Knowledge, Attitude and Practice of Disposal of Unused, Unwanted and Expired Medicines among Healthcare Professionals.

Background Unused, unwanted and expired medicines stored at home pose threats to both health systems and environments. Healthcare professionals (HCPs) should be aware of the proper disposal methods of such medicines. Objective To assess the knowledge, attitude and practice of disposal of unused, unwanted and expired medicines among healthcare professionals. Method A web-based cross-sectional descriptive study was conducted among faculties and junior residents at B.P. Koirala Institute of Health Sciences, Dharan, Nepal using a semi-structured proforma. The data were collected through Google Form. Descriptive statistics were calculated. Chi-square test and Student's t test were used for analysis using statistical package for the social sciences at p value of 0.05. Result A total of 294 healthcare professionals with mean age 35.37± 6.630 years were participated out of which 231 (78.6%) were male and 151 (51.4%) were faculties. Mean knowledge score was higher in faculties (2.37±1.111) than the Junior residents (2.33±1.155) [F(1,293)=0.102, p=0.750]. Junior residents (140 out of 143, 97.9%) had a better attitude than faculties (141 out of 151, 93.3%) regarding the disposal of medicines [χ2 (1)=3.558, p=0.059]. Junior residents (36 out of 143, 25.1%) also had a better practice than faculties (24 out of 151, 15.8%) regarding the disposal of medicines [χ2 (1)=3.895, p=0.048]. Conclusion Majority of the Healthcare professionals had positive attitude but poor knowledge and practice regarding disposal of expired and unused medicines. There was a high practice of keeping medicines at home by healthcare professionals. The findings would be useful for planning strategies to minimize unused medicines and foster the appropriate disposal practice.

Massive Hemoptysis and Pulmonary Thromboembolism in a Patient with Pulmonary Tuberculosis: A Therapeutic Conundrum Managed with Bronchial Artery Embolization.

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe lifethreatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

Human Resources for Cardiovascular Disease Management in Nepal: A National Need Assessment.

Background Human resources are the mainstay of the healthcare system. Higher numbers of health workers have better healthcare coverage and outcomes. Availability of trained human resources to address the exponential rise in cardiovascular disease in Nepal is a national concern. Objective To assess the need of human resources for cardiovascular disease management in Nepal. Method We conducted an exploratory sequential mixed-method study. We developed a task force and organized a national workshop to engage stakeholders and collect feedback on the research process. We did a desk review and conducted 24 key informant interviews. We did thematic analysis from the codes generated. Result There is no clear definition and required estimation of health workers for cardiovascular disease management. There is a shortage of health workers with 8.9 doctors, 20.8 nurses, 0.05 cardiologist/cardiac surgeon, 4.2 pharmacist, 10.2 laboratory technicians per 10,000 population. There is a comprehensive human resource plan but it does not provide details of human resources for cardiovascular disease management. There is a lack of public private collaboration for human resource management. However, there is production of human resources for cardiovascular disease management through pre-service specialized courses and inservice training. Conclusion A clear definition and estimation of health workers with stringent human resource plan for cardiovascular disease management is essential. The government can still address these gaps by establishing a well-equipped central health workforce unit and expanding collaboration with private sectors.

Medical Products for Cardiovascular Disease Management in Nepal: a needs assessment study.

Background Medical Products and Technologies is a key component of the health system. Quality medicines and efficient management of the medical products can secure effective cardiovascular diseases management. Objective To collate information and identify strengths, weaknesses, opportunities and threats (SWOT) associated with medical products and technology component for cardiovascular disease management in Nepal. Method This study is a part of a larger rapid assessment of Nepal's health system for cardiovascular disease management and based on The Health System Assessment Approach: A How-To Manual (USAID). The authors conducted a desk review of documents related to the WHO "medical product and technology" building block component and key informant interviews using a pre-tested interview protocol. The first eight interviews were transcribed verbatim and analysed inductively to generate a codebook; and the remaining, transcribed and deductively coded based on the codebook. Findings were categorised into relevant topical area and SWOT components. Result Nepal has laws and provisions for medicine regulation, pharmacovigilance, post marketing surveillance, registration and licensing provisions for pharmacy industries/ outlets, essential medicine lists and national formulary. These provisions also apply to medicines used for cardiovascular diseases. The challenge however, is the lack of effective implementation and monitoring, due to shortages of technical workforce and state of art information and technologies. Information on pharmaceutical expenditures for cardiovascular disease management is scarce; there are no standard national level guidelines that are consistently used to manage cardiovascular diseases in health facilities. Conclusion There are limited provisions and information on medical products for cardiovascular disease management in Nepal, and a need to strengthen existing provisions for medicine regulations and surveillance.

Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal.

Background A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking. Objective This study attempted to assess Nepal's health system gap on organization and delivery of cardiovascular disease prevention and management services. Method This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery. Result We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking. Conclusion Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverage.

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal.

Background Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal. Objective The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes. Method A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using "The Health System Assessment Approach". Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews. Result Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols. Conclusion Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building. KEY WORDS Cardiovascular diseases, Governance, Leadership, Needs assessment, Nepal.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study.

Background Health information system is an integral component of a country's capacity to integrate, process, report, and use information in improving health services. Objective This study aims to assess the infrastructure and capacity of the national Health information system to address cardiovascular diseases in Nepal. Method We adopted the United States Agency for International Development manual "The Health System Assessment Approach: A How-To Manual", Version 2.0. Three topical areas: input, process and output, were identified. Stepwise approach for Health information system assessment was done. A desk review and key informant interview was performed. Audio recordings were transcribed in Nepali language and intercoder reliability was checked. Result The upgraded District Health Information Software 2.3 provides a comprehensive online data management solution. Sustainable funding to upgrade the system exists. Annual report provides performance of all the components of the health care delivery system. Data were reviewed quarterly. However, no dedicated section for cardiovascular diseases in the Health information system is present. Private health facilities are poorly represented. Strategic planning, management, and evaluation of the Health information system are lacking. Inadequacy of timeliness, completeness, and periodicity of the reporting still exist. Conclusion A separate section of cardiovascular diseases in the Health information system is required. Better reporting of private sectors and its inclusion in databases is of utmost importance. Adaptation in the recently introduced federal structure is key for development of Health information system in the country.

National Needs Assessment of Health Information System to Address Cardiovascular Diseases in Nepal: A Mixed Method Study.

Background Health financing is a major domain of health system building blocks. With the epidemiological transition and increasing trend of Cardiovascular diseases (CVDs), it is crucial to assess the status of health financing to address the gap of prevention, control, and treatment of CVDs in Nepal. Objective This paper aims to assess the situation of healthcare financing on Cardiovascular diseases in Nepal. We framed three key functions of health system financing: (a) revenue collection, (b) pooling of resources, and (c) purchasing of services for this study. Method We used sequential explanatory mixed-method research design. We conducted desk reviews, analyzed secondary data on health financing followed by Key-Informant Interviews with five relevant policymakers and experts between February and September 2019. We obtained the Ethical clearance from the Nepal Health Research Council. Result Out of pocket (OOP) expenditure remains the highest source (52%) of total health care expenditure in Nepal, and two third of it is made for NCDs. Out of total current health expenditure on outpatient and inpatient services for fiscal year 2015/16, only 7% of total NCDs was spent on CVDs. Hypertension is the third-most utilized insurance service out of 36 CVD related services provided by the Health Insurance Board. The existing health related social service schemes covers the high costs associated with treatment, and streamlining these services including provider payment mechanisms with the health insurance program could open up opportunities to expand quality CVD services and make it accessible to the marginalized population. Conclusion Health Financing is the integral part of the health system. With the rising burden of cardiovascular diseases and its impact on impoverishment due to high OOP, integrated health care services, budget specification based on the evidence-based burden of disease such as CVD needs to be prioritized by the government.

Radiation Exposure to the Patient During Diagnostic Coronary Angiogram at Dhulikhel Hospital.

BACKGROUND: Radiation is a necessary evil in Coronary Angiogram. The Interventional Cardiology procedure provides huge benefit to the patient but at the cost of radiation. There is evidence of cumulative effect of radiation. Therefore it is essential to keep the radiation dose as minimum as possible. OBJECTIVE: The aim of this study is to find out radiation exposed to the patient undergoing diagnostic coronary angiogram. METHOD: A retrospective study was done. Those patients who underwent diagnostic coronary angiogram were selected for the study. There were total of 166 patients. Radiation exposure in terms of fluoroscopy time in minute and dose area product (DAP) in Gy.cm2 was recorded. RESULT: Out 166 patients 92 were male and 74 female. Age range was from 39 to 79 years with mean age 58.13±9.14. Amount of contrast used was in range of 30 to 100 ml with mean of 45.54±14.06. Range of fluoroscopy time was 2.60 to 37.00 minutes with mean 11.38±6.80. Mean fluoroscopy time in male was 10.92±5.82 minutes and in females it was 11.92±7.68 minutes, with p 0.331. The range of DAP was 11.00 Gy.cm2 to 106.00 Gy.cm2 with mean 40.73±23.58 Gy.cm2. The mean DAP in male and female was 38.77±23.26 Gy.cm2 and 43.16±23.90 Gy.cm2 respectively with p 0.234. CONCLUSION: From this study we can conclude that the radiation exposure to our patient undergoing coronary angiogram is similar to the international values in terms DAP but more in terms of fluoroscopy time. When males and females compared there is no difference.

Assessment of knowledge and practice of community pharmacy personnel on diabetes mellitus management in Kathmandu district: a cross sectional descriptive study.

BACKGROUND: Pharmacists are the most reachable healthcare professionals to many chronically ill patients. It has been found that pharmacists see patients with diabetes up to five times more often than any other healthcare provider. Therefore, to provide quality health care to patients it is important that they have appropriate knowledge and practice on diabetes mellitus management. Thus, this study was conducted to assess the knowledge and practice of diabetes mellitus management among community pharmacy personnel involved in retail community pharmacies of Kathmandu. METHODS: Three hundred and fifteen community pharmacies, selected by systematic random sampling were surveyed by using pre-validated self-administered questionnaires. The first set of questionnaire evaluated the community pharmacy personnel's diabetes knowledge based on a pre-validated 20-item questionnaire. The second set of questionnaire documented about the practice of community pharmacy personnel on diabetes mellitus management which contained 22 questions. Data was entered in EPI Data and analyzed by using SPSS version 20. RESULTS: This survey demonstrated that 76.5 % respondents had poor knowledge and 86.4 % had negative practice on diabetes mellitus (DM) management. Only 26.2 % respondents had good knowledge as well as good practice. 31.4 % of respondents had poor knowledge as well as poor practice on DM management. CONCLUSIONS: Laws and regulations regarding community pharmacy personnel need to be implemented. There should be more advanced and experiment based training. Additionally, the provision for further education curriculum in pharmacy education should be implemented which should intensively include disease and proper management. Guidelines covering diabetes care should be distributed and implemented throughout community pharmacies.

School Teachers' Knowledge about Epilepsy in Kathmandu Metropolitan City.

Background Studies on Knowledge towards epilepsy among school teachers are very limited on developing countries especially with reference to Nepal. Level of knowledge of schoolteachers plays an important role on providing a greater educational support for epileptic child and to maintain good communication skills between epileptic and normal child. Objective Objective of this study is to assess the level of knowledge about epilepsy and its associated factors among school teachers. Method A cross sectional study was conducted from 10th June to 4th July, 2014 among 165 teachers teaching in six different schools of Kathmandu Metropolitan City. A selfadministrated questionnaire consisting of structured and multiple choice questions were designed to collect information on the teacher's socio-demographic profile and knowledge about epilepsy. A scoring system was developed for each question: each correct answer was given a score of 1, and a score of 0 for wrong answer. Total score was categorized on two categories: Good Knowledge and Poor Knowledge. Result Teacher's age did not correlate significantly with their knowledge about epilepsy but total years of teaching experiences and knowledge about epilepsy were found to be positively correlated (ρ= 0.165, p= 0.01). Academic qualification of teachers and different teaching level were associated with level of knowledge (p= 0.023, p= 0.021). Significant difference on knowledge score was found among teachers having different academic qualification (p= 0.019). Conclusion All teachers were aware about epilepsy, but their knowledge about epilepsy was not sufficient therefore, health education training program about epilepsy is needed for teachers.

Exome Sequencing and CNV Analysis on Chromosome 18 in Small Intestinal Neuroendocrine Tumors: Ruling Out a Suspect?

The genetic background in small intestinal neuroendocrine tumors is poorly understood, but several studies have revealed numerical imbalances. Loss of one copy of chromosome 18 is the most frequent genetic aberration in this tumor type, which indirectly suggests that a driver mutation may be present in the remaining allele. The aim of this study was to evaluate the mutation status on chromosome 18 in small intestinal neuroendocrine tumors. DNAs from 7 small intestinal neuroendocrine tumors were subjected to whole exome capture, followed by next generation sequencing and high resolution SNP array followed by copy number variation analysis. Exome capture sequencing generated an average coverage of 50.6-138.2. Only 19 genes were covered less than 8X. No tumor-specific somatic mutation was identified. Genomic profiling revealed loss of chromosome 18 in 5 out of 7 small intestinal neuroendocrine tumors and a number of other aberrancies. Loss of chromosome 18 is the most frequent genetic aberration in small intestinal neuroendocrine tumors, but no evidence for eventual mutations in the remaining allele. This suggests involvement of other mechanisms than point mutations in small intestinal neuroendocrine tumors tumorigenesis.

Return to preinjury status after routine knee arthroscopy in military population.

BACKGROUND: Knee arthroscopy is frequently advised procedure for knee-related problems in serving soldiers. The scanty published literatures have documented wide range of recovery duration ranging from nine days to four weeks even for routine uncomplicated arthroscopy. However, neither of these studies evaluated military population, where arthroscopic procedures are frequent and physical demands are different. The aim of this study was to ascertain the time required to return to unrestricted physical activities in serving military population. METHODS: This was a prospective descriptive study enrolling 51 patients who underwent two portal arthroscopic procedures like diagnostic arthroscopy, meniscectomy, loose body removal and excision of plica or combination of these. A uniform home based physiotherapy protocol was used for everyone. All of them were followed up at 2nd, 4th, 6th, 8th and 12th postoperative weeks. At each follow up, 2000 International Knee Documentation Committee subjective knee evaluation form was filled and submitted for analysis. RESULTS: Although all of our patients were able to walk around without any support at two weeks follow up, 88% had restriction to activities of daily living because of knee related problems. The mean International Knee Documentation Committee score was 41 at 1st follow up, which gradually improved to 64, 86, 94, 94 at 4th, 6th, 8th and 12th week follow up respectively. At 6 weeks 91% resumed their preinjury status which reached 94% in eight weeks. CONCLUSIONS: Most of the soldiers return to unrestricted activities within six to eight weeks after diagnostic arthroscopy, meniscectomy, loose body removal and excision of plica or combination of these procedures.

The basis of antagonistic pleiotropy in hfq mutations that have opposite effects on fitness at slow and fast growth rates.

Mutations beneficial in one environment may cause costs in different environments, resulting in antagonistic pleiotropy. Here, we describe a novel form of antagonistic pleiotropy that operates even within the same environment, where benefits and deleterious effects exhibit themselves at different growth rates. The fitness of hfq mutations in Escherichia coli affecting the RNA chaperone involved in small-RNA regulation is remarkably sensitive to growth rate. E. coli populations evolving in chemostats under nutrient limitation acquired beneficial mutations in hfq during slow growth (0.1 h(-1)) but not in populations growing sixfold faster. Four identified hfq alleles from parallel populations were beneficial at 0.1 h(-1) and deleterious at 0.6 h(-1). The hfq mutations were beneficial, deleterious or neutral at an intermediate growth rate (0.5 h(-1)) and one changed from beneficial to deleterious within a 36 min difference in doubling time. The benefit of hfq mutations was due to the greater transport of limiting nutrient, which diminished at higher growth rates. The deleterious effects of hfq mutations at 0.6 h(-1) were less clear, with decreased viability a contributing factor. The results demonstrate distinct pleiotropy characteristics in the alleles of the same gene, probably because the altered residues in Hfq affected the regulation of expression of different genes in distinct ways. In addition, these results point to a source of variation in experimental measurement of the selective advantage of a mutation; estimates of fitness need to consider variation in growth rate impacting on the magnitude of the benefit of mutations and on their fitness distributions.