Suspected cutaneous anthrax in a yak herder in a highland community in Bhutan, 2023: A case report.

This case presents cutaneous anthrax in yak herder from a central highland community in Bhutan. We highlight the clinical presentation, diagnosis and management of the case in a resource-limited setting, and the public health response through the One Health approach.

Prevalence of vitamin D deficiency in patients with autoimmune rheumatic diseases visiting the rheumatology clinic at the National Referral Hospital, Bhutan.

Objective: Vitamin D deficiency in a patient with autoimmune rheumatic disease is the most discussed topic these days, is considered to be a pandemic, and its prevalence and associations have been studied by many countries. We aim to study the prevalence of vitamin D deficiency in autoimmune rheumatic diseases in patients visiting the rheumatology clinic at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu. Methods: A descriptive study was conducted on 126 patients in Jigme Dorji Wangchuck National Referral Hospital, who were visiting the rheumatology clinic. Vitamin D levels were analysed among these rheumatology patients. EpiData software is used for data entry and analysis. Results: Out of 126 patients, 71 had rheumatoid arthritis, 34 had systemic erythema-tosus, 8 mixed connective tissue disease and 13 had other autoimmune rheumatic diseases. Among these, only 12 (9.52%) patients had normal vitamin D levels, and 114 (90.5%) patients had lower than normal serum levels of the vitamin. Among these, 75 (59.5%) were deficient and 39 (31.0%) were insufficient. Conclusion: The study found that the prevalence of Vitamin D deficiency is high with 59.5% among patients with autoimmune rheumatic diseases and only with 9.5% were with normal levels of vitamin D.

Profile and outcome of patients with Warfarin Toxicity admitted in a tertiary care hospital in Bhutan: a cross-sectional study investigators and institutions.

OBJECTIVE: To study the profile, clinical presentation and outcome of hospital stay among patients admitted with warfarin toxicity at the Jigme Dorji Wangchuck National Referral Hospital, Bhutan. This was a cross-sectional study with a review of hospital records of patients admitted between 01 and 2018 and 30 June 2020. RESULTS: There were 22 admissions due to warfarin toxicity. The mean age of patients was 55.9 (± SD 20.2) years, the median duration of warfarin therapy was 30 months (IQR 4.8, 69 months). The indications for warfarin were atrial fibrillation (9, 40.9%), mechanical heart valves (6, 27.3%), deep vein thrombosis (6, 27.3%) and pulmonary thromboembolism (1, 4.5%). The mean of dosage of warfarin was 4.3 (± 2.6) mg and the cumulative dosage in the week prior to admission was 30.9 (± 18.6) mg. The mean of INR at presentation was 7.7 (± 4.3) with the maximum noted at 20. The patients presented with gastrointestinal bleeding, muscle haematomas, epistaxis and oral cavity bleeding. There was no mortality related to warfarin toxicity. The reasons for warfarin toxicity included patient dosing error and drug interactions. Warfarin therapy requires appropriate patient education, adequate facilities for follow-up and avoidance of warfarin wherever possible in clinical settings.

Team approach to fall reduction in paediatric ward of national referral hospital, Thimphu, Bhutan: a quality improvement initiative.

Falls are common and preventable adverse events that occur in a hospital setting. Falls can cause pain, damage, increase cost and mistrust in the health system. Inpatient fall is a multifactorial event which can be reduced with multistrategic interventions.In this project, we aimed to reduce the fall rate in paediatric ward of Jigme Dorji Wangchuck National Referral Hospital, Bhutan by 25% from the baseline over a period of 6 months by focusing on fall risk assessment, staff education on fall prevention measures and devoting more attention to patients at high risk of fall.We tested three sets of interventions using the Plan-Do-Study-Act approach. For the first cycle, emphasis was on staff education in terms of proper use of fall risk assessment form, risk categorisation and fall prevention advice. In the second cycle, in addition to the first we introduced the 'high risk of fall package' and the third cycle focused on early and easy identification of high-risk patients by continuous fall risk assessment and use of high risk of fall sticker.We observed that at the start of the quality improvement project despite our intervention the fall rate of our ward went up but as we continued adding more ideas focusing on high risk patients, we could achieve a fall reduction of 49.3% from the base line by end of third cycle. Our ward saw fall free days of almost 90 days at the end of project.We conclude that inpatient falls occur due to multiple factors therefore a multi-pronged strategy is needed to prevent it. One of the prime preventive strategy is identifying patients who are at high risk of fall and concentrating attention to those patients.

Knowledge, Attitude, and Practice of Infection Control and Waste Management among Traditional Medicine Practitioners in Bhutan, 2019: A Nationwide Cross-Sectional Survey.

BACKGROUND: In Bhutan, Traditional Medicine (TM) is a part of the government-sponsored free healthcare system and Traditional Medicine Units (TMUs) are colocated with allopathic hospitals. Prevention of healthcare-associated infections and patient safety must apply to all institutionalized healthcare settings including TMUs. This study assessed the knowledge, attitude, and practice of TM practitioners in Bhutan in the field of infection control and waste management practices. METHODS: This was a descriptive study among TM practitioners selected through simple random sampling. Data were collected using a structured pro forma and entered in EpiData 3.1 and analyzed in STATA 13.1. RESULTS: There were 132 respondents (response rate 98%). The majority (64%) knew the seven steps of handwashing but their knowledge of WHO's Five Moments for Handwashing was poor, especially handwashing after aseptic procedures (17%) and handwashing after touching patient surroundings (5%). Handwashing before palpation of the pulse (37%) and using gloves while dispensing medicines (9%) were poor; but the proportions of handwashing before performing moxibustion (96%), correct disposal of sharps (84%), and disinfection of cupping sets (78%) were high. The majority of participants hold a positive attitude towards the adoption of infection control and waste management practices for the benefit of patients. Only 23% had received preservice and 44% had received in-service training on infection control. CONCLUSIONS: The knowledge and practices of infection control and waste management are optimal only in select domains of practice. The practitioners hold a positive attitude towards the adoption of infection control and waste management standards.

Identifying conservation priorities for threatened Eastern Himalayan mammals.

To augment mammal conservation in the Eastern Himalayan region, we assessed the resident 255 terrestrial mammal species and identified the 50 most threatened species based on conservation status, endemism, range size, and evolutionary distinctiveness. By using the spatial analysis package letsR and the complementarity core-area method in the conservation planning software Zonation, we assessed the current efficacy of their protection and identified priority conservation areas by comparing protected areas (PAs), land cover, and global ecoregion 2017 maps at a 100 × 100 m spatial scale. The 50 species that were most threatened, geographically restricted, and evolutionarily distinct faced a greater extinction risk than globally nonthreatened and wide-ranging species and species with several close relatives. Small, medium-sized, and data-deficient species faced extinction from inadequate protection in PAs relative to wide-ranging charismatic species. There was a mismatch between current PA distribution and priority areas for conservation of the 50 most endangered species. To protect these species, the skewed regional PA distribution would require expansion. Where possible, new PAs and transboundary reserves in the 35 priority areas we identified should be established. There are adequate remaining natural areas in which to expand current Eastern Himalayan PAs. Consolidation and expansion of PAs in the EH requires strengthening national and regional transboundary collaboration, formulating comprehensive regional land-use plans, diversifying conservation funding, and enhancing information sharing through a consolidated regional database.

An Outbreak of Aeromonas hydrophila Food Poisoning in Deptsang Village, Samdrup Jongkhar, Bhutan, 2016.

BACKGROUND: An outbreak investigation was carried out to determine the cause and confirm the source of food poisoning in Deptsang village for implementing prevention and control measures. METHODS: We conducted a retrospective cohort study for the outbreak investigation. Stool specimens were collected from cases to perform culture and antibiogram. The team also inspected the environment and hygiene practices in both the construction site and the entire community. The association between the exposure to carcass meat and their outcome of acute gastroenteritis was assessed by risk ratio. P<0.05 was considered statistically significant. RESULTS: Fifty-five villagers consumed the carcass meat during lunch and dinner resulting in 33 cases. Multi-drug resistant Aeromonas hydrophila was isolated from stool specimens of cases, which were susceptible to chloramphenicol only. A risk ratio of 2.1 was found between those people who consumed the carcass meat and those who did not consume the carcass meat (P<0.001). CONCLUSIONS: The current outbreak of food poisoning was caused by the consumption of carcass meat contaminated with A. hydrophila. Provision of health education with emphasis on food hygiene is needed in remote areas to prevent such outbreaks in the future.

Habitat correlates of the red panda in the temperate forests of Bhutan.

Anthropogenic activities and associated global climate change are threatening the biodiversity in the Himalayas against a backdrop of poor knowledge of the region's threatened species. The red panda (Ailurus fulgens) is a threatened mammal confined to the eastern Himalayas, and because of Bhutan's central location in the distributional range of red pandas, its forests are integral to the long-term viability of wild populations. Detailed habitat requirements of the red panda are largely speculative, and there is virtually no ecological information available on this species in Bhutan. Between 2007 and 2009, we established 615 presence/absence plots in a systematic sampling of resident habitat types within Jigme Dorji and Thrumshingla National Parks, Bhutan, to investigate broad and fine-scale red panda habitat associations. Additional locality records of red pandas were obtained from interviewing 664 park residents. Red pandas were generally confined to cool broadleaf and conifer forests from 2,110-4,389 m above sea level (asl), with the majority of records between 2,400-3,700 m asl on south and east-facing slopes. At a finer scale, multivariate analysis revealed that red pandas were strongly associated with old growth Bhutan Fir (Abies densa) forest dominated by a dense cover of Yushania and Arundanaria bamboo with a high density of fallen logs and tree stumps at ground level; a high density of trees, dead snags, and rhododendron shrubs in the mid-storey; and locations that were close to water. Because Bhutan's temperate forests that encompass prime red panda habitat are also integral to human subsistence and socio-economic development, there exists an inadvertent conflict between the needs of people and red pandas. As such, careful sustainable management of Bhutan's temperate forests is necessary if a balance is to be met between the socioeconomic needs of people and the conservation goals for red pandas.