Search

Introduction and Importance: Hypertensive disorders of pregnancy, including preeclampsia, causes major pregnancy associated morbidity and mortality. Massive ascites is a rare complication in a severe preeclampsia. This case report high lights the importance of obstetrician being aware of such complications of severe preeclampsia, and avoid non-therapeutic interventions such as exploratory laparotomy., Case Presentation: A 39-year-old woman from remote village of Bhutan with severe preeclampsia had spontaneous vaginal delivery in the ambulance at 34 +6 weeks of gestation enroute to a tertiary care hospital. In the postpartum period, she had a massive ascites, and she underwent exploratory laparotomy., Discussion: Ascites in severe preeclampsia is a rare complication. Diagnosis and management of such a rare condition is challenging in a resource constraint setting. In addition, prevalence of tuberculosis and gynecological malignancies in our setting prompts obstetricians to perform an invasive procedure such as exploratory laparotomy in view of excluding these conditions., Conclusion: This case report highlights the importance of obstetricians to be aware of the possibility of ascites in preeclampsia which may be managed medically, without the need for surgical interventions., Competing Interests: Declaration of competing interest The author(s) declare(s) no conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Postoperative nausea and vomiting (PONV) are common distressing symptoms experienced after laparoscopic cholecystectomy. We report the rate, and the factors associated with postoperative nausea and vomiting, the patterns of prophylactic antiemetic prescription, and the anesthetic techniques used among patients who underwent laparoscopic cholecystectomy at the Jigme Dorji Wangchuck (JDW) National Referral Hospital, Bhutan., Methods: A cross-sectional study was conducted at the JDW National Referral Hospital, from January to December 2018. All the patients who underwent laparoscopic cholecystectomy under general anesthesia were included in the study. The demographic variables, premedication, induction agents, muscle relaxants, inhalational agents for maintenance, opioid and adjuvant analgesics, the reversal agents used, and the occurrence of PONV within 24 h were recorded. Data were analyzed using SPSS (version 23). Continuous variables were compared using a t-test or Mann-Whitney test, categorical variables were tested using chi-square or Fisher's exact tests. Binary logistic regression analysis was performed to determine the factors associated with postoperative nausea and vomiting., Results: 190 patients underwent laparoscopic cholecystectomy under general anesthesia. The rate of PONV after laparoscopic cholecystectomy was 31.1% (59/190). Over half (53.7%, 102/190) of the study population were within 21-40 years of age, over 80% (157/190) were female, and 2/3rd were overweight and obese. The most frequently used premedication was ranitidine (39%, 34/87) and metoclopramide (31%, 27/87). More than half (57.4%, 109/190) of the patients received morphine as an opioid analgesic before induction. Sodium thiopentone was a commonly used induction agent (65.8%, 125/190). Succinylcholine and atracurium were mostly preferred muscle relaxants. Isoflurane and air were the most used inhalational anesthetic agents for the maintenance of anesthesia. Ondansetron was the most preferred anti-emetics during the intraoperative period. Previous history of motion sickness (OR 5.8, 95%CI 2.9-11.2, p < 0.001), and use of sodium thiopental (OR 4.1, 95%CI 1.9-9.1, p < 0.001) were independent risk factors for PONV. The use of antiemetics (OR 0.1, 95%CI 0.0-0.4, p = 0.002), propofol (OR 0.2, 95%CI 0.1-0.5, p < 0.001), adjuvant analgesic paracetamol (OR 0.4, 95%CI 0.2-0.8, p = 0.026), and adequate hydration with IV fluids (OR 0.9, 95%CI 0.9-1.0, p = 0.042) were preventive factors for PONV., Conclusion: The rate of PONV after laparoscopic cholecystectomy was high. History of motion sickness and use of sodium thiopental for induction were independent risk factors of PONV. The use of multimodal prophylactic antiemetics was robust and superior to monotherapy in preventing PONV. This finding re-emphasizes the need for risk stratification and appropriate use of antiemetics and anesthetic agents to prevent PONV., (© 2024. The Author(s).)

Bovine tuberculosis (bTB) is a chronic zoonotic disease affecting cattle of all age groups including wild animals. It poses a significant threat to public health and high economic losses to dairy farmers. While the disease has been eradicated from most of the developed countries through extensive surveillance, testing and culling strategy, it is endemic in Africa, Asia, and the Middle East countries. Currently, there is limited research regarding the prevalence of bTB in cattle in Bhutan. This study aimed to determine the seroprevalence of bTB in cattle in six districts of eastern Bhutan. A two-stage probability proportional to size (PPS) sampling strategy was used to determine the number of animals from which serum samples needed to be collected in each district and sub-district. All farms and cattle for sampling were randomly selected from the data in the annual livestock census of 2020. The samples were tested using bTB ELISA test kit. The seroprevalence and their 95% confidence intervals were calculated. Logistic regression models were constructed to assess the influence of various individual animal and environmental risk factors (breed, age, sex, source of animal, body condition scores of animals, respiratory system status) associated with sero-positivity in animals. The study revealed an apparent seroprevalence of 2.57% (25/971 cattle; 95% CI:1.58-3.57), with an estimated true seroprevalence of 0.91% (95% CI: 0.0-2.81). However, none of the variables were found to be significantly associated with bTB seroprevalence in cattle. We recommend, further sampling and employment of confirmatory testing to fully ascertain the extent of bTB in the cattle herds in eastern Bhutan for prevention and control., Competing Interests: ‘The authors have declared that no competing interests exist., (Copyright: © 2024 Wangmo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan., Methods: This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants., Results: Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05)., Conclusion: The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception., (© 2024. The Author(s).)

Background: "REACH-Bhutan" aimed to evaluate the feasibility and clinical performance of a community-based screening program for cervical cancer in rural Bhutan using self-collected samples for high-risk human papillomavirus (HR-HPV) testing., Methods: In April/May 2016, 2590 women aged 30-60 years were screened across rural Bhutan by providing a self-collected sample for careHPV testing. All careHPV-positive women, plus a random sample of careHPV-negative women, were recalled for colposcopy and biopsy. Self-samples also underwent GP5+/6+ polymerase chain reaction (PCR)-based HR-HPV DNA detection and genotyping. Cross-sectional screening indices were estimated against histological high-grade squamous intraepithelial lesions or worse (hHSIL+), including imputation of hHSIL+ in women without colposcopy., Results: HR-HPV positivity was 10.2% by careHPV and 14.8% by GP5+/6+ PCR. Twenty-two cases of hHSIL+ were histologically diagnosed, including one invasive cancer; an additional 7 hHSIL+ were imputed in women without colposcopy. HR-HPV testing by GP5+/6+ showed higher sensitivity for hHSIL+ (89.7%, 95% CI 72.6-97.8) than careHPV (75.9%, 95% CI 56.5-89.7). Negative predictive value was also slightly higher for GP5+/6+ (99.9%, 95% CI 99.6-100) than careHPV (99.7%, 95% CI 99.4-99.9). Specificity, however, was lower for GP5+/6+ (86.1%, 95% CI 84.6-87.4) than careHPV (90.6%, 95% CI 89.4-91.7), as was positive predictive value (6.9%, 95% CI 4.5-9.9 vs. 8.5%, 95% CI 5.4-12.6). Of 377 HR-HPV-positive women by GP5+/6+, 173 (45.9%) were careHPV-positive, including 54.7% HPV16-positive and 30.2% HPV18-positive women., Conclusions: The final REACH-Bhutan results show that screening for cervical cancer with self-collection of samples and HR-HPV testing, in addition to our previous report of achieving high participation, can also perform well to detect women with hHSIL+., (© 2023 International Agency for Research on Cancer; licensed by John Wiley & Sons Ltd. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Colposcopy is a tool for triaging screen positive women regardless of method used for cervical cancer screening. The objective of this study was to evaluate the diagnostic performance of colposcopy in the diagnosis of histologic cervical intraepithelial neoplasia 2+ (CIN 2+) at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu, Bhutan., Methods: This cross-sectional study was conducted from March 2021 to August 2021 among 299 women who availed colposcopy services at the colposcopy clinic of JDWNRH, Bhutan. Women included in this study were either screen positive (Pap smear) or were suspected to have invasive cancer; they underwent colposcopy and a cervical biopsy irrespective of colposcopy impression. This histopathologic assessment was considered as the gold standard test for the diagnosis of cervical intraepithelial neoplasia (CIN) or invasive cancer., Results: The mean age of the study participants was 43 years (ranges, 25-76 years). The sensitivity, specificity and accuracy of senior colposcopists to diagnose histologic CIN 2+ were 80.0% (95% CI 59.30, 93.17), 71.07% (95% CI 62.13, 78.95), and 72.60% (95% CI 64.61, 79.65), and for junior colposcopists were 59.46% (95% CI 42.10, 75.25), 76.72% (95% CI 67.97, 84.04), and 72.55% (95% CI 64.76, 79.45) respectively. The overall sensitivity, specificity, and accuracy of colposcopy to diagnose histologic CIN 2+ were 66.67% (95% CI 53.66, 78.05), 73.73% (95% CI 67.63, 79.23), and 72.24% (95% CI 66.79, 77.24) respectively., Conclusions: In this study, the senior and junior colposcopists had a comparable colposcopic accuracy to diagnose histologic CIN 2+, whereas senior had a higher sensitivity but a lower specificity than junior colposcopists., (© 2022. The Author(s).)

Stomach cancer is a common public health problem in South East Asia including Bhutan. Chronic infection with Helicobacter pylori is regarded as the principal cause of stomach cancer. Herein, we present the incidence of stomach cancer in Bhutan for eight years (from 2014 to 2021). We also discuss the steps taken for the prevention and early detection of stomach cancer., (© Association of Surgeons of India 2022.)

Background and Aims: The shortage of beds at the maternity ward is ever increasing with an increasing trend in total birth and cesarean section deliveries thereby increasing the daily number of obstetric patients awaiting admission. This quality improvement (QI) project was conducted to mitigate the problem of bed shortage by implementing modified enhanced recovery after surgery in low-risk cesarean section mothers. We aimed to increase the process measure of second day postoperative discharge in low-risk cesarean section mothers admitted in the maternity ward from 0% to 25% over 2 months period. Simultaneously, the outcome measure of daily number of obstetric patients awaiting admission was assessed., Methods: The study was conducted at the maternity ward, Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan. Fishbone analysis was used to analyze problems leading to delayed discharge. Interventions were discussed, implemented, and reviewed using Plan, Do, Study, and Act (PDSA) cycle over 8 week period from June 1 to July 31, 2021. Data were collected using the EXCEL sheet and analyzed using STATA 13. Process and outcome measures during the pre and postintervention period were analyzed. Descriptive statistics were used to express the results. Wilcoxon Signed-Rank test was used to determine the statistical significance at p  < 0.05., Results: The postintervention second day postoperative discharge increased to a median value of 65.5% (interquartile range [IQR]: 45-80) compared to the preintervention value of zero. The number of daily waiting obstetric patients decreased from the preintervention median value of 6.0 (IQR: 0-7) to the postintervention median value of 1.0 (IQR: 0-2) which was statistically significant at p  = 0.0001., Conclusion: QI initiative can address bed shortages by increasing the early postoperative discharge, thereby reducing the number of obstetric patients awaiting admissions. The outcome of this QI initiative can be used to provide evidence to modify the existing Standard Operating Procedures in our setup., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Objective: To describe the clinical profile of minimal invasive procedures performed in gynecology at the national referral hospital in Bhutan. A review of such procedures performed in gynecology was needed to assess the baseline information and generate our own experience. We conducted a descriptive study with a review of hospital records of minimal invasive procedures performed from 1st January to 31st December 2020 at the Department of Gynecology. Data were extracted into a structured pro forma. Descriptive statistics were used to express the results., Results: The mean age of the patients was 33.9 ± 8.6 years of which the maximum was in the age group 25-34 years. 28 (17.5%) and 132 (82.5%) patients underwent emergency and elective procedures respectively. 142 (88.8%) and 18 (11.2%) patients underwent laparoscopic and hysteroscopic procedures respectively. Ovarian cystectomy was the most commonly performed procedure. The median operating time was 100 min (IQR 62.5-157.5). The overall complication rate was 2.5%. The median postoperative length of hospital stay was 24 h (IQR 3-24). Using our data and experience, we recommend a new health policy to recognize MIS in gynecology as a subspecialty and strengthen the existing service in gynecological MIS., (© 2022. The Author(s).)

Objective: To investigate the factors associated with cesarean section (CS) in Bhutan., Methods: This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan., Results: The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS., Conclusion: In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph., (© 2020 International Federation of Gynecology and Obstetrics.)

Objectives: The Bhutanese Screening Programme recommends a Pap smear every 3 years for women aged 25-65 years, and coverage ranges from 20% to 60%, being especially challenging in rural settings. The 'REACH-Bhutan' study was conducted to assess the feasibility and outcomes of a novel approach to cervical cancer screening in rural Bhutan., Design: Cross-sectional, population-based study of cervical cancer screening based on the care HPV test on self-collected samples., Setting: Women were recruited in rural primary healthcare centres, that is, Basic Health Units (BHU), across Bhutan., Participants: Overall, 3648 women aged 30-60 were invited from 15 BHUs differing in accessibility, size and ethnic composition of the population., Interventions: Participants provided a self-collected cervicovaginal sample and were interviewed. Samples were tested using care HPV in Thimphu (the Bhutanese capital) referral laboratory., Main Outcome Measures: Screening participation by geographic area, centre, age and travelling time. Previous screening history and care HPV positivity by selected characteristics of the participants., Results: In April/May 2016, 2590 women (median age: 41) were enrolled. Study participation was 71% and significantly heterogeneous by BHU (range: 31%-96%). Participation decreased with increase in age (81% in women aged 30-39 years; 59% in ≥50 years) and travelling time (90% in women living <30 min from the BHU vs 62% among those >6 hours away). 50% of participants reported no previous screening, with the proportion of never-screened women varying significantly by BHU (range: 2%-72%). 265 women (10%; 95% CI 9% to 11%) were care HPV positive, with a significant variation by BHU (range: 5%-19%) and number of sexual partners (prevalence ratio for ≥3 vs 0-1, 1.55; 95% CI 1.05 to 2.27)., Conclusions: Community-based cervical cancer screening by testing self-collected samples for human papillomavirus (HPV) can achieve high coverage in rural Bhutan. However, solutions to bring self-collection, HPV testing and precancer treatment closer to the remotest villages are needed., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)