skill. Higher age groups, longer years of experience and participants from Terai region found to be associated with lower retention of knowledge. A better enabling environment and higher case load retained higher patient encounter skill. CONCLUSIONS: The competency retention among Mid-level Practicum trained mid-level health workers was found to be higher. Factors found associated with competency retention were age, geographic region, years of experience, case load and enabling environment.

Perception Regarding Tooth Carving Using wax Block among the Dental Practitioners.

BACKGROUND: The various pedagogical methods applied for teaching dental anatomy to dental students includes lectures, analysis of extracted natural teeth and carving of wax blocks to accurately replicate the morphology of teeth. The thorough knowledge of dental morphology is indispensable for a successful dental practice. This study was thus aimed to assess the perceived relevance of tooth carving using wax block among the dental practitioners. METHODS: A cross-sectional study was designed with the objective of involving dental practitioners working in Kathmandu. Self-administered questionnaires were used for the data collection. The results were later analyzed for descriptive statistics using the Statistical Package for the Social Sciences (SPSS) 16 software. RESULTS: About 232 (98.3%) participants practiced tooth carving using wax block to study dental anatomy. More than 96% of the participants agreed that tooth carving exercises have helped them better understand tooth morphology and more than 85% feel that their manual dexterity was developed by these exercises. A total of 223 (94.5%) were of the opinion that tooth carving should be continued in the BDS preclinical curriculum. CONCLUSIONS: The dental wax carving is an effective pedagogical strategy to develop manual dexterity of dental students by recreating tooth morphological features using a wax block, thereby achieving the mandatory psychomotor skills.

Digital Eye Strain among Adults Presenting to Tertiary Care Hospital in the Era of COVID-19 Pandemic: A Descriptive Cross-sectional Study.

INTRODUCTION: The Novel Coronavirus disease 2019 pandemic has sent humanity indoors, replacing human contact with an electronic connection. The mandatory online classes and work from home policy to maintain the social distancing during the pandemic has forced the individual to spend most of the time in front of laptops or mobile screens. Digital eye strain is a group of vision-related symptoms that result from the continuous use of devices with digital displays, such as computers, tablets, and smartphones. The present study is done to find out the prevalence of digital eye strain among the adult population in a tertiary care hospital in the era of the COVID-19 pandemic. METHODS: This descriptive cross-sectional study was done from January 2021 to July 2021 in a tertiary care hospital of Nepal after receiving ethical approval from the Institutional Review Committee (Registration number: 077/78/30). Convenience sampling was done. The sample size calculated in our study was 322. Data collection and entry were done in Microsoft Excel, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: The prevalence of digital eye strain was 300 (94.3%) (91.8-96.8 at 95% Confidence Interval) among 318 respondents. Eye strain (irritation, heaviness) was the most common digital eye strain symptom 199 (62.6%) followed by the tiredness of eyes 162 (50.9%). CONCLUSIONS: The present study concluded that the prevalence of digital eye strain in the era of COVID-19 is high as compared to other studies conducted among adults.

Perceptions of Medical Students About Bedside Teaching in a Medical School.

INTRODUCTION: Bedside teaching is an important and established learning tool in medical education. However there is a decline in bedside teachings over the years throughout the world including Nepal, due to advancement in medical technology, clinical skills labs and simulation techniques. This study aimed to find out the perception of Nepalese medical students towards different domains of bedside teaching. METHODS: This was a descriptive cross-sectional study. A questionnaire consisting of Likert scale, open ended and closed ended questions was developed on different aspect of bedside teaching and the filled questionnaires were included for analysis. RESULTS: Three hundred and six questionnaires were included. Almost all of medical students responded that bedside teaching is a useful learning modality in clinical teaching 304 (99.3%) and provides active learning in real context 291 (95%). The majority of medical students 233 (76%) were satisfied with the steps of history taking, examination followed by management discussion employed at bedside teaching. The students 223 (73%) were satisfied, how to elicit signs following demonstration of clinical exam by teachers at bedside. However majority 196 (64%) felt lack of individual opportunity at bedside. According to students, focussing more on practically oriented clinical skills with proper supervision would improve learning while hindering factors were large number of students and patient's uncooperativeness. Good communication was considered the best method of alleviating patient discomfort at bedside teaching in this study. CONCLUSIONS: The study concluded that medical students have positive response and learning attitudes towards different aspects of bedside teaching.

Anxiety Level of Patients Undergoing Oral Surgical Procedures.

BACKGROUND: Evidences on dental anxiety scale are essential in dental practice for better service delivery. The main objective of this study was to determine the anxiety level of patients undergoing oral surgical procedures and explore its associated factors. METHODS: This was a cross sectional study enrolling 142 patients. Semi structured questionnaire based on Corah's dental anxiety scale was prepared and administered to gather information. Descriptive statistics, chi- square test and independent t- test were used to analyze the data. RESULTS: Sixty nine percent were feeling relaxed in waiting area. Nine patients (6.3%) were afraid of persons in white attire. About 17% reported that they were afraid of sound of dental apparatus. Many participant (81%) expected better outcomes of their dental procedures. When waiting for their procedure at the waiting area, about 50% stated to sense restlessness. Nearly 56% felt unease while waiting at dental chair. Nearly 70 % of cases had less than 7 dental anxiety scale score indicating low anxiety to dental procedures, 23.2% showed moderate anxiety with score of 7 to 9 and 7% showed high anxiety by scoring 10 or more out of score of 15.Average dental anxiety scale scores did not vary as per age differences. The anxiety scores for both sexes were alike. CONCLUSIONS: Even though anxiety level was low among the cases undergoing oral surgical procedure, being in waiting area and dental chair raises their apprehension.

Prevalence of poor mental health among medical students in Nepal: a cross-sectional study.

BACKGROUND: Poor mental health among medical students is widely acknowledged. Studies on mental health among medical students of Nepal are lacking. Therefore, we conducted a study to determine the prevalence of mental disorders. METHODS: A cross-sectional study was conducted among medical students at KIST Medical College and Teaching Hospital, Nepal from December 2016 to February 2017. Our survey instrument consisted of the Patient Health Questionnaire (PHQ) and questions about socio-demographic factors, smoking, marijuana use, suicidal ideation and thoughts of dropping out of medical school. RESULTS: The prevalence rates were 29.2% (95% CI, 24.4% - 34.3%) depression, 22.4% (95% CI, 18.0% - 26.9%) medium to highly severe somatic symptoms, 4.1% (95% CI, 2.0% - 6.2%) panic syndrome, 5.8% (95% CI, 3.4% - 8.3%) other anxiety syndrome, 5% (95% CI, 2.7% - 7.3%) binge eating disorder and 1.2% (95% CI, 0.0% - 2.3%) bulimia nervosa. Sixteen students [4.7% (95% CI, 2.4% - 6.9%)] seriously considered committing suicide while in medical school. Thirty-four students [9.9% (95% CI, 6.8% - 13.1%)] considered dropping out of medical school within the past month. About 15% (95% CI, 11.1% - 18.6%) of the students reported use of marijuana during medical school. CONCLUSIONS: We found high prevalence of poor mental health among medical students of Nepal. Future studies are required to identify the factors associated with poor mental health.

Left axis deviation in electrocardiogram with normal QRS duration in ambulatory adults without cardiac symptoms: a possible marker of glucose intolerance.

INTRODUCTION: We are increasingly noticing isolated left axis deviation (LAD) in electrocardiogram in younger people with diabetes without obvious heart disease and association of LAD with glucose intolerance has not been explicitly raised before. We planned a study of ambulatory adults with borderline (0° to -30°) and moderate-to-marked (<-30° to -90°) LAD looking into their possible association with glucose intolerance with fasting plasma glucose (FPG)≥100 mg/dL. METHODS: We consecutively enrolled adults aged 30 or more, with electrocardiogram normal duration QRS axis between 0° to -90°, without cardiac symptoms, not on any medication, attending outdoor-clinics for health checkup. RESULTS: Out of 100 participants enrolled, about 90% were aged between 30 and 60 and 47% had borderline and 53% moderate-to-marked LAD. Moderate-to-marked LAD group had higher frequencies of abnormal blood pressure (BP), FPG, and lipids than borderline LAD group even after conditioning effects of age and sex (p≤0.03) and of FPG after conditioning effects of BP (p=0.02). The frequencies of glucose intolerance were 48.9% even in borderline LAD with 84.9% in moderate-to-marked LAD group. In moderate-to-marked LAD group mean values of BP, FPG, and lipid profiles were higher (p<0.001) and abnormal. In borderline LAD group though mean BP and lipid values were normal, FPG was impaired. CONCLUSIONS: Impaired mean FPG values and high frequencies of glucose intolerance in both borderline LAD group with normal BP and moderate-to-marked LAD group with conditioning of effects of BP in relatively younger ambulatory adults without cardiac symptoms indicate possible association between LAD and glucose intolerance.