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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.

BackgroundNepal, in recent years, is witnessing an increasing problem of type 2 diabetes that has resulted significant premature deaths and disability. Prevention and management of non-communicable diseases (NCDs) including diabetes have been prioritized in the national policies and guidelines of the Nepal Government. However, research looking at the overview of the implementation of the existing policies and guidelines for diabetes prevention and control is scarce. Hence, this study reviewed diabetes related existing policies and its implementation process at the primary health care level in Nepal.MethodsThis study involved two phases: Phase I: situation analyses through review of documents and Phase II: qualitative exploratory study. In phase I, four databases (Medline, Web of Science, Embase and PubMed) were systematically searched using key search terms related to diabetes care and policies between January 2000 and June 2021. Also, relevant gray literature was reviewed to understand the trajectory of policy development and its translation with regards to diabetes prevention and management at primary health care level in Nepal. Following the phase I, we conducted in-depth interviews (IDI) and key informant interviews (KII) with health care providers, policy makers, and managers (IDI = 13, and KII = 7) at peripheral and central levels in Kavrepalanchowk and Nuwakot districts of Nepal. The in-depth interviews were audio recorded, transcribed, and coded. The triangulation of data from document review and interviews was done and presented in themes.ResultsFour key themes were identified through triangulating findings from the document review and interviews including (i) limited implementation of policies into practices; (ii) lack of coordination among the different levels of service providers; (iii) lack of trained human resources for health and inadequate quality services at the primary health care level, and (iv) inadequate access and utilization of diabetes care services at primary health care level. Specifically, this study identified some key pertinent challenges to the implementation of policies and programs including inadequate resources, limited engagement of stakeholders in service design and delivery, lack of trained health care providers, lack of financial resources to strengthen peripheral health services, fragmented health governance, and weak reporting and monitoring systems.ConclusionThis study revealed that the policies, plans, and strategies for prevention and management of NCDs in Nepal recognized the importance of diabetes prevention and control. However, a major gap remains with adequate and lack of clarity in terms of implementation of available policies, plans, strategies, and programs to address the problem of diabetes. We suggest the need for multisectoral approach (engaging both health and non-health sectors) at central as well as peripheral levels to strengthen the policies implementation process, building capacity of health care providers, ensuring adequate financial and non-financial resources, and improving quality of services at primary health care levels.

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.

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

Given the scarcity of data on diabetes prevalence and associated risk factors among women in rural Nepal, we aimed to examine this, using glycated hemoglobin (HbA1c) as a diagnostic tool. A cross-sectional survey addressing reproductive health and non-communicable diseases was conducted in 2012–2013 among non-pregnant, married women in Bolde, a rural district of Nepal. HbA1c ≥ 6.5% (48 mmol/mol) was used as diagnostic criterion for diabetes, a cut-off of 7.0% (53 mmol/mol) was used to increase the specificity. HbA1c was measured in 757 women (17–86 years). The prevalence of diabetes and prediabetes was 13.5% and 38.5%, respectively. When using 7.0% as a cut-off, the prevalence of diabetes was 5.8%. Aging, intake of instant noodles and milk and vegetarian food (ns) were associated with increased risk for diabetes. Waist circumference was higher among women with diabetes, although not significant. The women were uneducated (87.6%), and only 12% had heard about diabetes. In conclusion, we observed a higher prevalence of diabetes and prediabetes than anticipated among rural, Nepalese women. The increased risk was mainly attributed to dietary factors. In contrast to most previous studies in Nepal, we used HbA1c as diagnostic criterion.

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

Background In South Asia, data on enteric fever are sparse outside of urban areas. We characterized enteric fever diagnosis patterns and the burden of culture-confirmed cases in peri-urban and rural Nepal. Methods We used national reports to estimate enteric fever diagnosis rates over 20 years (1994–2014) and conducted a prospective study of patients presenting with a >72-hour history of fever to 4 peri-urban and rural healthcare facilities (during August 2013–June 2016). We compared clinical characteristics of patients with culture-confirmed Salmonella Typhi or Paratyphi infection to those of patients without enteric fever. We used generalized additive models with logistic link functions to evaluate associations of age and population density with culture positivity. Results National rates of enteric fever diagnosis were high, reaching 18.8 cases per 1000 during 2009–2014. We enrolled 4309 participants with acute febrile illness. Among those with a provisional clinical diagnosis, 55% (1334 of 2412) received a diagnosis of enteric fever; however, only 4.1% of these had culture-confirmed typhoidal Salmonella infection. Culture positivity was highest among young adults and was strongly associated with higher population density (P < .001). Conclusions Enteric fever diagnosis rates were very high throughout Nepal, but in rural settings, few patients had culture-confirmed disease. Expanded surveillance may inform local enteric fever treatment and prevention strategies.

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

Background The increasing elderly population worldwide is likely to increase mental health problems such as geriatric depression, which has mostly been studied in high-income countries. Similar studies are scarce in low-and-middle-income-countries like Nepal. Methods A cross-sectional, population-based, door-to-door survey was conducted in randomly selected rural and urban population clusters of the Kavre district, Nepal. Trained nurses (field interviewers) administered structured questionnaires that included a validated Nepali version of the Geriatric Depression Scale short form (GDS-15) for identifying geriatric depression among elderly (≥60 years) participants (N=460). Those scoring ≥6 on GDS-15 were considered depressed. Logistic regression analysis explored the associations of geriatric depression with regard to socio-demographic information, life style, family support and physical well-being variables. Results Of the total 460 selected elderly participants, 439 took part in the study. More than half of them were females (54.2%). The mean age was 70.9 (± 8.6) years. Approximately half (50.6%) were rural inhabitants, the majority (86.1%) were illiterate, and about three-fifths (60.1%) were living with their spouses. The gender-and-age adjusted prevalence of geriatric depression was 53.1%. Geriatric depression was significantly associated with rural habitation (AOR 1.6), illiteracy (AOR 2.1), limited time provided by families (AOR 1.8), and exposure to verbal and/or physical abuse (AOR 1.7). Conclusion Geriatric depression is highly prevalent in the Kavre, Nepal. The findings call for urgent prioritization of delivery of elderly mental health care services in the country. [Word count 230]

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. Fil: Aifah, Angela. No especifíca; Fil: Iwelunmor, Juliet. No especifíca; Fil: Akwanalo, Constantine. No especifíca; Fil: Allison, Jeroan. Massachusetts Institute of Technology; Estados Unidos Fil: Amberbir, Alemayehu. No especifíca; Fil: Asante, Kwaku P.. No especifíca; Fil: Baumann, Ana. Washington University in St. Louis; Estados Unidos Fil: Brown, Angela. Washington University in St. Louis; Estados Unidos Fil: Butler, Mark. No especifíca; Fil: Dalton, Milena. No especifíca; Fil: Davila Roman, Victor. Washington University in St. Louis; Estados Unidos Fil: Fitzpatrick, Annette L.. No especifíca; Fil: Fort, Meredith. State University of Colorado at Boulder; Estados Unidos Fil: Goldberg, Robert. No especifíca; Fil: Gondwe, Austrida. No especifíca; Fil: Ha, Duc. No especifíca; Fil: He, Jiang. University of Tulane; Estados Unidos Fil: Hosseinipour, Mina. No especifíca; 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: Kamano, Jemima. No especifíca; Fil: Karengera, Stephen. Washington University in St. Louis; Estados Unidos Fil: Karmacharya, Biraj M.. No especifíca; Fil: Koju, Rajendra. No especifíca; Fil: Maharjan, Rashmi. No especifíca; Fil: Mohan, Sailesh. No especifíca; Fil: Mutabazi, Vincent. No especifíca; Fil: Mutimura, Eugene. No especifíca; Fil: Muula, Adamson. No especifíca; Fil: Narayan, K.M.V.. University of Emory; Estados Unidos Fil: Nguyen, Hoa. No especifíca; Fil: Njuguna, Benson. No especifíca; Fil: Nyirenda, Moffat. No especifíca; Fil: Ogedegbe, Gbenga. No especifíca; Fil: van Oosterhout, Joep. No especifíca; Fil: Onakomaiya, Deborah. No especifíca; Fil: Patel, Shivani. University of Emory; Estados Unidos Fil: Paniagua-Ávila, Alejandra. No especifíca; Fil: Ramirez zea, Manuel. No especifíca; Fil: Plange Rhule, Jacob. No especifíca; Fil: Roche, Dina. No especifíca; Fil: Shrestha, Archana. No especifíca; Fil: Sharma, Hanspria. No especifíca; Fil: Tandon, Nikhil. No especifíca; Fil: Thu Cuc, Nguyen. No especifíca; Fil: Vaidya, Abhinav. No especifíca; Fil: Vedanthan, Rajesh. No especifíca; Fil: Weber, Mary Beth. University of Emory; Estados Unidos

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 Infections with soil-transmitted helminths and pathogenic intestinal protozoa pose a considerable public health burden, particularly in low- and middle-income countries, including Nepal. We assessed the extent of intestinal parasite infections among schoolchildren in two districts of Nepal and determined underlying risk factors. Methods A cross-sectional survey was conducted between March and May 2015 in the districts of Dolakha and Ramechhap, Nepal. A total of 708 children, aged 8–16 years from 16 purposively selected schools, were enrolled. Each child provided a single stool sample that was subjected to a suite of copro-microscopic diagnoses for intestinal protozoa and helminths. Drinking water samples from different sources at schools (n = 29), community places (n = 43) and households (n = 562) were analysed for contamination with thermotolerant coliforms (TTC). A questionnaire was administered to determine individual- and household-level risk factors of intestinal parasite infections. Self-reported symptoms were assessed and a clinical examination was undertaken by a physician. Haemoglobin was measured and used as a proxy for anaemia. Mixed logistic regression models were applied to investigate associations. Results The overall prevalence of intestinal parasite infections was 39.7%. Trichuris trichiura (30.9%), Giardia intestinalis (30.5%) and hookworm (30.2%) were the predominant intestinal parasite infections. Children from households lacking soap for handwashing were at higher odds of intestinal parasite infections than children who had soap [adjusted odds ratio (aOR) 1.81; 95% confidence interval (CI): 1.13–2.89; P = 0.01]. Children from households without freely roaming domestic animals showed lower odds of G. intestinalis compared to children from households with freely roaming animals (aOR 0.52; 95% CI: 0.33–0.83; P = 0.01). One out of three (31.0%) children suffered from fever and 22.4% had watery diarrhoea within a two-week recall period. Anaemia was diagnosed in 23.6% of the children. Water contamination with TTC showed no clear association with intestinal parasite infection. Conclusions Intestinal parasites are common among schoolchildren in the two surveyed districts of Nepal. An important risk factor was lack of soap for handwashing. Our findings call for efforts to control intestinal parasite infection and emphasis should be placed on improvements in water, sanitation and hygiene interventions. Trial registration ISRCTN17968589 (date assigned: 17 July 2015). Electronic supplementary material The online version of this article (10.1186/s13071-018-3105-0) contains supplementary material, which is available to authorized users.

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 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.

Typhoid Fever: Combined vs. Single Antibiotic Therapy

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.