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1.  Comparison of complications in diabetic outpatients with or without mental illness 
Diabetes Mellitus (DM) and psychiatric illness are related in many ways by prevalence, burden, course, and outcome. Co-morbid mental illness may play a role in determining the complication in diabetic patients. This study was conducted in 2010 among consecutive diabetic out-patients diagnosed as per American Diabetes Association (ADA) guidelines 2009, of age above 14 years, to compare the complications in diabetic patients with or without mental illness. Diabetic neuropathies, cardiovascular complications, and morbid obesity were among the complications significantly more among diabetic patients with mental illness (GHQ-12 ≥ 2) than without mental illness (GHQ-12 ≤ 2).
doi:10.4103/2230-8210.119643
PMCID: PMC3830344  PMID: 24251198
B. P. Koirala Institute of Health Sciences; complications; diabetes mellitus; mental illness; outpatient clinic
2.  Rheumatic heart disease: pilot study for a population-based evaluation of prevalence and cardiovascular outcomes among schoolchildren in Nepal 
BMJ Open  2012;2(5):e001616.
Objectives
To evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention.
Design
Observational survey with a subsequent prospective cohort study.
Setting
Private boarding school in the urban area of the Sunsari district situated on the foothills of the Lower Himalayan Range in Eastern Nepal.
Participants
Fifty-four unselected school-going children 5–15 years of age, 24 girls and 30 boys.
Primary outcome measure
Logistic feasibility of a large-scale population-based screening study using the echocardiographic criteria formulated by the World Heart Federation, with longitudinal follow-up of children with definite or borderline RHD in a prospective cohort study.
Results
Standardised interview, physical examination and screening echocardiography were performed in a three-staged process and took approximately 6 min per child. Socio-economic status was assessed using surrogate markers such as the occupation of the primary caregiver, numbers of rooms at home, car, television, cell phone and internet connection. Physical examination was focused on cardiac auscultation and signs of acute rheumatic fever and targeted echocardiography was performed by an independent examiner without knowledge of the clinical findings. Two children with evidence of borderline RHD were re-examined at B.P. Koirala Institute of Health Sciences and the indication for secondary antibiotic prevention was discussed with the parents and the children. At 6 months of follow-up, echocardiographic findings were stable in both children. Implementation of secondary antibiotic prevention was challenged by impaired awareness of subclinical RHD among parents and inadequate cooperation with family physicians.
Conclusions
This pilot study shows that the methods outlined in the protocol can be translated into a large-scale population-based study. We learned that education and collaboration with teachers, parents and family physicians/paediatricians will be of key importance in order to establish a sustainable programme.
doi:10.1136/bmjopen-2012-001616
PMCID: PMC3488717  PMID: 23087010
Cardiology
3.  The alcohol use disorders identification test (AUDIT): validation of a Nepali version for the detection of alcohol use disorders and hazardous drinking in medical settings 
Background
Alcohol problems are a major health issue in Nepal and remain under diagnosed. Increase in consumption are due to many factors, including advertising, pricing and availability, but accurate information is lacking on the prevalence of current alcohol use disorders. The AUDIT (Alcohol Use Disorder Identification Test) questionnaire developed by WHO identifies individuals along the full spectrum of alcohol misuse and hence provides an opportunity for early intervention in non-specialty settings. This study aims to validate a Nepali version of AUDIT among patients attending a university hospital and assess the prevalence of alcohol use disorders along the full spectrum of alcohol misuse.
Methods
This cross-sectional study was conducted in patients attending the medicine out-patient department of a university hospital. DSM-IV diagnostic categories (alcohol abuse and alcohol dependence) were used as the gold standard to calculate the diagnostic parameters of the AUDIT. Hazardous drinking was defined as self reported consumption of ≥21 standard drink units per week for males and ≥14 standard drink units per week for females.
Results
A total of 1068 individuals successfully completed the study. According to DSM-IV, drinkers were classified as follows: No alcohol problem (n=562; 59.5%), alcohol abusers (n= 78; 8.3%) and alcohol dependent (n=304; 32.2%). The prevalence of hazardous drinker was 67.1%. The Nepali version of AUDIT is a reliable and valid screening tool to identify individuals with alcohol use disorders in the Nepalese population. AUDIT showed a good capacity to discriminate dependent patients (with AUDIT ≥11 for both the gender) and hazardous drinkers (with AUDIT ≥5 for males and ≥4 for females). For alcohol dependence/abuse the cut off values was ≥9 for both males and females.
Conclusion
The AUDIT questionnaire is a good screening instrument for detecting alcohol use disorders in patients attending a university hospital. This study also reveals a very high prevalence of alcohol use disorders in Nepal.
doi:10.1186/1747-597X-7-42
PMCID: PMC3508982  PMID: 23039711
Alcohol use disorder; AUDIT; SCID for DSM- IV
4.  Protocol for a population-based study of rheumatic heart disease prevalence and cardiovascular outcomes among schoolchildren in Nepal 
BMJ Open  2012;2(3):e001320.
Introduction
Rheumatic heart disease (RHD) remains a major contributor to morbidity and mortality in developing countries. The reported prevalence rates of RHD are highly variable and mainly attributable to differences in the sensitivity of either clinical screening to detect advanced heart disease or echocardiographic evaluation where disease is diagnosed earlier across a continuous spectrum. The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established.
Methods and analysis
The authors designed a cross-sectional survey to determine the prevalence of RHD in children from private and public schools between the age of 5 and 15 years in urban and rural areas of Eastern Nepal using both cardiac auscultation and echocardiographic evaluation. Children with RHD will be treated with secondary prevention and enrolled in a prospective cohort study. The authors will compare the prevalence rates by cardiac auscultation and echocardiography, determine risk factors associated with diagnosis and progression of RHD, investigate social and economic barriers for receiving adequate cardiac care and assess clinical outcomes with regular medical surveillance as a function of stage of disease at the time of diagnosis. Prospective clinical studies investigating the impact of secondary prevention for subclinical RHD on long-term clinical outcome will be of central relevance for future health resource utilisation in developing countries.
Ethics and dissemination
The study was considered ethically uncritical and was given an exempt status by the ethics committee at University of Bern, Switzerland. The study has been submitted to the National Nepal Health Research Council and was registered with http://www.ClinicalTrials.gov (NCT01550068). The study findings will be reported in peer-reviewed publications.
ClinicalTrials.gov Identifier
NCT01550068.
Article summary
Article focus
Study protocol of a population-based evaluation of the prevalence rate of RHD among schoolchildren in Eastern Nepal, with a subsequent prospective longitudinal cohort study assessing long-term clinical outcome of children undergoing secondary prevention for borderline and definite RHD according to the World Heart Federation criteria.
Key messages
RHD remains a major contributor to morbidity and mortality in developing countries.
Echocardiographic screening allows diagnosis of RHD at an earlier stage across a continuous spectrum as compared with cardiac auscultation.
The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established.
Strengths and limitations of this study
The protocol describes a comprehensive approach to implement echocardiographic screening in a high prevalence region as recommended by the WHO and outlines a robust analysis plan to investigate clinical outcome with secondary prevention for subclinical RHD.
Since access to education is a marker of socioeconomic status, restriction of screening to school going children is subjected to selection bias likely to underestimate the real disease burden related to RHD in Eastern Nepal.
Cultural sensitivity with education programmes and focus group discussions will anticipate the potential social stigma of a diagnosis with a heart condition during childhood and increase public awareness.
doi:10.1136/bmjopen-2012-001320
PMCID: PMC3371575  PMID: 22685225
5.  Managing a wooden foreign body in the neck 
An interesting case is presented of a wooden foreign body in the neck entering through the right lower vestibule of the mouth. The foreign body traveled subcutaneously in the neck and got stuck in the clavicle, without damaging any vital structures. In this case, the authors highlight the mode of entry of the foreign body, the peculiarity of the wooden foreign body, the management protocol and the outcomes of the penetrating neck injury by the wooden stick.
doi:10.4103/0974-2700.55340
PMCID: PMC2776368  PMID: 20009310
Foreign body; management; outcome; wooden
6.  Population Preference of Net Texture prior to Bed Net Trial in Kala-Azar–Endemic Areas 
Prior to a community-based efficacy trial of long-lasting insecticidal nets (LLINs) in the prevention of visceral leishmaniasis (VL; also called kala-azar), a pilot study on preference of tools was held in endemic areas of India and Nepal in September 2005.
LLINs made of polyester and polyethylene were distributed to 60 participants, who used the nets sequentially for 7 d. Acceptability and preference were evaluated via indirect indicators through questionnaires at three defined time points before and after use of the LLINs and through focus group discussions (FGDs). In the latter, preferences for color and size were also assessed. Untreated bed nets were owned by 87% of the households prior to the study. All users liked textures of both LLIN types after 7 d of use, but had a slight preference for those made of polyester if they were to recommend a LLIN to relatives or friends (p<0.05), mainly because of their relatively greater softness in comparison to polyethylene LLINs. Users reported that both net types reduced mosquito bites and number of insects, including sand fly (bhusana; genus Phlebotomus), inside the house. Side effects were minor and disappeared quickly.
The large-scale intervention trial considered the preferences of the study population to decide on the best tool of intervention—light-blue, rectangular, polyester LLINs of different sizes.
Author Summary
Visceral leishmaniasis (VL) is a neglected, life-threatening, vector-borne disease. More than 90% of the reported VL cases occur in the Sudan and the Indian subcontinent, where it is considered a problem of great public health importance. To improve its control, which is currently mainly based on case detection and treatment, research is needed on preventive measures, such as the use of bed nets impregnated with long-lasting insecticide (LLINs). Prior to an efficacy trial on LLINs, we conducted a pilot study to assess community preferences for size, color, and texture of bed nets. Such an acceptance study aims at evaluating user preferences as a way to maximize usage and, consequently, to anticipate how effective a control tool might become. That pilot study concluded that different textures and colors of LLIN are accepted by users, although there was a slight preference for the softer polyester net. These results were utilized in the large-scale efficacy trial in order to maximize the coverage, uptake, and use of the LLINs.
doi:10.1371/journal.pntd.0000100
PMCID: PMC2154387  PMID: 18160976

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