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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.

Objectives To understand the impact of the international medical elective (IME) on Nepali patients and physicians alongside visiting European and American medical students. Methods At a hospital in Nepal, semi-structured interviews were conducted with 15 patients and 15 physicians about positive and negative experiences with visiting medical students. Likert scale surveys about knowledge of Nepal, clinical competencies, and post-elective feedback were administered to 56 visiting medical students before and after their elective. Interviews were coded using conventional content analysis and surveys were analyzed using descriptive statistics and paired t-tests. Results Emergent positive themes from interviews were that visiting students enhanced the reputation of the hospital, afforded financial benefits, improved international collaboration, and increased knowledge, culture and language exchange. However, negative themes were the language barrier and time expended to orient students. Before vs. after the elective, visiting students had increased knowledge of Nepal's healthcare system (M=1.9, SD=0.6 vs. M=3.2, SD=0.6, t(55)=-10.22, p

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.

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

Objectives: The aim of this study was to explore positive and negative preferences towards problem-based learning in relation to personality traits and socio-cultural context. Method: The study was an anonymous and voluntary crosssectional survey of medical students (N=449) in hybrid problem-based curricula in Nepal, Norway and North Dakota. Data was collected on gender, age, year of study, cohabitation and medical school. The PBL Preference Inventory identified students’ positive and negative preferences in relation to problem-based learning; the personality traits were detected by the NEO Five-Factor Inventory. The determinants of the two kinds of preferences were analyzed by hierarchical multiple linear regressions. Results: Positive preferences were mostly determined by personality; associations were found with the traits Extraversion, Openness to experience, Conscientiousness and Neuroticism; the first three are related to sociability, curiosity and orderliness, the last, to mental health. The learning environments of such curricula may be supportive for some and unnerving for others who score high on Neuroticism. Negative preferences were rather determined by culture, but also, they correlated with Neuroticism and Conscientiousness. Negative preferences were lower among females and students living in symmetrical relationships. Some high on Conscientiousness disliked group work, and the negative correlation with Agreeableness indicated that less sociable students were not predisposed to this kind of learning activity. Conclusions: Preferences related to problem-based learning were significantly and independently determined both by personality traits and culture. More insights into the nature of students’ preferences may guide aspects of curriculum modifications and the daily facilitation of groups.

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 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

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

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

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

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.

Aim The aim this paper was to report how standard method developed by Lifting The Burden for population-based study was carried out in Nepal, a country with rather unusual physiographic challenges. The final goal of the research was to find the prevalence and burden of the major disorders of the brain – headache, anxiety, and depression in the adult population. Methods Expert group collaboration was initially the method used to arrive at the instruments to be employed. Subsequently, pre-pilot and pilot studies were made to test and modify the final version. The study was an unannounced door-todoor survey to cover all parts of the country. Fifteen representative districts out of 75 in the country were investigated. Furthermore, households in the cluster were selected by using a “spin the bottle” method. Face-to-face interviews were carried out and involved one randomly selected adult family member. The structured questionnaire, originally developed by Lifting The Burden, with the addition of the Hospital Anxiety Depression Scale and the Eysenck’s neuroticism scale was used. These additional scales were translated into Nepali and psychometric validation was also done. Results Among 2,210 contacted households, 2,109 were eligible for the study, and 2,100 (99.6%) adults from eligible households finally participated in the study. Conclusion The reported method and the extended and translated HARDSHIP questionnaire were found adequate for the Nepali context. No conflict of interest.

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

Background The major disorders of the brain (MDBs), in terms of their prevalence and the burdens of ill health, disability and financial cost that they impose on individuals and society, are headache, depression and anxiety. No population-based studies have been conducted in Nepal. Aim Our purpose was to assess the prevalence and burden attributable to MDBs in Nepal in order to inform health policy. Here we report the methodology. Methods The unusual sociocultural diversity and extreme geographical variation of the country required adaptation of standard methodology. We ran pre-pilot and pilot studies before embarking on the main study. The study design was cross-sectional. The population of interest were adults aged 18–65 years who were Nepali speaking and living in Nepal. We selected, employed and trained groups of interviewers to visit randomly selected households by cold-calling. Households were selected from 15 representative districts out of 75 in the country through multistage cluster sampling. One participant was selected randomly from each household. We used structured questionnaires (the HARDSHIP questionnaire, Hospital Anxiety and Depression Scale, and Eysenck Personality Questionnaire -Neuroticism), culturally adapted and translated into Nepali. We recorded blood pressure, weight, height and waist circumference, and altitude of each household. We implemented various quality-assurances measures. Results We completed the survey in one month, prior to onset of the monsoon. Among 2,210 selected households, all were contacted, 2,109 were eligible for the study and, from these, 2,100 adults participated. The participation rate was 99.6%. Conclusion Standard methodology was successfully applied in Nepal, with some adaptations. The sociocultural and extraordinary geographic diversity were challenging, but did not require us to compromise the scientific quality of the study.

Background Headache, anxiety and depression are major disorders of the brain in terms of their prevalence and the burdens and costs they impose on society. Nationwide population-based studies of these disorders are necessary to inform health policy but, in research-naïve and resource-poor countries such as Nepal, a host of methodological problems are encountered: cultural, geographic, logistic and philosophical. Methods Expert consensus was sought among researchers from different professional and cultural backgrounds in planning and conceptualizing an epidemiological study and adapting established methods to the special situation and circumstances of Nepal. Results The methodological problems were sorted into different themes: study design; climate; geography, access and transport; sociocultural issues; safety of interviewers. Each of these was dealt with separately, and their inter-relationships explored, in finding solutions that were sometimes pragmatic. A cross-sectional questionnaire-based study, with teams of interviewers visiting households across the three physiographic divisions (with extremes in altitude) in each of the five development regions of the country, would enable national sampling with sociocultural representativeness. However, the study instruments and interviews would be in Nepali only. Transport and access challenges were considerable, and their solutions combined travel by air, bus, river and foot, with allowances for rain-damaged roads, collapsed bridges and cancelled scheduled flights. The monsoon would render many routes impassable, and therefore set an absolute time limitation. Engaging participants willingly in the enquiry would be the key to success, and several tactics would be employed to enhance the success of this, most importantly enlisting the support of local community volunteers in each study site. Conclusion Anticipating problems in advance of investing substantial resources in a large nationwide epidemiological study in Nepal was a sensible precaution. The difficulties could be resolved or circumvented without expected compromise in scientific quality. Expert consensus was an effective means of achieving this outcome.

capacity building for health professionals in the area of global health and designed a GHD program focusing on practicality of the training by using hands-on experience and involving participants in real situations. Countries in SEA have conducted the GHD workshop since 2010 with the aim to build up and strengthen the capacity of health and health-related professionals on global health agenda setting and policy formulation. This process has generated committed professionals who could participate more actively and negotiate more effectively in the international forum. Through country delegates’ skills in GHD, they could augment international cooperation and assure benefits of global public majority from global public health policies. Structure/Method/Design: The GHD workshops are usually implemented in the form of 5-day training providing in-depth understanding on the global health architecture and strategic practices through role plays, hands-on experience sharing, and interventionmaking exercises to enhance participants’ negotiation skills and to be well prepared to serve as the country delegates as well as to understand instruments and mechanisms in global health and foreign policy issues. Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): With this engaging program and continuing efforts, the success of the model has been approved by a more active and effective role of the SEA region delegates in participating in the international forum particularly at the World Health Assembly (WHA). Feedback from participants positively evaluated the program as the very useful platform of practices, networking, and learning to understand more about global health and the processes technically related to it. Summary/Conclusion: The capacity building on GHD requires continuity of participants and adjustment of the program to respond to the quickly changing global health situation.

Health care delivery is vastly diverse worldwide. This is more unequal in low and middle-income countries like Nepal. Hospitals equipped with advanced diagnostic means and qualified medical doctors are abundantly available in urban areas whereas remote peripheral villages are suffering from dearth of infrastructure and medical doctors. Although the system has always tried to distribute infrastructure and human resources equally to remote urban areas according to necessity, the reality is different than what it is expected to be.

Background The endocrine changes related to altitude adaptation in human have attracted physiologists around the globe for long. A number of high altitude studies to detect the physiological changes have been performed now and then. But, the study to see the hormonal changes to compare populations residing at different high altitudes is a scarce. Hence, we have performed a study in native populations of different high altitude comparing changes in thyroid hormones in western Nepal. The Jharkot population included in this study is at altitude of 3760m and Jomsom population at 2800m height from sea bed. Objective The study is to compare changes in thyroid hormones at two different high altitude natives. Methods To compare thyroid status between high altitude natives at two different altitudes a cross sectional study is performed by random sampling method. The blood sample was collected in a vacutainer from fifty eight individuals after obtaining the informed consent of participants. The blood collected from antecubital vein was centrifuged in an hour and the serum obtained was used for biochemical analysis of free triiodothyronine, free thyroxine and thyroid stimulating hormone. Results Mean free thyroxine (fT4) of Jharkot population is significantly larger (p = 0.001) than Jomsom population. Mean thyroid stimulating hormone (TSH) with p = 0.597, does not indicate the difference between this two population. There is no significant difference between mean free triiodothyronine (fT3) of Jharkot and Jomsom population (p = 0.345). Conclusion The rise in free thyroid hormone at high altitude is not dependent on the thyroid stimulating hormone released from anterior pituitary. The rise in free thyroxine is found at higher altitude and no difference in fT3 level is detected in population studied at high altitudes. DOI: http://dx.doi.org/10.3126/kumj.v11i1.11017 Kathmandu University Medical Journal Vol.11(1) 2013: 18-21

Background Cardiovascular disease (CVD), is the primary cause of morbidity and mortality in patients with diabetes and have approximately - two to four times higher CVD rate than adult without diabetes. Low density lipoprotein cholesterol (LDL-C) is primarily used as the marker of cardiovascular risk in diabetes despite its several limitations. Although several newer markers of CVD are emerging, no marker has been established in Nepal. Objectives The study was designed to evaluate the non-high-density-lipoprotein- cholesterol(Non-HDL-C) and Total Cholesterol to High density lipoprotein cholesterol (TC:HDL-C ratio) as CVD risk marker in diabetes mellitus. Methods The study was conducted in the Department of Bbiochemistry, Kathmandu University School of Medical Sciences. The study comprised of 76 diabetic subjects and 60 non-diabetic subjects. The anthropometric and biochemical parameters were measured. The Non-HDL-C and TC:HDL-C ratio were also calculated employing their respective formula. Results Body mass index (BMI), waist circumference (WC), blood pressure and lipid parameters were significantly different between diabetic subjects and non-diabetic subjects. There was increased non-HDL-C and TC:HDL-C ratio in subjects with diabetes mellitus. Furthermore, statistically significant correlations of non-HDL-C and TC:HDL-C ratio were obtained with BMI, WC, total cholesterol, HDL-C and LDL-C in diabetic subjects. Conclusions The present study observation revealed that the Non-HDL-C and TC: HDL-C strongly correlate with established independent risk factors such as obesity(WC), elevated blood pressure, HDL-C and LDL-C in diabetes. Thus, the evaluation of Non-HDL-C and TC: HDL-C ratio can be used as the simple, cost-effective and cumulative marker of cardiovascular risk in diabetes mellitus.http://dx.doi.org/10.3126/kumj.v8i4.6239 Kathmandu Univ Med J 2010;8(4):398-404

Objective: The objective of the present study is to evaluate the characteristics of acute poisoning cases admitted to emergency department over a one year period. The demographic, clinical and psycho-social aspects of the patients were analysed. Materials and methods: A hospital based study was carried out in the emergency department, Kathmandu University Teaching Hospital/ Dhulikhel Hospital, Dhulikhel analysing the data of the poisoning cases attended for one year. The study was carried out amongst inpatients attending emergency with acute poisoning. Results: A total of 54 patients were admitted to the emergency department with acute poisoning. The female-to-male ratio was 1.34:1. Most poisoning occurred in the age group of above 40 years. The mean ages of female and male were 29.87 ±14.85 years and 35.54±15.02 years respectively. By occupation 40.38% of the cases were farmers. Only 35.29% of the patients were illiterate. 79.24% of the cases intentionally consume the poison. Organ phosphorus poisoning (OP) was the most common poisoning. Oral route was the commonest route of poisoning accounting 98.1%. Sixty-six percentage (66.66%) of the cases had the poison stored in their home with 27.7% bought from the market once needed. Among the cases of acute poisoning 5.55% were fatal. Conclusion: The following conclusions were reached: (1) females were at greater risk for poisoning than males, (2) self-poisoning cases constituted the majority of all poisonings, and (3) the main agents of self-poisoning were OP poisoning. Key words: poisoning; insecticides; organophosphorus DOI: 10.3126/kumj.v7i2.2711 Kathmandu University Medical Journal (2009) Vol.7, No.2 Issue 26,152-156

Background: Thyroid hormone has its effect in the lipid metabolism. Thus, thyroid disorder is usually associated with the dyslipidaemia. Hypercholesterolemia is an established risk factor for the cardiovascular disease (CVD) and therefore in case of overt hypothyroidism which is associated with hypercholesterolemia, CVD is most likely to occur. Objectives: controversies still persist about the hypercholesterolemia and sub clinical hypothyroidism. Hence, we conducted our study to elucidate the relation of thyroid hormone with cholesterol in different thyroid disorder. Material and Method: All patients suspected of thyroid disorder within a period of one year were included in the study and free thyroxine-3 (fT3), free thyroxine-4 fT4, Thyroid Stimulating Hormone (TSH) and total cholesterol (TC) in the serum were estimated. Statistical analysis was carried out by using SPSS. 13. Results: Among the 169 cases, 32.5% of the patients were having thyroid disorder. In which 8.3% were of hypothyroid, 7.1% were of sub clinical hypothyroid, 8.3% were of hyperthyroid, 7.7% were of sub clinical hyperthyroid and 1.2% cases were of pan hypothyroid. We observed significant negative correlation between TC & fT3(r = -0.226, p = 0.003), significant negative correlation between total cholesterol & fT4(r = -0.197, p = 0.010) and significant positive correlation between TC & TSH(r = 0.365, p = 0.000). Total cholesterol was significantly raised in hypothyroidism (Mean ±SD 283±53, p = 0.000) in comparison to euthyroid population (mean ±SD, 195±58). But cholesterol was not significantly increased in sub clinical hypothyroidism (mean ±SD, 240±46) Conclusion: Our results show that total cholesterol level in serum is affected by the blood thyroid hormone level. Therefore, screening for hypercholesterolemia could be useful in patients with hypothyroidism to reduce associated disease. Key words: Thyroid hormone; Cholesterol; Nepal DOI: 10.3126/kumj.v8i2.3573 Kathmandu University Medical Journal (2010), Vol. 8, No. 2, Issue 30, 265-268

Background: The upper gastrointestinal bleeding (UGIB) is defined as bleeding within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the ligament of Treitz. It is one of the important medical emergencies worldwide. Objective : The objective of this study is to study the aetiology of upper gastrointestinal bleeding based on endoscopic examination findings in patients of various demographic characteristics. Materials and methods: This is a retrospective observational study. The endoscopic record book from 2007 January to 2009 October was reviewed for all the cases who underwent oesophago-gastro-duodenoscopic examination for upper GI bleeding. The clinico-epidemiological data of all the patients was reviewed and analyzed in concert with the aetiology of bleeding. Results: A total of 90 patients (58 males, 32 females; mean age 45.32+ 18.47 years) of upper gastrointestinal bleeding was studied and analyzed in terms of aetiology of bleeding and demographic profile. Among the ethnic groups, Aryan 46 (51%) was the most common ethnic group to have upper GI bleeding followed by Newars 24 (27%), Mongolians 16 (18%), Dalits 3 (3%) and others 1 (1%). Out of 90 patients, 47( 52.2%) cases was less than 45 years of age, 30(33.3%) of 46 to 65 age ; and 13(14.4 %) more than 65 years of age. Gastric ulcer 23(25.6%) was the most common endoscopic finding, followed by oesophageal varices 14 (15.6%), acute erosive/haemorrhagic gastropathy 11 (12.2%), duodenal ulcer 9(10%), growth 7(7.8%), vascular lesions 3(3.3%), Mallory-Weiss tear 1(1.1%), fundal varices 1(1.1%) and, no cause was identified in 21(23.3%) cases. The peptic ulcer bleeding was the most common finding in Aryan 22(47.9%), whereas oesophageal varices and growth were more common in Newar 7(29.2%) and 3 (12.5%) respectively. Conclusion: Peptic ulcer disease is the most common cause of upper GI bleeding which was most commonly found in Aryan population; followed by oesophageal varices and growth as second and third most common causes and were more prevalent in Newar and Mongolian people. Key words: Endoscopy; Peptic ulcer disease; Upper GI bleeding; Varices DOI: 10.3126/kumj.v8i2.3560 Kathmandu University Medical Journal (2010), Vol. 8, No. 2, Issue 30, 208-211

Background Cyanotic congenital heart disease is not a rare entity, but fistula between the right pulmonary artery and the left atrium is an uncommon vascular anomaly. Although it is a real challenge to diagnose the case, detailed clinical evaluation and selective investigations are keys for diagnosis, and surgical intervention is still considered the best treatment option. Case presentation A 19 years old girl from the remote village of Nepal presented with the history of exercise intolerance associated with cyanosis and clubbing of the extremities. We diagnosed her as a case of right pulmonary artery to left atrial fistula, a rare variant of pulmonary arteriovenous malformation. She underwent successful surgical correction of the anomaly under cardiopulmonary bypass surgery. Conclusion Direct communication between the right pulmonary artery and the left atrium is a rare cyanotic congenital heart disease, which is diagnosed late and often associated with the atrial septal defect. The best treatment available is surgical correction.