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Highlights • Diaphragmatic rupture is a rare complication of abdominal trauma. • Herniation of abdominal contents can occur following diaphragmatic rupture. • Spleen was present in the thorax in a case following blunt abdominal trauma. • Care should be taken when inserting a chest tube in suspected cases. • Treatment is surgical via Laparotomy or Thoracotomy., Introduction Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur. Presentation of case Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax. Discussion Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents. Conclusion Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

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.

Background Hypertension and headache disorders are major contributors to public ill health, linked by a long-standing but questionable belief that hypertension is a conspicuous cause of headache. In Nepal, where hypertension is common and often untreated, we assessed the substance of this belief, hypothesising that, should hypertension be a significant cause of headache, a clear positive association between these disorders would exist. Methods In a cross-sectional, nationwide study, trained health workers conducted face-to-face structured interviews, during unannounced home visits, with a representative sample of the Nepalese adult population (18–65 years). They applied standard diagnostic criteria for headache disorders and measured blood pressure digitally. Hypertension was defined as systolic pressure ≥140 and/or diastolic ≥90 mm Hg. Results Of 2,100 participants (59.0% female, mean age 36.4 ± 12.8 years), 317 (15.1%) had hypertension (41.0% female) and 1,794 (85.4%) had headache (61.6% female; 728 migraine, 863 tension-type headache, 161 headache on ≥15 days/month [mutually exclusive diagnoses]; 42 unclassified headaches). All headache collectively was less prevalent among hypertension cases (78.9%) than non-cases (86.6%; p = 0.001). A negative association between hypertension and all headache was demonstrated in bivariate analysis (odds ratio: 0.6 [95% Confidence interval: 0.4–0.8]; p Conclusions If any association exists between hypertension and headache disorders, it is negative. From the public-health perspective, headache disorders and hypertension are unrelated entities: they need distinct policies and programs for prevention, control and management.

ObjectiveTo explore the perception of obesity and overweight among Nepalese adults living in a suburban community.DesignA qualitative study composed of focus group discussion (FGD) and in-depth interview (IDI).SettingCommunity and healthcare facilities in Dhulikhel, Nepal.ParticipantsFour FGDs were conducted with community members (n=22) and four IDIs were conducted with healthcare providers (HCPs).ResultsObesity is a rising problem in this suburban community. Participants had inadequate knowledge regarding the consequences of obesity, and they perceived overweight as normal, healthy and attractive. The participants above 40 years of age did not perceive themselves to be overweight or obese. Despite participants’ awareness of the importance of diet control and exercise to prevent obesity, these were not translated into practice.ConclusionsThis study provided insight into perceptions of obesity in a suburban Dhulikhel community through both community members’ and HCPs’ perspective. Misconceptions and inadequate knowledge of obesity among people in this community indicate the need for health education and intervention programme to increase health awareness and preventive practices.

While chronic lung disease causes substantial global morbidity and mortality, global estimates have primarily been based on broad assumptions. Specific country data from low-income countries such as Nepal are limited. This review assessed primary evidence on chronic respiratory disease burden among adults in Nepal. A systematic search was performed in June 2019 (updated May 2020) for studies through nine databases. High levels of heterogeneity deemed a narrative synthesis appropriate. Among 27 eligible studies identified, most were low-moderate quality with cross-sectional and retrospective study design. Chronic lung diseases identified were chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis and restrictive lung diseases. Studies were categorised as: (i) community-based, (ii) hospital-based and (iii) comorbidity-related and disease burden. Reported disease prevalence varied widely (COPD, 1.67–14.3%; asthma, 4.2–8.9%). The prevalence of airflow obstruction was higher among rural dwellers (15.8%) and those exposed to household air pollution from domestic biomass burning as opposed to liquid petroleum gas users (Odds Ratio: 2.06). Several comorbidities, including hypertension and diabetes mellitus added to the disease burden. The review shows limited literature on lung disease burden in Nepal. Publications varied in terms of overall quality. Good quality research studies with prospective cohorts related to respiratory conditions are required.

Background Cardiovascular diseases (CVDs) are the leading cause of death and disease burden globally, disproportionately affecting low and middle-income countries. The continued scarcity of literature on CVDs burden in Nepal has thwarted efforts to develop population-specific prevention and management strategies. This article reports the burden of CVDs in Nepal including, prevalence, incidence, and disability basis as well as trends over the past two decades by age and gender. The findings from this study provide a base for public health priorities and for creating evidence-informed policies.Methods We used the Institute of Health Metrics and Evaluation (IHME)’s Global Burden of Diseases (GBD) database on cardiovascular disease mortality rates, prevalence, incidence, disability-adjusted life-years (DALYs), years of life lost (YLLs) and years lived with disability (YLDs) from Nepal to describe the most recent data available (2017) and trends by age, gender and year from 1990 to 2017. Tables, graphs and histograms are used to compare patterns and trends across all metrics. Data are presented as percentages or as rates per 100,000 population.Results In 2017, CVDs contributed to 26·9% of total deaths and 12·8% of total DALYs in Nepal. Ischemic heart disease and stroke were the predominant CVDs, contributing 16·4% and 7·5% to total deaths and 7·5% and 3·5% to total DALYs, respectively. Cardiovascular disease incidence and mortality rates have increased from 1990 to 2017, with the burden greater among males and among older age groups. The leading risk factors for CVDs were determined to be high systolic blood pressure, high low density lipoprotein (LDL) cholesterol, smoking, air pollution, a diet low in whole grains, and a diet low in fruit.Conclusion CVDs are a major public health problem in Nepal contributing to the high DALYs with unacceptable numbers of premature deaths. There is an urgent need to address the increasing burden of CVDs and their associated risk factors, particularly high blood pressure, body mass index (BMI) and unhealthy diet.

The 3 pillars that are effective in improving trainee performance and retention among busy early career investigators are companionship, light, and fuel.The research training process is a long-term journey where having companionship from peers and senior colleagues is essential.Strong mentorship provides light along the way whose successes can serve as lighthouses and beacons while illuminating the paths of early career investigators.Seed grants enable trainees to actually do research, applying what they have learned into practice to make a difference in global cardiovascular health. Fil: Yan, Lijing L.. Duke Kunshan University; China Fil: Vedanthan, Rajesh. University of New York; Estados Unidos Fil: Mensah, George A.. Kathmandu University; Nepal Fil: Karmacharya, Biraj. Kathmandu University; Nepal Fil: Shrestha, Archana. Kathmandu University; Nepal Fil: Fitzpatrick, Annette. University of Washington; Estados Unidos Fil: Duc, Ha Anh. No especifíca; Fil: Tandon, Nikhil. No especifíca; Fil: Davila Roman, Victor G.. University of Washington; Estados Unidos Fil: Huffman, Mark D.. Northwestern University; Estados Unidos. George Institute For Global Health; Australia Fil: Miranda, J. Jaime. Universidad Peruana Cayetano Heredia; Perú Fil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Koju, Rajendra. Kathmandu University; Nepal Fil: Newsome, Brad. No especifíca; Fil: Yusuf, Salim. Hamilton Health Sciences; Canadá

Rheumatic heart disease is the most important consequence of acute rheumatic fever. Both are common cardiovascular problems in Nepal. Echocardiographic detection of rheumatic heart disease is important to establish the diagnosis. The involvement of valves and their severity guides the therapeutic options. A total of 133 valvular heart disease cases attended in Dhulikhel Hospital between July 2008 to June 2009 were analyzed. Fifty-one patients, in whom the problems were rheumatic in origin were studied. Among them, 12% (6) had isolated aortic valve involvement, 35%(18) had isolated mitral valve and 53%(27) ahd mixed involvement. Severe mitral stenosis accounts for 24% of all mitral stenosis and severe aortic stenosis is 20% fo all aortic stenosis. The rates for severe mitral regurgitation and severe aortic regurgitaiton are 30% and 28% respectively. Although the study population has a high number of female patients, the differences in the rates of involvement of aortic or mitral valve in both genders are statistically insignificant. The study, although small, confirms that in this population, females are more commonly affected, that the mitral valve is the most commonly damaged valve and that disease affecting multiple valves is marginally more common than isolated valve disease. The detection of valvular involvement at different stages can guide the therapeutic options.

Background Cardiovascular disease represents the largest burden on global health, important modifiable risk factor being hypertension. Difference in response to antihypertensive medication depending on ethnic group is well recognized. There is very few data regarding this difference in the South Asian population especially from Nepal.Objective The aim of this study is to find out which antihypertensive medication has better efficacy in our population.Method One seventy two newly diagnosed hypertensive patients who presented to cardiology OPD were included. Blood Pressure (BP) was recorded in both arms at least three times. Patients were counseled for lifestyle and dietary modification and were prescribed one of the three drugs Hydrochlorthiazide 25 mg or Amlodipine 5 mg or Enalapril 5 mg. Patients were called back in 4-6 weeks time and Blood Pressure was recorded in similar manner.Result Out of 172 patients, 97 were male and 75 female. The mean age was 55.49±1.03 years. Mean Systolic BP before treatment was 156.2±10.6 mm of Hg and Mean Diastolic BP before treatment was 100.5 ±6.8 with no statistically significant difference among different groups. However Systolic BP reduction was 14.6 ±5.1, 21.9±5.9 and 21.8±7.4 by Hydrochlorthiazide , Amlodipine and Enalapril respectively. Diastolic BP reduction was 8.8±2.5, 14.2±2.8 and 14.3±2.9 by Hydrochlorthiazide, Amlodipine and Enalapril respectively.Conclusion Amlodipine and Enalapril are equally effective in controlling BP in our population. Hydrochlorthiazide is less effective than both Amlodipine and Enalapril.

Introduction: Tuberculosis (TB) ranks as the seventh leading cause of death in Nepal. Similarly, the prevalence of Diabetes Mellitus (DM) has also shown an increasing trend in the country and it has been observed that diabetes is strongly associated with falling treatment outcome of tuberculosis. Hence, the association of tuberculosis with Type 2 Diabetes Mellitus (T2DM) might be higher than the assumption and it needs more attention as well as appropriate measures to improve treatment outcomes of both diseases. Aim: To determine the risk factors of T2DM comorbidity among TB patients in the Central Development Region of Nepal. Materials and Methods: A case-control study was conducted by administration of structured questionnaire interview among all forms of pulmonary tuberculosis patients. A total of 102 tuberculosis patients with T2DM who met the inclusion criteria were considered as cases and 306 non-diabetes tuberculosis cases were considered as controls. The study was conducted among the patients attending the tuberculosis treatment centres of all 19 districts of central Nepal. The risk factors of diabetes among tuberculosis patients was estimated by using unconditional multiple logistic regression, adjusted odds ratio and their 95% CI were measured. Results: This present study found that the risk factors of type 2 DM comorbidity among tuberculosis patients were; age ≥45 years (adj. OR=8.00, 95% CI: 4.21-15.21, p-value

Introduction: Low and middle income countries have the largest burden of stroke, accounting for more than 85% of stroke deaths globally. As many low- and middle-income countries, including Nepal, transition from communicable to non-communicable diseases (NCDs), the impact of stroke on cognition becomes increasingly important. Methods: Data on cardiovascular risk factors and cognition were collected as part of the Dhulikhel Heart Study, a longitudinal study to evaluate risk factors for heart disease and stroke in Dhulikhel, a community outside of Kathmandu, Nepal. In Phase 1 of the baseline exam, 252 randomly-selected adults age 50 and older completed the Mini-Mental Exam (MMSE) and Digit Spans ( DST) forward and backward as part of a home interview. Mild stroke symptoms were collected by self-report the Questionnaire for Verifying Stroke-Free Status (QVSFS). Multiple linear regression evaluated associations between stroke symptoms and cognition adjusted for demographics (age, sex, education, religion, and ethnicity) and CVD risk factors (smoking, exercise, BMI, blood pressure, hypertension, and diabetes). Results: Mean age of study participants was 62.4 years (SD 9.2) and 57.5% were women. The mean MMSE score (weighted for illiteracy) was 18.7 (SD 6.4) and 19% reported to have had at least one of five stroke symptoms (sudden one-sided numbness or weakness, sudden vision-loss, inability to express oneself or inability to understand). An increased risk of lower memory score was found with report of a previous episode of numbness (DST backward: B=-1.17, SE=0.34, p=0.001). Borderline associations (.05 < p Conclusions: Associations between previous stroke symptoms and reduced cognition emphasize the need to screen and treat persons with undiagnosed stroke or TIAs in low-resource settings. A reduction in modifiable vascular risk factors is also needed to reduce CVD and associated dementia.

Background There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal. Methods Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days. Results In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%). Conclusions Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed. © Author(s) 2019. This work is distributed under the Creative Commons Attribution 4.0 License.

Tuberculosis (TB) is still a major public health challenge in Nepal and worldwide. Most transmissions occur between the onset of symptoms and the consultation with formal health care centers. This study aimed to determine the duration of delay for the first consultation and its associated factors with unacceptable delay among the new sputum pulmonary tuberculosis cases in the central development region of Nepal. An analytical cross-sectional study was conducted in the central development region of Nepal between January and May 2015. New pulmonary sputum positive tuberculosis patients were interviewed by using a structured questionnaire and their medical records were reviewed. Among a total of 374 patients, the magnitude of patient delay was 53.21% (95% CI: 48.12–58.28%) with a median delay of 32 days and an interquartile range of 11–70 days. The factors associated with unacceptable patient delay (duration ≥ 30 days) were residence in the rural area (adj. OR = 3.10, 95% CI: 1.10–8.72;pvalue = 0.032) and DOTS center located more than 5 km away from their residences (adj. OR = 5.53, 95% CI: 2.18–13.99;pvalue < 0.001). Unemployed patients were more likely to have patient delay (adj. OR = 7.79, 95% CI: 1.64–37.00;pvalue = 0.010) when controlled for other variables.

Objective The purpose of this study was to translate, cross-culturally adapt, and assess the reliability and validity of the Pelvic Girdle Questionnaire (PGQ) in pregnant Nepalese women. Methods The cross-cultural adaptation process was conducted according to the Guillemin guidelines. Reliability and validity were assessed using cross-sectional design. The participants responded to questionnaires of sociodemographics, the Nepali version of the PGQ, the Oswestry Disability Index, the Patient-Specific Functional Scale, the 5-item version of the Edinburgh Depression Scale, and the Numerical Pain Rating Scale. The internal consistency was assessed with Cronbach's alpha. The test–retest reliability was calculated using the intraclass correlation coefficient and smallest detectable change. Construct validity was assessed by testing 9 a priori hypotheses that examine correlations between the PGQ activity and symptom subscales, and also among the PGQ subscales and Oswestry Disability Index, Numerical Pain Rating Scale, Patient-Specific Functional Scale, and 5-item version of the Edinburgh Depression Scale. Spearman and Pearson's correlation were used to assess the correlations. Results A sample of 111 pregnant women were included in the study. The Cronbach's alpha for the Nepali version of the total PGQ was good (α = 0.83), and the test–retest reliability was acceptable (ICC2.1, 0.72) with a measurement error of SDC95% 18.6 points. Seven of the 9 hypotheses found support, which confirms acceptable construct validity of the Nepali PGQ. Conclusion The Nepali version of the PGQ is a reliable and valid tool for assessing pelvic girdle pain in pregnant Nepalese women.

Introduction Natural disasters pose a great challenge to the health systems and individual health facilities. In low-resource settings, disaster preparedness systems are often limited and not been well described. Two devastating earthquakes hit Nepal within a 17-days period in 2015. This study aims to describe the burden and distribution of emergency cases to a local hospital. Methods This is a prospective observational study of patients presenting to a local hospital for a period of 21 days following the earthquake on April 25, 2015. Demographic and clinical information was prospectively registered for all patients in the systematic emergency registry. Systematic telephone interviews were conducted in a random sample of the patients 90 days after admission to the hospital. Results A total of 2,003 emergency patients were registered during the period. The average daily number of emergency patients during the first five days was almost five times higher (n = 150) than the pre-incident daily average (n = 35). The majority of injuries were fractures (58%), 348 (56%) in the lower extremities. A total of 345 surgical procedures were performed and the hospital treated 111 patients with severe injuries related to the earthquake (compartment syndrome, crush injury, and internal injury). Among those with follow-up interviews, over 90% reported that they had been severely affected by the earthquakes; complete house damage, living in temporary shelter, or loss of close family member. Conclusion The hospital experienced a very high caseload during the first days, and the majority of patients needed orthopaedic services. The proportion of severely injured and in-hospital deaths were relatively low, probably indicating that the most severely injured did not reach the hospital in time. The experiences underline the need for robust and easily available local health services that can respond to disasters. © 2018 Giri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License.

Objective This study aimed to evaluate if domestic violence affected women’s ability to prepare for childbirth. Birth preparedness and complication readiness (BP/CR) includes saving money, arranging transportation, identifying a skilled birth attendant, a health facility, and a blood donor before childbirth. During data collection, Nepal experienced two earthquakes and therefore it was possible to examine associations between domestic violence, women’s BP/CR and effects of the earthquakes. Methods Women who were between 12 and 28 weeks of gestation participated in a descriptive cross-sectional study at a hospital antenatal clinic in Nepal, where they completed a structured questionnaire on sociodemographic characteristics, obstetric history, experiences of domestic violence, and BP/CR. The 5-item Abuse Assessment Screen was used to assess prevalence of domestic violence, and a questionnaire on safe motherhood obtained from Jhpiego was used to assess BP/CR status. The participants self-completed the questionnaire on a tablet computer. Those who reported at least three out of five BP/CR activities were considered prepared for childbirth. Results A total of 1011 women participated in the study: 433 pre-earthquakes and 578 post-earthquakes. With respect to BP/CR, 78% had identified a health facility for childbirth and 65% had saved money prior to childbirth. Less than 50% had identified a birth attendant to assist with the delivery, transportation to a health facility, or arranged for a potential blood donor. Prior to the earthquakes, 38% were unprepared; by contrast, almost 62% were not prepared after the earthquakes. A significant association was found between exposure to violence and not being prepared for childbirth (AOR = 2.3, 95% CI: 1.4–3.9). The women with increased odds of not being prepared for childbirth were illiterate (AOR = 9.9, 95% CI:5.7–17), young (AOR = 3.4, 95% CI:1.6–7.2), from the most oppressed social classes (AOR = 3.0, 95% CI:1.2–7.6), were married to illiterate husbands (AOR = 2.5, 95% CI:1.2–5.2), had attended fewer than four antenatal visits (AOR = 2.0, 95% CI: 1.4–2.6), had low incomes (AOR = 1.7, 95% CI:1.1–2.9) or lived in rural settings (AOR = 1.5, 95% confidence interval CI:1.2–2.1). Conclusion The paper identifies vulnerable women who require extra care from the health system, and draws attention to the need for interventions to reduce the harmful effects of domestic violence on women’s preparations for childbirth. © 2018 Pun 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.

Background Thyroid dysfunction (TD) and metabolic syndrome (MetS) are known risk factors for atherosclerotic cardiovascular disease (ASCVD). TD is risk factor for ASCVD mediated by the effects of thyroid hormones on lipid metabolism and blood pressure hence the components of MetS. It is possible that coexistence of these two disease entities and unrecognized TD in patients with MetS might substantially increase ASCVD risk. Moreover, little is known about the relationship between TD and the components of MetS. Thus, the purpose of this study was to evaluate the pattern of TD in patients with MetS and its relationship with components of the MetS. Methods A total of 358 previously diagnosed patients with MetS were recruited in the study. The thyroid function test parameters were measured to classify TD at Dhulikhel Hospital-Kathmandu University Hospital, Dhulikhel, Nepal. Statistical analyses were performed using SPSS version 16.0 to evaluate pattern and relationship. Results The overall prevalence of TD in patients with MetS was 31.84% with high prevalence of subclinical hypothyroidism (29.32%). We found no evidence of a relationship between TD and components of MetS, although there was significant difference in waist circumference between four groups of TD. Conclusion Patients with MetS had subclinical hypothyroidism greatly. Although there was no evidence of any relationship between thyroid status and all components of MetS, TD should be taken into account when evaluating and treating patients with MetS to reduce the impending risk.

Although previous studies have suggested alarming rise in the prevalence of hypertension in Nepal, there is dearth of information on its awareness, treatment and control. In this cross-sectional study, we assessed awareness, treatment and control of hypertension among 298 hypertensive adults from the suburban town of Dhulikhel, Nepal.This cross-sectional study is based on Dhulikhel Heart Study, which included 1073 adults, aged ≥18 years, recruited from randomly selected households. Comprehensive health interviews and blood pressure measurements were completed during home interviews. Hypertensives (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or receiving antihypertensive medication) were further evaluated for awareness, treatment and control of hypertension. Multivariate regression model quantified the association of the sociodemographic characteristics and the cardiovascular disease (CVD) risk factors with hypertension awareness. Differences between sociodemographic characteristics and CVD risk factors with treatment and control of hypertension were tested using χA total of 43.6% of all hypertensives (n=298) were aware of their hypertension status. In multivariate analyses, hypertension awareness was associated with increasing age (p0.001). More than three-fourth (76.1%) of those who were aware of their hypertension status (n=130) were currently on treatment. There were significant differences in treatment status by sex, occupation, age, income quartiles and body mass index. Only 35.3% of those on treatment (n=99) had blood pressure control.The levels of awareness, treatment and control of hypertension in this sample of Nepalese adults were low.

This study assessed drinking water quality, sanitation, and hygiene (WASH) conditions among 708 schoolchildren and 562 households in Dolakha and Ramechhap districts of Nepal. Cross-sectional surveys were carried out in March and June 2015. A Delagua water quality testing kit was employed on 634 water samples obtained from 16 purposively selected schools, 40 community water sources, and 562 households to examine water quality. A flame atomic absorption spectrophotometer was used to test lead and arsenic content of the same samples. Additionally, a questionnaire survey was conducted to obtain WASH predictors. A total of 75% of school drinking water source samples and 76.9% point-of-use samples (water bottles) at schools, 39.5% water source samples in the community, and 27.4% point-of-use samples at household levels were contaminated with thermo-tolerant coliforms. The values of water samples for pH (6.8–7.6), free and total residual chlorine (0.1–0.5 mg/L), mean lead concentration (0.01 mg/L), and mean arsenic concentration (0.05 mg/L) were within national drinking water quality standards. The presence of domestic animals roaming inside schoolchildren’s homes was significantly associated with drinking water contamination (adjusted odds ratio: 1.64; 95% confidence interval: 1.08–2.50; p = 0.02). Our findings call for an improvement of WASH conditions at the unit of school, households, and communities.

We developed a food frequency questionnaire (FFQ) designed to measure the dietary practices of adult Nepalese. The present study examined the validity and reproducibility of the FFQ. To evaluate the reproducibility of the FFQ, 116 subjects completed two 115-item FFQ across a four-month interval. Six 24-h dietary recalls were collected (1 each month) to assess the validity of the FFQ. Seven major food groups and 23 subgroups were clustered from the FFQ based on macronutrient composition. Spearman correlation coefficients evaluating reproducibility for all food groups were greater than 0.5, with the exceptions of oil. The correlations varied from 0.41 (oil) to 0.81 (vegetables). All crude spearman coefficients for validity were greater than 0.5 except for dairy products, pizzas/pastas and sausage/burgers. The FFQ was found to be reliable and valid for ranking the intake of food groups for Nepalese dietary intake.

Background Peer leadership is widely recognized as an effective approach to health promotion and empowerment among people of similar ages, especially the youth. Such programs build peer leaders who in turn help empower the youths in their groups to improve their health and life skills related to health. Most previous studies have focused on the effectiveness of such activities in target groups but have neglected to effectively address and explore the transformations in peer leaders themselves. Objectives This descriptive study aimed to investigate the level of social change and health consciousness among student peer leaders in three Youth health promotion programs in Thailand: Friend’s Corner, Smart Consumer and Volunteer Minded Young Dentists, and to compare them with the general students. Methods The study was conducted using a self-administered questionnaire, which was developed based on Tyree’s Social Change Model of leadership, Gould’s concept and Dutta-Bergman’s concept. The study population comprised of 11th grade students (N=660) from Kalasin Province in Thailand, 320 of whom were peer leaders. Results The findings revealed that the peer leaders scored higher than non peer leaders in all domains. Among the peer leaders, it was found that Volunteer Minded Young Dentists group had the highest scores in “controversy with civility”, “social change agent” characteristics, “holistic health perceptions” and “responsibility for one’s own health” regarding health consciousness. Conclusion The results of this study confirmed that the peer leadership approach can help young people to develop life skills through social transformation and increase health consciousness for better status of health in the community. DOI: http://dx.doi.org/10.3126/kumj.v11i1.11025 Kathmandu University Medical Journal Vol.11(1) 2013: 41-44

Background and Aim : Echocardiograph is an important diagnostic tool to evaluate cardiac disease and is indispensible for management. So it is important to know the spectrum of cardiac abnormalities that can be detected by echocardiograph and the frequency of these findings may vary depending on where the echocardiogram is performed. Aim of this study was to find out the spectrum of echocardiographic finding in different age group in a medical college hospital. Methods and materials : A retrospective observational study was done to at Dhulikhel Hospital to review Echocardiographic profile of 3310 patients who were indicated for echocardiogram over a period of 3 years. Data collected from echocardiograph report registry. Data analysis was done using SPSS 17. Result : Congenital Heart Disease(CHD) (37.74%),Normal finding( 21.19%), Pericardial Heart Disease(19.21%) and Rheumatic Heart Disease(RHD)(17.88%) were the echocardiographic finding in children. In adolescents and young adults Rheumatic Heart Disease (49.90%), Hypertensive Heart Disease (13.34%), Congenital Heart Disease (6.58%), and Pericardial Disease (4.38%) were found. Most common finding in middle age was cor-pulmonale (34.76%) followed by Diastolic Dysfunction (20.60%), Hypertensive Heart Disease(17.06%),Ischemic Heart Disease(IHD) (12.80%). In elderly age most common finding was Diastolic Dysfunction (57.14%). Conclusion : The spectrum of echocardiograph finding in a medical college hospital ranges from Congenital Heart Disease, Rheumatic Heart Disease, Ischemic Heart Disease ,Pericardial disease, Corpulmonale, Diastolic Dysfunction, systolic dysfunction and degenerative valve disease. Streptococcal sore throat leading to Rheumatic Heart Disease and complication of tuberculosis and parasitic infestation leading to pericardial diseases, as well as Hypertensive Heart Disease, and Ischemic Heart Disease constitutes burden in Nepal. Cor-pulmonale and ) Sanjaya Humagain, Ramsundar Twayana, Rajendra Koju. DOI: http://dx.doi.org/10.3126/njh.v11i1.10976 Nepalese Heart Journal 2014;11(1): 13-17

Highlights NCD represent a serious challenge globally, particularly in LMIC. Implementation research capacity building are critical to inform the prevention and control of NCD in LMIC. Sustainable evidence-based strategies can reduce mortality and prevent avoidable illness from NCD. Strategic change agents (i.e., key stakeholders, institutions, communities, health systems, patients, and families) should work collaboratively to make the necessary advancements to reducing the burden of NCD in LMIC.

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. Kathmandu University Medical Journal Vol.13(1) 2015; 61-63

Hypertension is one of the major cardiovascular problems in middle and low income countries. There are few studies conducted in Nepal which shows significant number of hypertensive popu­lation in suburban area. Systematic random sampling from voter lists of all the members more than 18 years of age of Dhulikhel Municipality was done. 796 among 1150 sampled population were interviewed and their blood pressure was measured twice using mercury sphygmomanom­eter in standard method in their home. The average blood pressure was taken for study. Hyper­tension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, and/or on antihypertensive treatment. Total number of study population was 796. Among them 490 (61.6%) were female and 306 (38.4%) were male with age ranging from 18 years to 88 years (mean 48.41±17.38). Overall prevalence of hypertension was 28.9% (male 28.8%, female 29%). The prevalence was increasing with age (11.1% in 70 years). Ac­cording to JNC 7, 29.1% were in Pre-hypertensive group. This study shows that Hypertension is significant in suburban area of Nepal. Nepalese Heart Journal | Volume 7 | No.1 | November 2010 (special issue) | Page 35-39 DOI: http://dx.doi.org/10.3126/njh.v7i1.8500

A stroke is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. It is a medical emergency that requires rapid diagnosis and treatment. The availability of CT Scan has made it easier for early diagnosis and intervention. The aim of this study was to identify the risk factors (eg. hypertension, diabetes mellitus and cigarette smoking) commonly seen in patients admitted in the hospital with stroke along with age group, sex distribution, duration of stay in the hospital and the occupancy of stroke patients admitted in medical ward. A total of 51 stroke patient were admitted in medical ward in the review period. CT scan was used to dif­ferentiate hemorrhagic from ischemic stroke. Patients were analyzed in terms of risk factors (like hypertension, diabetes mellitus and cigarette smoking) along with age and sex. In case of ischemic stroke along with CT Scan, ECG, Echocardiography, Carotid Doppler was done accordingly. Out of 2307 total admissions in medical ward, 51 cases (2.2%) were stroke patients. Among the stroke cases, 59% constituted male and 41% female. Similarly around 25% of the total cases were Dia­betic / Hypertensive both or alone, 35% of the total cases were smokers, 48.6% of the cases were in the 51-70 age groups. 61% stayed in the hospital for 5 days or less. Cerebrovascular disease carries a lot of financial, physical, social and emotional implications. If we can address the modifiable risk factors, we can reduce the incidence of stroke. Nepalese Heart Journal | Volume 7 | No.1 | November 2010 (special issue) | Page 40-43 DOI: http://dx.doi.org/10.3126/njh.v7i1.8501

The ischaemic heart disease is one of the most common cause of preventable deaths. The number of deaths due to ischaemic heart disease has been reported to be on the rise in the low and mid­dle income countries. Data on the prevalence and risk profile of ischaemic heart disease is scarce in Nepal. The aim of this study was to analyze the demographic and risk profile of patients with ischaemic heart disease admitted at Dhulikhel hospital. 115 patients in the period between 2008 to 2009 with the diagnosis of ischaemic heart disease were identified and analyzed. The mean age of patients with IHD was 62.9+/- 12.79 years and the youngest was aged 34 years. The number of male patients was greater (54.8%) than the females (45.2%). Among the risk factors hypertension and diabetes were more common in females, where­as smoking was more common in males. The study also showed more people with IHD came from rural than urban areas. In conclusion, the ischaemic heart disease is a rising public health problem affecting even the younger age groups and people from lower socioeconomic strata. Nepalese Heart Journal | Volume 7 | No.1 | November 2010 (special issue) | Page 1-4 DOI: http://dx.doi.org/10.3126/njh.v7i1.8493

Background Coronary Artery Diseases (CAD), one of the the leading causes of death, is increasing globally. The number of CAD is also increasing in Nepal. Dhulikhel Hospital is also providing cardiovascular services to populations from semiurban and rural population of mid region of country. It started coronary angiography services from April 2012. This paper aims to analyze pattern of coronary artery occlusion in patients undergoing coronary angiography during April to September months of 2012. Methods There were a total of 36 cases of diagnostic angiography and coronary interventions done in Dhulikhel Hospital from April to September 2012. Among them 32 cases of coronary angiography done for Acute Coronary Syndrome and Stable Angina, were analyzed using SPSS 17. Results Males were higher in number than females and majority of the patients were above 55 years. Out of 32 cases, 13 (40.6%) had Acute Coronary Syndrome (ACS) and 19(59.4%) had Stable Angina. Six out of 32 were found to have normal coronaries. One patient with ACS had normal coronary. Out of all the patients with coronary stenosis, four had left main disease, 14 had LAD stenosis, 7 had LCX stenosis and 12 patients had RCA stenosis. Thirteen had severe coronary stenosis. Nine out of 12 ACS patients had more than one coronary artery involved, which is significantly higher than the stable angina group ( P

Background Rheumatic heart disease (RHD) is the most common cardiovascular disease in children and young adults. Though declined and almost non-existent in developed nations, RHD is still one of the leading cause for premature death and disability in developing countries. Prevalence of RHD is high in both rural as well as urban area of Nepal. Present study is designed to look at the pattern of valvular involvement and demographic features in RHD. Methods 326 Patients indicated for inj. Benzathine penicillin were selected and echocardiograph performed to see the pattern of vavular involvement. Data analysis was done using SPSS 17. Result The most common type of lesion was mixed type with mitral valve involvement. MR was the most common isolated lesion. MS was more commonly seen in females whereas AS was more common in males. Secondary prophylaxis was more common than primary prophylaxis. Conclusion RHD still being a major problem and a preventable disease so extensive screening program is required to identify them early and prevent the complication. DOI: http://dx.doi.org/10.3126/njh.v9i1.8342 Nepalese Heart Journal Vol.9(1) 2012 pp.16-19

Background Hypertension is the leading cause of morbidity and mortality worldwide. Because hypertension is usually asymptomatic yet requires long term therapy, consideration of potential of undesirable effects of drugs used for its treatment is important for making the appropriate choice. In this context, a precise understanding typical adverse reaction profile of the different drugs is essential. Objective This study was done to assess the side effects profile of different antihypertensive drugs (calcium channel blocker, beta blocker, ACE inhibitor) among the hypertensive patient. Methods A mixed retrospective & prospective cross sectional study of 61 patients was done at Medical Out Patient Department of Dhulikhel Hospital KUTH were included in the study. Result Dry cough was experienced by most of the patients (66.7%) and both dry cough and dizziness was reported by only one patient (6.7%) taking enalapril. In case of atenolol, bradycardia, dizziness and insomnia were experienced by same number of patients (14.3%) separately. Among amlodipine users, side effects experienced were peripheral edema (23%), flushing (2.6%), dyspnoea (2.6%), headache (5.1%), dizziness (2.6%), palpitation (2.6%) and insomnia (2.6%).Patients on enalapril had significantly more complaints regarding side effects (73.3%) compared to those taking amlodipine (41%) (OR=4, p =0.033) and atenolol (42.9%).There was no significant difference in the occurrence of side effects between enalapril- atenolol ( p >0.05) and amlodipine- atenolol ( p >0.05). Conclusion Although all three drugs were well tolerated, more side effects were seen in case of enalapril. Enalapril has 4 times higher rate of side effects than amlodipine. DOI: http://dx.doi.org/10.3126/njh.v9i1.8344 Nepalese Heart Journal Vol.9(1) 2012 pp.25-29

Background Chronic Obstructive Pulmonary Disease (COPD) is a common global problem and most common medical problem in Nepal having significant morbidity and mortality. One of the pathogenesis of COPD in long run is the elevation of Pulmonary Artery Systolic Pressure (PASP) leading to right heart failure. A simple investigation - an Electrocardiograph (ECG) is assessed to co-relate with elevated PASP measured by Echocardiography in COPD patients of Dhulikhel Hospital. Methods and Materials A retrospective case control study of 342 COPD patients was done with assessment of ECG to co-relate with elevated PASP and with normal PASP. Data were analyzed using SPSS 17. Result There was significant difference in mean age, P amplitude in Lead II, III and aVF, QRS axis and R wave in V1 and S in V6 between two groups. Conclusion ECG changes are fairly sensitive and specific for elevation of PASP. DOI: http://dx.doi.org/10.3126/njh.v8i1.8330 Nepalese Heart Journal Vol.8(1) 2011 pp.12-15

Background Cardiovascular disease (CVD) is a major cause of morbidity and mortality throughout the world including Nepal. The assessment of risk factors responsible for CVD can predict 10 year risk of CVD. World Health Organization (WHO) risk assessment chart, specially designed for South East Asia Sub-region D can predict the risk of CVD in Nepal. Method and Materials A total 532 study population from Panauti, Banepa and Dhulikhel were calculated their 10 year risk of CVD using WHO/ISH risk prediction chart on the basis of risk factors: age, gender, smoking status, diabetes, systolic blood pressure and total cholesterol. Result Ten year risk of developing cardiovascular disease is less than 10% among the population less than 50 years, irrespective of gender. 5% of male population had more than 10% chance of developing cardiovascular events in next ten years. One third of 60 – 69 years people had more than 10% chance of developing cardiovascular disease whereas it increased to 50% among 70 years and older group. Conclusion The assessment of risk factors is quite easy and cheap tool to predict the cardiovascular event, which support to practice the good clinical management to prevent the cardiovascular morbidity and mortality. DOI: http://dx.doi.org/10.3126/njh.v8i1.8328 Nepalese Heart Journal Vol.8(1) 2011 pp.3-7

Background The oxygen saturation of haemoglobin is reduced in high altitude-living organisms. Increase in the hematocrit is responsible for rise in the hemoglobin concentration so that the oxygen carrying capacity in the hypobaric hypoxic subject is elevated. Objectives To compare two different high altitude populations, in order to study the relationship between arterial oxygen saturation and hematocrit. Methods lIn the cross-sectional study of two populations residing at altitude of 2800 m and 3760 m are compared for the difference in hematocrit. The oxygen carrying capacity of arterial haemoglobin (SaO2) is determined by pulse oximetry. The sample is drawn from the natives of two small villages, Thini at Jomsom (2800 m) and Jharkot (3760 m) in Mustang district of Nepal. The natives at 2800 m are termed as lower high altitude population and local residents at 3760 m are said to be higher altitude population in this study. The sample blood was drawn by venipuncture and packed cell volume was determined by Wintrobe’s method. Results The hematocrit obtained from 3760 m altitude population and the lower high altitude population at altitude of 2800 m differ significantly with the p value < 0.0001and the SaO2 in both the population fails to show any difference with p value > 0.05. Deep breathing exercise in these populations however increased SaO2 significantly. Conclusion The higher altitude natives have greater arterial oxygen saturation than lower altitude population which is due to rise in red cell concentration. The slow deep breathing raises oxygen saturation irrespective of altitude. Kathmandu University Medical Journal | VOL.10 | NO. 3 | ISSUE 39 | JUL- SEP 2012 | Page 30-34 DOI: http://dx.doi.org/10.3126/kumj.v10i3.8014

Background Hypertension is a cardiovascular disorder rapidly emerging as a major public health problem in developing countries and is the most widely recognized modifiable risk factor for cardiovascular diseases. Objective The objective of this study was to find out the prevalence and associated risk factors with hypertension among people aged 50 years and more in Banepa Municipality, Kavre, Nepal. Methods It is a cross- sectional, population based study which was carried out in Banepa Municipality from May 15 to June 15, 2009. Among total 11 wards of Banepa municipally, wards number 1, 3, 5, 6, 7, and 10 were selected by using Simple Random Sampling Technique and 405 subjects of people aged 50 years and more were selected for study from the selected wards by using Cluster Sampling. The structured interview method was used for collection of data. Mercury sphygmomanometers with standard cuff were used to measure the indirect auscultatory arterial blood pressure. Two consecutive blood pressure readings were taken and average of them was calculated to determine single value of blood pressure. Results The prevalence of hypertension was 44.9 percent (47.75% in male and 42.73% in females). Among them, only 32.9 percent (60/182) were previously diagnosed as hypertension. The higher proportion of hypertensive cases were in age > 65 years (55.49%) than in the age group < 65 years (36.32%). The prevalence of hypertension was seen positively associated with non vegetarian eating habits, alcohol consumption, and > 25 Body max index. Taking green leafy vegetable at least once a week was negatively associated with the prevalence of the hypertension. Conclusion These findings provide important information on the prevalence, associated factors of hypertension in Banepa Municipality. Effective public health measures and strategies are needed to improve prevention, diagnosis and access to treatment of these 50 years and above population. Kathmandu University Medical Journal | VOL.10 | NO. 3 | ISSUE 39 | JUL- SEP 2012 | Page 35-38 DOI: http://dx.doi.org/10.3126/kumj.v10i3.8015

Objective About one-fourth of Nepalese adults are overweight or obese but no studies have examined their risk factors, especially pertaining to diet. The present study aimed to identify dietary patterns in a suburban Nepalese community and assess their associations with overweight and obesity prevalence. Methods This cross-sectional study used data from 1073 adults (18 years or older) participating in the baseline survey of the Dhulikhel Heart Study. We derived major dietary patterns from a principal component analysis of reported intake from a Food Frequency Questionnaire. Overweight was defined as Body Mass Index (BMI) of 25 kg/m 2 or higher and obesity was defined as BMI of 30 kg/m 2 or higher. Statistical analysis was conducted using generalised estimating equations with multivariate logistic regression (with household as cluster) adjusting for age, sex, ethnicity, religion, marital status, income, education, alcohol consumption, smoking, physical activity and systolic blood pressure. Results Four dietary patterns were derived: mixed, fast food, refined grain–meat–alcohol and solid fats–dairy. The refined grain–rice–alcohol pattern was significantly associated with overweight (adjusted OR 1.19, 95% CI 1.03 to 1.39; p=0.02) after adjusting for demographic and traditional cardiovascular risk factors. In adults of 40 years or older, the fast food pattern was associated with obesity controlling for demographic and traditional risk factors (adjusted OR 1.69, 95% CI 1.19 to 2.39; p value=0.003). Conclusions Our results suggest that refined grains–meat–alcohol intake is associated with higher prevalence of overweight, and fast food intake is associated with higher prevalence of obesity in older adults (40 years or above) in suburban Nepalese adults.

Introduction: Health system delay is the time for complete diagnosis of the disease after patient approaches a health care provider. Aim: The study aims to identify the characteristics and the determinants of unacceptable health system delay (≥ 7 days delay from health system) in diagnosis of new pulmonary tuberculosis patients attending in Direct Observation Treatment Short course (DOTS) centers of Nepal. Materials and Methods: An analytical cross-sectional study was conducted by administrating a structured questionnaire interview and reviewing the medical record of the new sputum smear positive pulmonary tuberculosis cases during January– May 2015. The generalized linear model (GLM) was applied to control the clustering effects. Multiple logistic regressions were performed to identify the association between variables with ≥ 7 days of unacceptable health system delay. Results: Of the 374 new sputum smear positive pulmonary tuberculosis cases, the factors that were associated with unacceptable health system delay (time ≥ 7 days) were doing business (adj.OR= 1.61, 95% CI: 1.22-2.11; p-value

Communicable and respiratory tract diseases especially chronic obstructive pulmonary diseases are the main reasons of admission in medical ward of low and middle income countries. This is different from the developed countries where non communicable diseases are the main reasons of hospital admission. In developing countries the data of hospital admission are still lacking. Therefore this study will help us to assess the common patterns of diseases admitted in a medical ward, the average length of hospital stay etc. The record of 1040 hospitalized patients in medical ward was analyzed for the period of six months from Jan 2010 to Jun 2010. Patient’s medical records were retrieved and data analysis was done to obtain age, sex, common diagnosis, the affected system and the duration of the hospital stay. The data was analyzed by using SPSSV 16. After reviewing the data the most common age of patients being admitted were between 46-65 years (31.5%) followed by more than 65 years (25%) between 26-45 years (21.28%) and less than 25 years (21.28%). Among the admitted patients females were more than the males except in neurolog ward. The most effected system was respiratory (31.73 %),and the most common diagnosis was Chronic obstructive pulmonary diseases (23.17%). The next common system involved was gastroenterology including liver (18.64%) ,genitourinary (12.01%), cardiovascular ( 11.34%), neurology (9.23%), endocrine (4.80%) hematology (2.30%). The cause for hospital admission by infection in different system was (30.08%) The average duration of hospital stay of the patients was less than 7 days. The respiratory diseases and the infectious disease are the most common disease in Nepal. The communicable diseases still hold a greater position, while non communicable diseases are main reasons for admission to the medical wards in developed countries. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-2, 7-11 DOI: http://dx.doi.org/10.3126/jcmsn.v8i2.6831

Megaloblastic anemia is not uncommon, however varied of presentation makes difficult to come to conclusion. It’s more difficult when resources are limited. In this back ground clinical features of megaloblastic anemia are very important for diagnosis and treatment. It is a retrospective analysis of data from December 2003 to September 2009. During the period, bone marrow aspiration was done for analysis of cause and type of anemia.A total of 14 cases bone marrow findings was consistent with megaloblastic anemia. These reports were taken into consideration after pathologist impression. Serum Vitamin B12 and RBC folate were not done in view of limited resources and financial constrain. In the analysis 14 (11.96%) bone marrow findings were consistent with megaloblastic anemia. Regarding clinical presentation; pallor was 13 (92.85%) followed by glossitis 5 (35.71%) and Jaundice 5 (35.71%), paresthesia 3 (21.42%), and pigmentation, ataxia, confusion each case (7.14 %). Mostly the patients were between the 21- 40 years of age. Megloblastic anemia is common clinical problem with pallor and glossitis as major presentation. However some had neurological features. This disease can be diagnosed and treated on the basis of bone marrow aspiration when resources are limited.Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-2, 41-44DOI: http://dx.doi.org/10.3126/jcmsn.v7i2.6679

Background In several languages and settings, the Hospital Anxiety and Depression Scale (HADS) has demonstrated reliable and valid screening properties in psychiatry. Objective To develop a Nepali version of HADS with acceptable reliability and construct validity for use among hospital patients and in the general population. Method The original English version was translated into Nepali using a forward-backward translation protocol. Psychometric properties were tested by factor analysis and Cronbach’s alpha. The translated scale was administered to three groups of adult in-patients in a university hospital in three trials, and to a sample of adults from the community in a fourth trial. Some of the 14 items were reworded reiteratively to achieve viable semantic and statistical solutions. Results The two-factor solution with anxiety and depression subscales eventually explained 40.3% of the total variance. Cronbach’s alpha was 0.76 for anxiety (HADS-A) and 0.68 for depression (HADS-D). All seven HADS-A items showed at least acceptable item-to-factor correlations (range 0.44-0.74), and full construct validity was achieved for this subscale. Item-to-factor correlations for six HADS-D items were also at least acceptable (range 0.42-0.70); one item (D4) had persistently low correlations throughout all trials, although construct validity was still satisfactory. Conclusion Reiterated rewording of items guided by statistical testing resulted in a Nepali version of HADS with satisfactory psychometric properties.

Background The Neuroticism subscale of the Eysenck Personality Questionnaire Revised Short Form (12 items) (EPQRS-N) has proven to be a reliable and valid measure in multiple languages. Objective To develop a single-factor Nepali-language version of the EPQRS-N for use in the adult population of Nepal. Method The original English version of EPQRS-N was translated into Nepali using a forward-backward translation protocol. The first set of translated items was modified after testing by factor analysis with principal component extraction in an outpatient sample. Items with low factor correlations or poor semantic consistencies were reworded to fit the gist of the original items in a Nepali cultural context; the revised version was then tested in a representative random sample from the general population. Again, the same statistical procedures were applied. Results The first trial gave three factors. Based on the factor distribution of the items or their semantic quality, five were reworded. In the second trial, a two-factor solution emerged; the second factor had only one item with high correlation, which also had modest correlation with the first factor. Accordingly, a forced one-factor solution was chosen. This gave an internal consistency (Cronbach’s alpha) of 0.80, with item-to-factor correlations from 0.40 to 0.73, and item-to-sum correlations from 0.31 to 0.61. Conclusion The final Nepali version of EPQRS-N achieved satisfactory internal consistency. The item distribution coincided with the original English version, providing acceptable construct validity. It is psychometrically adequate for use in capturing the personality trait of neuroticism, and has broad applicability to the adult population of Nepal because of the diversity of the participant samples in which it was developed.

Background Hypertension (HTN), a major risk factor for cardiovascular diseases (CVDs), is a substantial global public health problem. Occasional studies indicate a high prevalence of HTN in the Nepalese population, but no nationwide population-based data exist so far. We opportunistically used a survey of major disorders of the brain in Nepal to measure blood pressure (BP) in participants selected randomly from the adult general population. Objective To establish the prevalence of elevated BP (eBP), and factors associated with it, regardless of any antihypertensive therapy being taken. We took this to be indicative of unmet health-care need. Method This was a cross-sectional study, conducted by unannounced household visits, employing multistage random cluster sampling. To achieve representativeness, 15 districts out of 75 in the country were investigated: one district from each of the three physiographic divisions in each of the five development regions of Nepal. One adult aged 18-65 years was selected from each household and interviewed by structured questionnaire. BP was recorded in a standardised manner by digital device (Microlife 3BM1-3®). Result From 2,109 eligible households, 2,100 adults (99.6%) participated. The prevalence of eBP (>140/90 mmHg on ?2 readings) was found to be 15.1%. Multivariate logistic regression showed significant and independent associations with demographic variables (higher age, male gender), with life-style factors (daily alcohol consumption, BMI ?25), and with living at high altitude (?2000 m). Conclusion In the context of the survey we could not collect data on antihypertensive therapy being taken but, clearly, whatever this might have been, it was failing to meet treatment needs. Almost one in six adults met criteria for hypertension, carrying risk implications for CVDs and their substantial public-health consequences. Two remediable associated factors were identified, although in a cross-sectional survey we could not prove causation. Kathmandu University Medical Journal Vol.13(1) 2015; 3-7

To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds ≥ 30%/≥ 40%) with single risk factor cutoff levels.Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40-80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries.A large fraction (90.0-98.9%) of the study population has a 10-year cardiovascular risk20%. Only 0.2-4.8% are in the high-risk categories (≥ 30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly.Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population.

Introduction Typhoid fever (TF) continues to cause considerable morbidity and mortality in Nepal, but only limited epidemiologic data is available about TF outside Kathmandu. Methods As part of an interventional trial, we performed a prospective cohort study of bacteremic TF patients in Dhulikhel Hospital between October 2012 and October 2014. Demographic, epidemiological, clinical, and microbiologic data were recorded. Results 116 bacteremic typhoid patients were included in the study. Most were young, healthy, adults (mean age 27.9±12 years), 41.4% of whom were female. More than 70% of patients were employed in non-manual services or were university students. Salmonella Typhi accounted for 64/115 (55.7%) of all isolates, while Salmonella Paratyphi accounted for 51/115 (44.3%), of which 42 were Paratyphi A and 9 Paratyphi B. A significant proportion of TF cases occurred also during the dry season (48/116, 41.6%). The clinical presentation of Salmonella Typhi and Paratyphi infections was similar, except for a greater proportion of arthralgia in patients with Salmonella Typhi. Most Salmonella Typhi and Paratyphi isolates were resistant to nalidixic acid and susceptible to older antibiotics. One Salmonella Paratyphi isolate was resistant to ceftriaxone. Conclusions TF remains common in the Dhulikhel area, even among those with a high level of education. Public health measures aimed at reducing the incidence of TF in the Dhulikhel area are warranted. The relative burden of TF caused by Salmonella Paratyphi is rising; a vaccine with activity against Salmonella Paratyphi is needed. Since Salmonella Paratyphi B was more prevalent in this cohort than in large cohorts of patients from Kathmandu, it is likely that there are significant regional variations in the epidemiology of TF outside Kathmandu.

Objective Hypertension is a significant and rising burden in Nepal. The disease remains undetected and inadequately managed. However, no studies have been conducted to understand the inhibiting and facilitating factors to hypertension treatment among newly diagnosed cases. This qualitative study aimed to explore barriers and facilitators to treatment among patients with newly diagnosed hypertension aged ≥18 years in Dhulikhel, Nepal. Methods We conducted seven focus group discussions with 35 patients with newly diagnosed hypertension identified through community surveillance of the Dhulikhel Heart Study, an observational cohort of Dhulikhel Hospital, Kathmandu University. Audiotaped discussions were transcribed, inductively coded and analysed by the thematic framework method using Atlas.ti V.7. Results Hypertension was viewed as a rising problem in the community. Participants had limited knowledge and many misbeliefs regarding hypertension and its treatment. The major barriers included absence of symptoms, reluctance to take medicine, low perceived seriousness of the disease, challenges in behaviour change (diet and exercise), lack of family support, and lack of communication and trust with the provider. The major reported facilitating factors were fear of consequences of the disease, and family support in controlling diet and adhering to treatment. Conclusions A number of factors emerged as barriers and facilitators to hypertension treatment. This information can be useful in designing appropriate health interventions to improve hypertension management.

Background: Early diagnosis is a determining factor for spread of tuberculosis. Delay in diagnosis and treatment of tuberculosis geometrically increases spread and infectivity of the disease and is associated with higher risk of mortality. Aim: The present study aimed to investigate the length of delays in diagnosis and treatment among new pulmonary tuberculosis patients in central development region of Nepal. Materials and Methods: A cross-sectional study was conducted by administration of structured questionnaire interview and reviewing the medical records of the new sputum smear positive pulmonary tuberculosis cases during January– May 2015. Simple random sampling was applied to select samples from 5 districts of 19 districts comprising at least one each from 3 ecological regions of Nepal. Results: A total of 374 new sputum smear positive pulmonary tuberculosis cases were included in the study. The median patient delay, health system delay, and total delay were 32 days, 3 days and 39.5 days respectively. The unacceptable patients delay was 53.21% (95% CI: 48.12-58.29) of all new patients, whereas it was 26.74% (95% CI: 22.23-31.24) for the unacceptable health system delay and the unacceptable total delay was 62.83% (95% CI: 57.91-67.75). Conclusion: TB diagnosis and treatment is still a significant problem of Nepal. Majority of unacceptable delays were from patients. Identifying factors influencing delays and developing evidence-based approaches to address those delays will help in advancing tuberculosis prevention and management in lowincome settings.

Background Coronary artery disease (CAD) is associated with the numbers of risk factors causing coronary atherosclerosis. Coronary artery stenosis is mostly caused by coronary atherosclerosis.Objective This study aims to analyze the association between coronary artery stenosis and cardiovascular risk factors.Methods An observational study was conducted among CAD patients. The diagnostic coronary angiogram was performed from femoral approach using standard catheters and techniques to find out any abnormalities.Result A total 73 patients (44 male and 29 female) with coronary artery disease undergoing diagnostic coronary angiography was included with the documented cardiovascular risk factors. The coronary stenosis was found in 40 patients on the basis of stenosis grading. Among the established cardiovascular risk factors, sex, diabetes mellitus and smokers show are significantly associated with coronary stenosis among CAD patients. The present study shows the significant association of coronary stenosis among male CAD patients (OR 2.47; CI 0.94 – 6.48, p

Context: Nepal is currently experiencing a rapid growth in noncommunicable diseases (NCDs). Depression has previously been associated with NCDs in South Asia; however, data regarding its prevalence and risk factors are lacking in Nepal. Aims: This study aims to describe the prevalence of and risk factors for depressive symptoms in a suburban population of adults within Nepal. Setting and Design: We conducted a cross-sectional analysis of baseline data collected from participants enrolled in the Dhulikhel Heart Study, a population-based, longitudinal cohort study investigating cardiovascular risk factors in Dhulikhel, a suburban town outside Kathmandu. Subjects and Methods: Baseline questionnaire data from 1073 adults age 18 years and older included the Center for Epidemiologic Studies Depression Scale (CES-D). A score of 16 or greater on the CES-D has been shown to indicate major depressive symptomatology. Statistical Analysis: Using STATA 13, we conducted Pearson's Chi-square tests and multiple logistic regressions to examine associations between the binary CES-D score and gender, age, education, marital status, body mass index, physical activity, and hypertensive status. Results: The mean CES-D score in the sample was 11.7 (standard deviation: 5.3), with 21.3% scoring 16 or greater. Age over 60 and lack of formal education were associated with increased risk of depressive symptoms. Being physically active was associated with decreased risk of depressive symptoms. Conclusions: The estimated prevalence of depression among adults in Dhulikhel was 21.3%. Significant risk factors for increased depressive symptoms included lack of formal education, age over 60, and physical inactivity.

Background Endoscopic Retrograde Cholangiopancreatography (ERCP) is an important but potentially invasive therapeutic procedure in treating various pancreatobiliary conditions. In Nepal, the ERCP services is limited to a few tertiary care centers mostly in the capital, Kathmandu. Dhulikhel hospital has started ERCP since 2011 providing services to patients from all over the country. The study analyzes the outcome from data since August 2011 to 2013 August.Objective To analyze the results of ERCP done in Dhulikhel hospital, Kathmandu University hospital.Method This is a retrospective study. The ERCP records of all the patients done since August 2011 to August 2013 were retrieved. A total of 516 attempts of ERCP were done since August 2011 to August 2013. Out of these, 423 were included for the analysis. The repeat ERCP for the same patient due to failed cannulation or patients undergone ERCP but incomplete documentation were excluded. The demographic data, indications, the findings, the outcome in terms of success or failure to cannulation, success or failure of stone extraction, stenting and complications were all derived and analyzed. SPSS 16 version was employed for data management and analysis.Result The female: male ratio was found to be 1.7 : 1. The mean age of patients were 50.57±17.8 Years. The most common indication for ERCP were: choledocholithiasis 208(49.17%); followed by: obstructive jaundice 69(16.3% ) of undetermined cause, acute biliary pancreatitis 26(6.4%), suspected bile duct injury during cholecystectomy 18(4.2%), periampullary growth 21( 4.96%), Cholangiocarcinoma 12(2.8%), chronic pancreatitis 10( 2.3%), CBD stent exchange 23(5.43%), dilated cbd 21(4.96%) , acute cholangitis 14(3.3%).The most common finding was CBD stone in 308(72.81%), normal in 51(12.1% ), bile duct stricture in 45(10.63%). Bile duct injury during cholecystectomy was found in 13(3.1%), biliary obstruction due to ampullary growth and pancreatic head mass was found in 21(4.96%) and 6(1.41%) respectively. Choledochal cyst was found in 5(1.2%), chronic pancreatitis in 7(1.7%). Biliary fascioliasis was found in one (0.24%); and roundworm in 1(0.24).The most common complication was acute pancreatitis in 17(4%), post-ERCP cholangitis 6(1.4%), bleeding 6(1.4%), duodenal perforation in 1(0.2%), arrhythmia in 1(0.2%) and one death (0.2%).Conclusion ERCP has been a potentially emerging therapeutic tool for various pancreato-biliary disorders in Nepal.Kathmandu University Medical Journal Vol.12(1) 2014: 55-59