Safety and immunogenicity of conjugate vaccine for typhoid (Vi-DT): Finding from an observer-blind, active-controlled, randomized, non-inferiority, phase III clinical trial among healthy volunteers.

Typhoid fever is a significant public health concern with most of the sufferers between 15 and 25 y of age in Nepal. We undertook this study to demonstrate Vi polysaccharide conjugated with diphtheria toxoid (Vi-DT) conjugate vaccine which is non-inferior to Typbar typhoid conjugate vaccine, a Vi polysaccharide vaccine conjugated with tetanus toxoid (Vi-TT) with a focus on the adult population from Dhulikhel Hospital which was one of the total four sites in Nepal. In this study, we assigned the eligible participants in 1:1:1:1 ratio by block randomization, and stratified into three age groups (6 months to less than 2 y, 2 y to less than 18 y, and 18 y to 45 y), allotted to Group A, B, C, and D. Group A, B, and C received 25 µg (0.5 mL) of Vi-DT study vaccine and participants in Group D received 25 µg (0.5 mL) Vi-TT vaccine. We descriptively analyzed safety in all the participants receiving one dose of the investigational vaccine. The anti-Vi-IgG seroconversion rate in Vi-DT recipients was 99.71% (97.5% CI 98.04-99.96; 344 of 345 participants) and 99.13% (94.27-99.87; 114 of 115) in Vi-TT recipients which indicates that Vi-DT vaccine is non-inferior to Vi-TT vaccine. In safety aspect, 16.81% of total subject had at least one solicited adverse reaction and 22.61% of the Vi-TT participants experienced at least one solicited adverse reaction with most of them being local adverse reactions. None of the enrolled participants reported serious adverse events. Our study shows that a single dose of the Vi-DT vaccine is immunogenic, safe to administer and non-inferior to the Vi-TT vaccine four weeks after vaccination.

Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

INTRODUCTION: Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. METHODS: We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels. RESULTS: The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions. CONCLUSION: The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

Health system gaps in cardiovascular disease prevention and management in Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Impact of the COVID-19 pandemic on suicide and self-harm among patients presenting to the emergency department of a teaching hospital in Nepal.

The COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm and suicide are its extreme effects. We aim to explore the impact of this pandemic on suicide and self-harm in our Emergency Department. A cross-sectional study was conducted including all fatal and nonfatal self-harm patients presenting to the emergency department during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) were included through the electronic medical record system. The prevalence and the clinical profile were compared between these three periods. A total of 125 (periods 1 = 55, 2 = 38, and 3 = 32) suicide and self-harm cases were analyzed. Suicide and self-harm had increased by 44% and 71.9% during the lockdown in comparison to periods 2 and 3. Organophosphate poisoning was the most common mode. Females were predominant in all three periods with a mean age of 32 (95%CI: 29.3-34.7). There was a significant delay in arrival of the patients in period 1 (p = 0.045) with increased hospital admission (p = 0.003) and in-hospital mortality (18.2% vs 2.6% and 3.1%) (p<0.001). Our study showed an increase in suicide and self-harm cases in the emergency department during the initial phase of the COVID-19 pandemic which may reflect the increased mental health crisis in the community in low resource settings like Nepal. This study highlights the importance of priming all mental health care stakeholders to initiate mental health screening and intervention for the vulnerable population during this period of crisis.

Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal.

PURPOSE: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting. METHODS: We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care. RESULTS: The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation. CONCLUSION: The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.

Unrecognized geriatric depression in the emergency Department of a Teaching Hospital in Nepal: prevalence, contributing factors, and metric properties of 5 item geriatric depression scale in this population.

BACKGROUND: Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to identify the frequency of unrecognized geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS. METHODS: This was a cross-sectional study of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into "no", "mild-moderate" and "severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviors were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach's alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, Spearman's correlation, receiver operating characteristic curve, and kappa coefficient. RESULTS: Two hundred eighty patients were enrolled with an overall prevalence of unrecognized depression of 45.7% [104 (81.3%) mild-moderate depression, and 24 (18.8%) severe depression]. The mean age of the sample was 71.36 with female predominance (61%), and 82.5% were illiterate. In the binary analysis, those who had more pain, visited the ED more often, had musculoskeletal diseases and sleep problems, mobility problems, visited local healers previously, and who reported self-perceived "heart and mind" disease showed statistically significant differences among the three categories. In multinomial regression analysis, visits to local healers, sleep problems and frequency of pain were significantly related to depression. The sensitivity, specificity, area under curve and Spearman's correlation of GDS-5 were 75.8%, 96%, 0.919, and 0.827 respectively. Cronbach's alpha for GDS-5 was low (0.416), therefore a new version was proposed which improved the sensitivity to 90.6% and Cronbach's alpha to 0.623. CONCLUSIONS: Unrecognized geriatric depression was highly prevalent which urges the need for ED-based interventions for screening and referral. The proposed brief GDS-5 correlated well with the GDS-15 with better validity and internal reliability and offers a more expeditious form of screening for geriatric depression in emergency settings in Nepal.

COVID-19 Emergency Department Protocols: Experience of Protocol Implementation Through in-situ Simulation.

PURPOSE: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emergency departments (EDs) for triaging of the patients and safety of staff is of utmost importance. The aim of our study was to develop and implement COVID-19 ED triage and protected intubation protocols for COVID-19 patients with in-situ simulation (ISS) training. The latent safety threats (LST) detection also served as a platform to test new system amendments and refine the protocols and workflows with infection control issues. We also explored the effectiveness of this approach based on Kirkpatrick's model of evaluating training outcomes. PARTICIPANTS AND METHODS: The protocols and simulation scenarios were developed and validated. A total of 22 triage and 13 intubation simulation sessions were conducted in the ED with multidisciplinary staff (physicians=18, nurses=20) during a period of four months. Each simulation was followed by a debriefing session to discuss the team performance. Pre- and post-simulation performances were compared. LSTs were identified and remediated. An online voluntary feedback was collected from the participants to explore the opinion about the ISS sessions and confidence level using a 5-point Likert scale. RESULTS: There was a significant improvement in triage knowledge score after ISS [5.5/10 (IQR 4-6) versus 8.5/10 (IQR 8-9), p<0.001]. There was a desirable proportion of correct responses (>75%) following the ISS for triage case scenarios. A pre-designed checklist was used during protective intubation simulations. Some important LSTs were missing medications, lack of mechanism to deliver patient samples to lab and faulty airway maneuvers. The participants' feedback on ISS showed increased skills and confidence level on triaging and protected intubation (p<0.001). They found the protocols easy to follow and they recommended for more such modules in future. CONCLUSION: ISS is a quick and efficient tool to implement the ED protocols for preparation of outbreaks like COVID-19. It helps the ED staff to triage and manage the airway safely. We recommend such an approach to train the multidisciplinary staff and continue to improve ourselves through ISS addressing the changing nature of the pandemic.

Worksite intervention study to prevent diabetes in Nepal: a randomised trial protocol.

INTRODUCTION: In Nepal, approximately 31% of adult industrial employees have diabetes. While the prevention of type 2 diabetes through behavioural intervention has been disseminated, worksite could be an effective platform for the translation of this knowledge into action as employed adults spend most of their workday waking hours at workplaces. METHODS AND ANALYSIS: We will conduct a randomised controlled trial to assess the effectiveness of a behavioural and a canteen intervention on diabetes risk reduction among those who are prediabetic at two worksites in eastern Nepal. We will recruit 162 adult full-time factory workers with haemoglobin A1c (HbA1c) of 5.7%-6.4% at baseline or fasting blood sugar of 100-125 mg/dL. The 8-14 months' control period will be followed by the behavioural intervention where half of the participants will be randomised to receive the behavioural intervention and half will act as a control and will not receive any intervention. Then, all participants will receive the canteen intervention. The analysis will be intent-to-treat, comparing the difference in the change in HbA1c% between the behavioural intervention group and the control group using a two-sample t-test. The within-participant changes in HbA1c after 6 or more months on the canteen intervention among those not randomised to the behavioural intervention in the previous period will be assessed using the paired t-test. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board at Yale School of Public Health, New Havens, USA and the Nepal Health Research Council. TRIAL REGISTRATION NUMBER: NCT04161937.

Diagnostic performance of the extended focused assessment with sonography for trauma (EFAST) patients in a tertiary care hospital of Nepal.

BACKGROUND: Thoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries. AIM: To evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal. METHODS: This was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. RESULTS: Out of 267 cases, 261 patients underwent an EFAST examination. The sensitivity and specificity were 94.8% and 99.5%, respectively. The negative predictive value was 98.53% whereas the positive predictive value was 98.21%. The overall accuracy was 99.4%. CONCLUSION: The results of this study suggest that EFAST examination performed by first-line healthcare providers is a useful method for assessment of thoracic and abdominal injuries. EFAST was found to have a high specificity (99.5%) and positive predictive value (98.21%) which indicates that it is an effective technique for detecting intra-abdominal or thoracic injuries. However, the effectiveness of EFAST is limited by its being operator dependent, and thereby human error. For negative EFAST cases, we recommend a monitoring period of at least 4 hours, serial fast scan, or further investigation through other methods such as a CECT. LEVEL OF EVIDENCE: Level I.

Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal.

PURPOSE: Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. MATERIALS AND METHODS: We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored. RESULTS: A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields. CONCLUSION: The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.

In-situ Simulation-Based Module to Train Interns in Resuscitation Skills During Cardiac Arrest.

PURPOSE: Competency to perform cardiopulmonary resuscitation is essential to improve the outcome during an event of cardiac arrest. Medical internship is a "transition phase" beyond which physicians are exposed to the unpreparedness and anxiety while dealing with life-threatening conditions which need rapid actions. Experiential learning, deliberate practice and immediate feedback are the primary advantages of simulation-based medical education. In-situ simulation occurs in a real patient care environment utilizing the available resources. Our aim was to introduce in-situ simulation-based resuscitation skills training for medical interns. METHODOLOGY: This was a prospective quasi-experimental study with mixed research design conducted in the emergency department. The knowledge score questionnaire, skill-score sheet, post-simulation feedback from the interns and staff were designed, validated through experts, peer-reviewed and pilot tested. All the interns posted in the emergency department participated in the training. Appropriate statistical analyses were applied for quantitative data. Thematic analysis of the data from the open-ended questions was used to identify the themes. RESULTS: Six groups of interns (n=35) participated in at least one of the 40 in-situ simulation sessions. The means of the pre- and post-simulation knowledge scores were 5.89± 2.8 SD and 11.74± 1.8 SD, respectively, and the difference was statistically significant [t (35) = 16.705, p<0.001]. The skill score had a positive correlation (Pearson correlation coefficient r=0.985, p=0.01) with the number of simulations performed in each group. The thematic analysis uncovered the themes related to the simulation methodology, reflective learning, enhancement of the non-technical skills and effective feedback. The self-reported enhancement in teamwork skills and the confidence level was significant. The feedback of the staff in the Emergency Department showed a positive attitude towards in-situ simulation. CONCLUSION: This study demonstrated an increase in the knowledge and skills of the interns after participation in the in-situ simulation sessions. Based on the results, the study recommends that in-situ simulation-based teaching should be incorporated in the existing medical education system.

Accuracy of Broselow tape in estimating the weight of the child for management of pediatric emergencies in Nepalese population.

BACKGROUND: Children with emergency conditions require immediate life-saving intervention and resuscitation. Unlike adults, the pediatric emergency drug dose, equipment sizes, and defibrillation energy doses are calculated based on the weight of the individual child. Broselow tape is a color-coded length-based tape that utilizes height/weight correlations for children. However, in low-income countries like Nepal, due to factors like undernutrition, the Broselow tape may not accurately estimate weight in all ranges of pediatric age group. METHODS: This study was conducted in the Department of Pediatrics of Dhulikhel Hospital, Kathmandu University Teaching Hospital, in children less than 15 years of age. Our study aims to prospectively compare the actual weights of urban and rural Nepalese children with the estimated weights using the Broselow tape (2017 edition) and the updated APLS formula. The errors in the selection of endotracheal tube size and adrenaline dose using the Broselow tape were also explored. RESULTS: This study included 315 children with male to female ratio of 0.63:1. They were divided into 3 groups according to their estimated weight by the Broselow tape into < 10 kg, 10-18, and > 18 kg. There was a total agreement of the estimated color zone according to the Broselow tape with the actual weight in the gray zone (p = 0.01). There was a positive relationship between the actual body weight and the estimated body weight (correlation (r = 0.970, p = 0.01) and accuracy (r2 = 0.941)). Our analysis showed that the accuracy of estimated weight with the Broselow tape decreases with increasing weight of children. The precision of the tape was relatively high in the lower length zones as compared to the higher length zones. The estimated size of the endotracheal tube (p = 0.01) and adrenaline dose (p = 0.08) by the Broselow tape was in agreement with that estimated using PALS formula in weight group of less than 18 kg, but decreases as the estimated weight increases further. CONCLUSIONS: The accuracy of the Broselow tape in estimating the weight of a child, endotracheal tube size, and dose of adrenaline is higher in weight group of less than 18 kg, and accuracy decreases as the weight of child increases. The Broselow tape should be avoided in children weighing more than 18 kg. Hence, PALS age-based formula for ET tube size estimation and weight-based formula for adrenaline dose calculation are recommended for children weighing more than 18 kg.

Interdisciplinary in situ simulation-based medical education in the emergency department of a teaching hospital in Nepal.

BACKGROUND: Simulation is well established as an effective strategy to train health care professionals in both technical and nontechnical skills and to prevent errors. Despite its known efficacy, adequate implementation is restricted due to the financial burden in resource-limited settings like ours. We therefore pursued to introduce cost-effective in situ simulation (ISS) in the emergency department (ED) to explore its impact on perception and learning experience among multidisciplinary health care professionals and to identify and remediate the latent safety threats (LST). METHODS: This is a prospective cross-sectional study with a mixed method research design, which was conducted in the ED of Dhulikhel Hospital-Kathmandu University Hospital. The pretest questionnaire was used to determine baseline knowledge, attitude, and confidence of the staff. The ISS with minimal added cost was conducted involving multidisciplinary healthcare workers. The LSTs were recorded and appropriate remediation was performed. Voluntary post simulation feedback was collected after the sessions. RESULTS: Overall 56 staff participated in at least one of the 35 simulation sessions, among which 45 (80%) responded to the questionnaires`. Twenty participants (45.5%) were reluctant to use the defibrillator. The self-reported confidence level of using defibrillator was low 29 (64.6%). The knowledge score ranged from 0 to 8 with the median score of 3 and a mean of 3.29 ± 1.8. There was no statistically significant difference in knowledge scores among participants of different occupational backgrounds, previous training, duration of work experience, and previous use of a defibrillator. A total of 366 LSTs {individual (43%), medication (17%), equipment (4%), and system/team (36%)} were identified (10.45 LST per ISS). The overall feedback from the participants was positive. Eighty percent of participants reported increased skills to use a defibrillator, and 82% reported increased confidence for managing such cases. They also agreed upon the need and continuity of such type of simulation in their workplace. CONCLUSIONS: The baseline knowledge score and the confidence level of the staff were low. Self-reported feedback suggested increased confidence level and teamwork skills after ISS. It promoted identification and remediation of latent safety threats. ISS serves as a cost-effective powerful educational model that can be implemented even in settings where finances and space are limited.

Prevalence of Dyspnea among Patients Attending the Emergency Department of a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Dyspnea is a common presenting complaint in the emergency department worldwide and a diagnostic challenge for emergency physicians. Our study aims to find the prevalence of dyspnea among patients attending emergency department in our hospital. METHODS: A descriptive cross-sectional study was conducted in the emergency department of Dhulikhel hospital from May 2019 to July 2019 after ethical approval from the institutional review committee. Total 1200 samples were collected by consecutive sampling method. All patients were triaged in the emergency department as a part of regular protocol. The participants were included in the study after obtaining an informed consent from the patient or caretaker (if the patient were not able to provide it). Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. The statistical analysis was done using R version 3.5.3 (2019-03-11). RESULTS: The prevalence of dyspnea among patients attending emergency department of a tertiary care hospital was 107 (8.9%) (4.6%-13.2%) at 95% confidence interval. The patients triaged into red, orange and yellow categories were 14 (13.1%), 50 (46.7%) and 43 (40.2%) respectively. Median age was 64 years and 74 (69%) were ≥60 years. Sixty-seven (62.6%) were females and 40 (37.4%) were males. Forty-four (41.1%) arrived by ambulance. Most commonly associated symptoms were cough and fever 59 (51.1%) and 44 (41.1%) respectively. CONCLUSIONS: The prevalence of dyspnea among patients attending emergency department of our hospital is higher compared to that of other studies. This warrants structured and prompt management of dyspnea for quality improvement.

Preparation, validation and user-testing of pictogram-based patient information leaflets for tuberculosis.

INTRODUCTION: Patient education is of paramount importance with regard to the condition of the disease and the treatment given besides lifestyle remodelling in order to get the desired therapeutic outcomes. When verbal information is provided to the patients, they often tend to forget it. Pictorial aids or pictograms, as they are commonly known, are tools that are widely used for imparting knowledge to the patients. The aim of the study is to prepare and validate a Pictogram-based Patient Information Leaflet (P-PILs) on Tuberculosis (TB). METHODS: P-PILs have been prepared from tertiary, secondary and primary sources. The knowledge-based questions are prepared with respect to the P-PILs. The baseline knowledge of the volunteers and patients has been analyzed before administering the P-PILs by using the validated questionnaire. The post-knowledge of the volunteers and patients has been analyzed after administering the P-PILs (20 minutes) by using the same questionnaire and the user-opinion has also been obtained at the end. RESULTS: The study results show that the mean scores of the overall user-testing knowledge assessment are found to have improved significantly from the pre-P-PILs administration score of 62.67 to the post-P-PILs administration score of 91. The overall user-opinion about the P-PILs has been found to be good (75%) followed by average (25%). CONCLUSION: The present study shows that there is significant improvement in the knowledge levels of the patients and volunteers after reading the validated leaflets. The P-PILs are found to be an effective educational tool for TB patients.