Effect of self-management intervention on patients with chronic obstructive pulmonary diseases, Chitwan, Nepal.

BACKGROUND: Self-management skills are important for patients with Chronic Obstructive Pulmonary Disease (COPD) who are responsible for their day to day care. Poor self-management behaviours have a significant influence on symptoms, functional impairments and quality of life. Evidence has shown that self-management interventions support patients to respond to changing symptoms and thereby make appropriate decisions regarding their self-management. OBJECTIVE: This study aimed to find out the effect of self-management interventions in patients with COPD in terms of self-management practice, inhaler practice, COPD symptoms burden, functional ability, self-perceived dyspnoea and emotional symptoms. METHODS: Quasi-experimental pre-test post-test design was carried out among patients with COPD attending respiratory units of Chitwan Medical College Teaching Hospital (CMC-TH), Nepal. Convenience sampling technique was used to select the 70 patients with COPD for the study. Baseline data was collected from the participants using (i) Semi-structured interview schedule for socio-demographic and clinical variables, (ii) COPD Self-Management Practice Questionnaire, (iii) Borg Dyspnoea Scale, and (iv) Six Minute Walking Distance (6MWD) Test (v) Pulmonary Function Test (PFT) and (vi) Observation Checklist. Self-management Intervention given was 2 ½ hour sessions per week for 6 weeks along with information booklets distribution. Participants were re-evaluated after 3 months of intervention using same tools. Data analysis was performed using IBMSPSS version 20.0 for window. Wilcoxon signed-rank test was performed to find the effectiveness of the self-management interventions on outcome parameters. RESULTS: Self-management interventions (2 ½ hour session per week for 6 weeks) elicited a statistically significant change on self-management practice (z = -7.215, p<0.001), inhaler practice (DPI practice z = -6.731, p<0.001, MDI practice, z = -1.816, p = 0.005), functional ability (z = -4.243, p<0.001), self-perceived dyspnoea (z = -4.443, p<0.001), COPD symptom burden (z = -7.009, p<0.001) and emotional symptoms (depression, z = -6.856, p<0.001, anxiety, z = -6.675, p<0.001) of patients with COPD. CONCLUSIONS: Self-management intervention acts as powerful equipment to improve self-management practice, COPD symptoms burden, functional ability, self-perceived dyspnoea and emotional symptoms of patients with COPD. Hence, clinician and policy maker need to plan and intervene the rehabilitation program for the patients with COPD to enhance the effectiveness of therapy, self-management practice and general longevity.

Inhaler Competence in Nepalese Patients with Asthma and Chronic Obstructive Pulmunory Disease: A Systematic Review.

BACKGROUND: Incorrect use of inhalers in patients with asthma and chronic obstructive pulmonary disease is prevalent internationally. This review aims to determine the prevalence and associated factors of incorrect inhaler use and effectiveness of intervention to improve the correct use among Nepalese patients with asthma and chronic obstructive pulmonary disease. METHODS: The protocol was registered in PROSPERO. Systematic literature search was performed in PubMed, Embase, CINAHL,and Google Scholar using predefined search terms. Studies in patients with asthma or chronic obstructive pulmonary disease, reporting at least one overall or critical error, using dry powder inhalers and pressurized metered dose inhalers were included. The quality of included studies was assessed using the National Heart, Lung, and Blood Quality Assessment Tools. A descriptive narrative synthesis was undertaken. RESULTS: Twelve studies were eligible for analysis. At least one overall and critical step of the inhaler technique was performed incorrectly by the large number of patients, ranging from 64-100% and 9-100%, respectively. The incorrect use was associated with factors related to patients, inhalers, and health care professionals. The interventions included a combination of verbal instruction, physical demonstration, and/or face-to-face training on correct inhaler use. Following the intervention, an improvement of 23-37% in the overall inhaler technique and 7-42% in the critical steps was achieved. CONCLUSIONS: Existing literature suggests that Nepalese patients with asthma and chronic obstructive pulmonary disease have high overall and critical error rates in the use of dry powder inhalers and pressurized metered dose inhalers. A well-designed educational intervention is necessary to improve the correct use of inhalers in this population.

Knowledge of Health Care Professionals and Medical Students Regarding Covid-19 in a Tertiary Care Hospital in Nepal.

INTRODUCTION: The lack of knowledge among health care professionals leads to diagnostic delays, further spread of disease, and poor infection control practices. Health care professionals must be updated knowledge regarding COVID-19. This study aims to assess the knowledge of health care professionals regarding COVID -19 in a medical college in Chitwan. METHODS: A Knowledge, Attitude and Practice Study was carried out in a tertiary care hospital in Chitwan, Nepal from April 22, 2020, to April 28, 2020. The institutional review committee of Chitwan Medical College provided ethical approval for the research. Data were collected with an online questionnaire using Google forms. The questionnaire was sent out to 724 potential responders who included health care professionals from medical, dental, nursing, and allied health sciences in Chitwan Medical College. A convenient sampling method was used for data collection. Data were analyzed using Statistical Package of Social Sciences. RESULTS: A total of 181 respondents completed the web survey. Overall, a total of 35 (19.3%) respondents were found to have "Good" knowledge; 105 (58%) respondents had "Fair" knowledge and 41 (22.7%) respondents had "Poor" knowledge regarding various aspects of COVID-19. There was no significant difference among the various health professional groups in their knowledge scores under the four knowledge domains. CONCLUSIONS: The study of knowledge of health care professionals could act as a reference for the prevention and better management of COVID-19. This study shows that there is a need to implement periodic educational interventions and training programs on infection control practices for COVID-19 across all healthcare professions.

Contextualizing Critical Care Medicine in the Face of Covid-19 Pandemic.

Critical Care Medicine is a specialty dealing with the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction. The glaring need of critical care services and human resources for critical care have become more evident in the face of the current COVID-19 Pandemic. At this juncture, when the world is facing threat to humanity with an increasing number of deaths due to COVID 19 pandemic, the discussion about the need for ICU beds and human resources for critical care management has re-surfaced and is being increasingly realized. In Nepal, as of 15th April, 2020, there are 194 hospitals with ICU facilities. The total ICU bed strength is 1595 in 194 hospitals (which is approximately 6% of all hospital beds) and only around 50% of them are equipped with ventilators (840). These figures indicate that Nepal has approximately 2.8 ICU beds per 100,000 population. As Nepal braces to contain a major COVID-19 outbreak, the hospital capacities of the country have already come under huge pressure. If the number of confirmed cases of COVID-19 continue to rise at the current pace, the shortage of critical care facilities will become more glaring than ever before. The current pandemic is a tremendous opportunity for health planners to accelerate action and ensure that the country is well-equipped to contain the COVID-19 pandemic. We need to be working towards infrastructure and human resource strengthening and expansion in critical care, in order to efficiently contain the pandemic.

COVID 19 and Nepal: Identification of Critical Public Health Measures.

The COVID-19 pandemic is unfolding at an unprecedented pace. The unprecedented threat provides an opportunity to emerge with robust health systems. Nepal has implemented several containment measures such as Rapid Response Team formulation; testing; isolation; quarantine; contact tracing;surveillance, establishment of COVID-19 Crisis Management Centre and designation of dedicated hospitals to gear up for the pandemic. The national public health emergency management mechanisms need further strengthening with the proactive engagement of relevant ministries; we need a strong, real-time national surveillance system and capacity building of a critical mass of health care workers; there is a need to further assess infection prevention and control capacity; expand the network of virus diagnostic laboratories in the private sector with adequate surge capacity;implement participatory community engagement interventions and plan for a phased lockdown exit strategy enabling sustainable suppression of transmission at low-level and enabling in resuming some parts of economic and social life.

Medical Thoracoscopy for Undiagnosed Exudative Pleural Effusion: Experience from Two Tertiary Care Hospitals of Nepal.

INTRODUCTION: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion. METHODS: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean ±SD and frequency (percentage). RESULTS: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma. Procedure related mortality and major complications were nil. Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively. CONCLUSIONS: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.

Outcome Predictors in Scrub Typhus Requiring Ventilator and Vasopressor Support.

BACKGROUND: Age and serum creatinine are known to be predictors of mortality in scrub typhus patients admitted in intensive care unit. This study aimed to explore the factors predicting mortality in patients with scrub typhus requiring both ventilator and vasopressor support in our set up. METHODS: A retrospective analysis of 43 patients with scrub typhus (ELISA IgM positive, optical density ?0.5) admitted in Medical Intensive Care unit of Chitwan Medical College Teaching Hospital between April 2016 to September 2017 was performed considering recovery or death (poor outcome) as outcome measurement. Potential variables (p<0.25) from bivariate analysis were used to perform a multivariate logistic regression analysis (p<0.10) to predict mortality. RESULTS: The mortality rate was 56% (24/43). Acute respiratory distress syndrome and shock were observed in all 43 patients. The median (IQR) duration of ventilation use and vasopressor use was 53(101) hours and 48(79.5) hours, respectively. On bivariate analysis, an independent and statistically significant association of mortality with age in years (p=0.039), number of vasopressor use (p<0.001) and serum creatinine more than 1.4 mg/dl (p=0.012) was observed and on multivariate regression analysis, these variables were also the predictors of mortality (age in years: p=0.011, ?=0.115, OR=1.211, 95% CI=1.027-1.225; number of vasopressor use: p=0.009, ?=3.705, OR=40.647, 95% CI=2.532-652.425; serum creatinine more than 1.4 mg/dl: p=0.046, ?=-2.205, OR=0.110, 95% CI=0.013-0.961) Conclusions: In scrub typhus with ARDS and septic shock, increasing age and serum creatinine, and requiring more than one vasopressor to maintain blood pressure are at increased risk of mortality.

Medical Thoracoscopy for Undiagnosed Exudative Pleural Effusion: A Descriptive Cross-sectional Study.

INTRODUCTION: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion. METHODS: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean±SD and frequency (percentage). RESULTS: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma.  Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively. CONCLUSIONS: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.

Renal Tubular Acidosis and Hypokalemic Paralysis as a First Presentation of Primary Sjögren's Syndrome.

Sjögren's syndrome is an autoimmune disease with multisystem involvement and varying clinical presentation. We report the clinical course and outcome of a case who presented with repeated episodes of hypokalemia mimicking hypokalemic periodic paralysis and metabolic acidosis, which was later diagnosed as distal renal tubular acidosis secondary to primary Sjögren's syndrome. A 50-year-old lady, who was previously diagnosed as hypokalemic periodic paralysis, presented with generalized weakness and fatigue. She was found to have severe hypokalemia with normal anion-gap metabolic acidosis consistent with distal renal tubular acidosis. Subsequent evaluation revealed Sjögren's syndrome as the cause of her problems. Kidney biopsy done to evaluate significant proteinuria revealed nonproliferative morphology with patchy acute tubular injury and significant chronic interstitial nephritis. The patient responded well to potassium supplementation and oral prednisolone. Presentation of this case highlights the necessity of close vigilance while managing a case of repeated hypokalemia, which could be one of the rare clinical manifestations of Sjögren's syndrome.

Assessment of Insulin Injection Practice of Nurses Working in a Tertiary Healthcare Center of Nepal.

INTRODUCTION: Sound knowledge and good practice on insulin injection technique are essential for nurses in order to administer insulin correctly and to educate patients or their relatives adequately. This study aimed to assess the insulin injection practice through the use of insulin pen among nurses working in a tertiary healthcare center of Nepal. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted among 67 nurses working in one of the tertiary healthcare centers of Nepal. Demographic information and insulin injection practice of nurses through the use of insulin pen were assessed using self-administered questionnaire. Each correct practice was scored "1" and incorrect practice was scored "0." Results. The median (IQR) insulin injection practice score of nurses was 11 (9-12) out of 16. Thirty-seven (55.2%) nurses store insulin pen filled with insulin cartridge at room temperature while 57 (85.1%) nurses store unopened cartridge at refrigerator (2-8°C). The practice of hand washing and injection site cleaning was mentioned by 92.5% and 82.1% of the nurses, respectively. However, just over half of the nurses mix the premix (cloudy) insulin and prime insulin pen before each injection. Thirty-four (50.7%) nurses do not lift skin during injection and more than half of the nurses keep needle beneath the skin for less than 5 seconds after completely injecting the required dose of insulin. One out of ten nurses massage injection site after injecting insulin. Most of the nurses (86.6%) use single needle more than once and the median (IQR) frequency of needle reuse was 6 (3-12). Similarly, systematic site rotation was performed by 59 (88.1%) nurses and twenty (29.9%) nurses claim that they use single insulin pen for two different cartridges. CONCLUSION: The insulin injection practice of nurses assessed through the use of insulin pen was suboptimal and highlights the need for urgent educational intervention.

Predictors of Mortality in Scrub Typhus Infection Requiring Intensive Care Admission in Tertiary Healthcare Centre of Nepal.

INTRODUCTION: This study aimed to explore the predictors of mortality from scrub typhus infection in patients requiring intensive care unit (ICU) admission. MATERIALS AND METHODS: A retrospective study was conducted on 120 patients with serum ELISA IgM positive for scrub typhus (optical density ≥ 0.5) admitted at the medical ICU of Chitwan Medical College Teaching Hospital between April 2016 and September 2017. Data was extracted from patient medical records and electronic database of the hospital. The outcome measurement was mortality (Yes/No) due to the infection. A multivariate binary logistic regression analysis (p < 0.10) using potential variables from bivariate analysis (p < 0.25) was adjusted to predict the mortality. RESULTS: The mortality rate was 20% (24/120). Factors associated with mortality, as found using bivariate analysis, were heart rate > 100/minute (p < 0.001), systolic blood pressure < 90 mmHg (p = 0.025), diastolic blood pressure < 60 mmHg (p = 0.032), serum creatinine > 1.4 mg/dl (p < 0.001), acute kidney injury requiring dialysis (p = 0.029), acute respiratory distress syndrome (p < 0.001), and shock requiring vasopressor (p < 0.001). Regression analysis showed age (odds ratio [OR] = 1.063; 95% CI = 1.010-1.118; p = 0.019) and serum creatinine (OR = 1.063; 95% CI = 1.010-1.118; p = 0.019) as significant predictors of poor outcome. CONCLUSION: Older age and high serum creatinine were found to be independent predictors of poor outcome in patients with scrub typhus admitted in medical ICU.

Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique.

Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.

Assessment of Insulin Injection Practice among Diabetes Patients in a Tertiary Healthcare Centre in Nepal: A Preliminary Study.

INTRODUCTION: Proper insulin injection practice is essential for better diabetic control. This study aims to assess the insulin injection practice of patients with diabetes. MATERIALS AND METHODS: A cross-sectional study was conducted at Chitwan Medical College Teaching Hospital, Bharatpur, Nepal, from February 2017 to May 2017. Patients injecting insulin through insulin pens (n = 43) for a minimum of 4 weeks were consecutively recruited. Patients' baseline characteristics, current insulin injection technique, insulin transportation practice, complications of insulin injection, disposal practice of used needle, and acceptability of insulin were recorded. Descriptive statistics were performed using IBM-SPSS 20.0. RESULTS: The insulin injection technique of patients and their relatives was inadequate. The majority of patients and their relatives (25, 58.1%) mentioned that they transport their insulin cartridge without maintaining cold chain. Thirteen patients (30.2%, n = 43) reported complications of insulin injection and the most common complication among those patients was bruising (10, 76.9%, n = 13). Almost all patients disposed the used needle improperly, and the common method was disposing the needle in a dustbin and then transferring to municipal waste disposal vehicle. Insulin was accepted by just 16 (37.2%) patients. CONCLUSION: There was a significant gap between the insulin delivery recommendation through insulin pen and current insulin injection practice.