Showing papers by "Dhulikhel Hospital published in 2020"

Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers

Abstract: Background Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal. Methods Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti. Results Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma. Conclusions Barriers embedded in health services and care seekers’ characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

Evaluation of a Rapid Point-of-Care Multiplex Immunochromatographic Assay for the Diagnosis of Enteric Fever.

Abstract: There is a critical need for an improved rapid diagnostic for enteric fever. We have previously demonstrated that serum IgA responses targeting Salmonella enterica serovar Typhi hemolysin E (HlyE) and lipopolysaccharide (LPS) are able to discriminate patients with acute typhoid from healthy controls in areas where enteric fever is endemic (healthy endemic controls) and from patients with other bacterial infections. We now have data demonstrating that IgA antibody responses against these antigens also work well for identifying patients with acute S. Paratyphi A infection. To develop a test for acute enteric fever detection, we have adapted a point-of-care immunochromatographic dual-path platform technology (DPP), which improves on the traditional lateral flow technology by using separate sample and conjugate paths and a compact, portable reader, resulting in diagnostics with higher sensitivity and multiplexing abilities. In this analysis, we have compared our standard enzyme-linked immunosorbent assay (ELISA) method to the DPP method in detecting acute phase plasma/serum anti-HlyE and anti-LPS IgA antibodies in a cohort of patients with culture-confirmed S. Typhi (n = 30) and Paratyphi A infection (n = 20), healthy endemic controls (n = 25), and febrile endemic controls (n = 25). We found that the DPP measurements highly correlated with ELISA results, and both antigens had an area under the curve (AUC) of 0.98 (sensitivity of 92%, specificity of 94%) with all controls and an AUC of 0.98 (sensitivity of 90%, specificity of 96%) with febrile endemic controls. Our results suggest that the point-of-care DPP Typhoid System has high diagnostic accuracy for the rapid detection of enteric fever and warrants further evaluation.IMPORTANCE Enteric fever remains a significant global problem, and control programs are significantly limited by the lack of an optimal assay for identifying individuals with acute infection. This is especially critical considering the recently released World Health Organization (WHO) position paper endorsing the role of the typhoid conjugate vaccine in communities where enteric fever is endemic. A reliable diagnostic test is needed to assess and evaluate typhoid intervention strategies and determine which high-burden areas may benefit most from a vaccine intervention. Our collaborative team has developed and evaluated a point-of-care serodiagnostic assay based on detection of anti-HlyE and LPS IgA. Our finding of the high diagnostic accuracy of the DPP Typhoid System for the rapid detection of enteric fever has the potential to have significant public health impact by allowing for improved surveillance and for control and prevention programs in areas with limited laboratory capacity.

The Impact of a Laparoscopic Surgery Training Course in a Developing Country.

Abstract: Surgeons training junior colleagues to perform laparoscopic surgery find the ‘apprenticeship’ model of surgical training inadequate. Therefore, the use of training courses involving simulation have become an important way to teach laparoscopic surgery. An annual laparoscopic surgery course began in Nepal in 2013. It is difficult to assess the impact of the course on trainees and demonstrate a subsequent improvement in patient outcomes, but one way is to ask delegates for reflections on their experience of the course and their perception of how it has impacted patients. The course involved simulation and patient-based training. A questionnaire to collect quantitative data and qualitative comments was sent to all 80 previous delegates (at least 9 months after the course) in September 2018. Twenty-eight delegates responded. The majority demonstrated career progression since completing the course (independent practitioners increased from 7 to 50%) and progression in their practice (18% had performed >20 laparoscopic procedures at the time of the course, vs 70% at the time of the questionnaire). All delegates felt that laparoscopic training is useful in the Nepalese context. Delegates felt the course was useful in developing skills, and improving confidence and safety. Suggestions for improvement included lengthening the course and increasing the amount of practical exposure. There was a positive outcome of the course to Kirkpatrick level 2. There is a need to expand the course’s scope to an advanced level, increase its length and start courses in other centres, to ensure the most possible benefit to patients.

Management of Bile Duct Injury Following Cholecystectomy.

Abstract: Background Laparoscopic cholecystectomy is responsible for 80-85% of the bileduct injury, and twice as frequentcompared to open cholecystectomy.Injury affects the quality of life and overall survival of the patient. The management of these injuries is complex and challenging. There are few locally published reports regarding management of bile duct injury. The objective of this study is to evaluate the management of bile duct injury and its outcome Methods: This retrospective study includes patients bile duct injury following cholecystectomy who were managed at Dhulikhel Hospital, Nepal, during January 2014 to December 2016. The clinical features, type of injuries(Strasberg classification) management, outcome (as per McDonald and colleague grading system) and follow up were analyzed descriptively. Results Out of 35 bile duct injuries,only 3 (8.57%)occurred following open cholecystectomy. Three (8.7%) cases of bile duct injury were diagnosed intraoperatively and had primary biliary anastomosis over T-tube. Five (14.28%) were diagnosed postoperatively and underwent Roux-en-y hepatojejunostomy 6 weeks after index surgery. And, 27(77.14%) with type A injuries were treated by endoscopic retrograde cholangio-pancreatography and stenting. After surgical repair, 1 (2.85%) had transient biliary leak. One patient had grade B outcome. During 18 months follow up, no stricture or cholangitis were observed. Conclusions Bile duct injury with intact continuity of the duct can be successfully managed with endoscopic stenting of the biliary tree. Intraoperative diagnosis of bile duct injury and immediate surgical management has good outcome.

The Relationship of The Mandibular Canal to The Roots of Impacted Third Molars- The Root Factor: A Panoramic Radiographic Study.

Abstract: Introduction: Third molar extractions are one of the most common reasons of injury to mandibular nerve and postoperative complications. Pre-operative assessment of pending doom is a must. In order to study the relations between change in Inferior Alveolar Canal (IAC) and Type, Class, and Level of impaction with radiographic root change of impacted third mandibular molar, we designed a study to assess the relationship of the mandibular canal to the roots of impacted third molar in reference to changes in roots and factors affecting it. Methods: This was a retrospective cross-sectional study wherein the panoramic radiographic records of subjects with impacted third molar were assessed for change in root and its correlation with change in IAC, Type, Class and Level of impacted mandibular third molar. Results: Roots of impacted third molar when in contact with IAC presented most often in our study subjects with the Darkening of roots in both sides {right side (16.79%) and left side (11.29%)} and both genders {males (right-14.29%, left-8.75%) and females (right-19.39%, left-13.94%)}. They were statistically significantly associated with interruption of white line of IAC, vertically impacted third molars and Pell and Gregory Class II, Level A of impaction. Conclusion: There is a need to properly identify radiographic risk predictor signs to avoid any surprises at the time of extraction and post operation complications following it.