Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia.

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

History of emergency medicine in Bhutan.

Emergency medicine in Bhutan has made significant progress in the past few decades and continues to evolve. In this article, we provide valuable insights into the history of emergency medicine at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and in Bhutan and highlight some of the future challenges we face as we move forward to meet the demands of increased patient volume and complexity.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities.

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

Improving Stroke Care in Bhutan.

Developing nations face the double burden of communicable and noncommunicable diseases. Bhutan is a developing country and has achieved significant milestones in its health indicators. Increasing burden of stroke and the lack of evidence-based stroke care system in the country's hospitals are proving to be a challenge to provide quality stroke care. Despite the logistical challenge of referring stroke patients on time, lack of trained health care professionals and resources, Bhutan has recently started various initiatives to improve stroke care with the help of WHO-SEARO, WHO-Geneva, and Christian Medical College, Ludhiana, India.

Postgraduate Surgical Education in Bhutan.

Postgraduate medical education in Bhutan began in 2014 which marked a new era in the medical education in the country. From a mere handful of surgeons in 2003 to the numbers today, general surgical services have come a long way in Bhutan. Medical education has progressed tremendously to adoption of modern medical educational methods promoting objectivity in all aspects. This article dwells with the historical perspective as well as the state of the general surgical education and the services in Bhutan. It is the first of its kind of article to be written.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016.

OBJECTIVES: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan. METHODS: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated. RESULTS: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior. CONCLUSION: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.

Prevalence of drink-driving in Thimphu, Bhutan: Targeted surveillance at sentinel sites.

INTRODUCTION AND AIMS: Bhutan has a high incidence of alcohol-related disease. With economic development, motorised transport is proliferating, increasing the potential for traffic injury. We investigated drink-driving in the country's largest urban environment. METHODS: Working with police, we set up checkpoints at major thoroughfares in Thimphu, on Tuesday, Friday and Saturday nights, from May to July 2017. Police directed cars to testing bays where drivers were breathalysed and interviewed. RESULTS: All 1596 drivers stopped by police were breathalysed, and 212 (13%) tested positive. Blood alcohol of >0.02 g/dL (which we defined as 'probable impairment') was detected in 178 drivers (11%), while 67 (4.2%) exceeded the legal limit of 0.08 g/dL. Probable impairment was more common in men, older drivers, on Tuesdays (versus Fridays or Saturdays) and later at night. CONCLUSION: Drink-driving is very common at night-time in Bhutan. Routine roadside random breath-testing, and media campaigns emphasising the risk of apprehension and consequent serious financial and social penalties, should be considered to deter drink-driving.

Internet Addiction among Secondary School Adolescents: A Mixed Methods Study.

INTRODUCTION: Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents. METHODS: This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. RESULTS: Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep. CONCLUSIONS: Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

Blood alcohol and injury in Bhutan: targeted surveillance in a national referral hospital emergency department.

Bhutan is a low-middle-income country with poor roads, rapidly increasing motor vehicle use and heavy alcohol consumption. We estimated the proportion of emergency department patients presenting with injury who had positive blood alcohol. We sought to breathalyse and interview all adult patients (≥18 years) presenting with injury at the Jigme Dorji Wangchuck National Referral Hospital in the capital city Thimphu, from April to October 2015. Breath tests and interviews were conducted with 339 (91%) of 374 eligible adult patients. A third (34%) were alcohol-positive and 22% had blood alcohol concentrations >0.08 g/dL. The highest alcohol-positive fractions were for assault (71%), falls (31%) and traffic crashes (30%). Over a third (36%) of patients had a delay of >2 h between injury and breath test. The results underestimate blood alcohol concentrations at the time of injury so the true prevalence of pre-injury alcohol impairment is greater than our estimates suggest. Countermeasures are urgently needed, particularly roadside random breath testing and alcohol controls.

Establishing a trauma registry in Bhutan: needs and process.

BACKGROUND: Globally, trauma represents a growing and significant burden of disease. Many health systems have limited metrics with which to guide development and appropriately inform policy and management decisions with regard to trauma related health care delivery. FINDINGS: This paper outlines the establishment of need for improved trauma related metrics in the country of Bhutan and the process of development of a trauma registry at Jigme Dorji Wangchuck National Referral Hospital to meet that need. CONCLUSIONS: Trauma registries are important tools allowing health systems to respond to the shifting burden of disease; successful establishment of a trauma registry requires an understanding of the health system and broad institutional support.

Formulas used by Tibetan doctors at Men-Tsee-Khang in India for the treatment of neuropsychiatric disorders and their correlation with pharmacological data.

The aim of the present study was to identify formulas used at Men-Tsee-Khang (Tibetan Medical and Astrological Institute), India, for the treatment of neuropsychiatric disorders and to compare the Tibetan usage of particular ingredients with pharmacological data from the scientific database. Using ethnographic methods, five doctors were selected and interviewed. A correlation was observed between central nervous system disorders and rLung, one of the three humors in Tibetan medicine, which imbalance is the source of mental disorders, and ten multi-ingredient formulas used to treat the imbalance of this particular humor were identified. These formulas utilize 61 ingredients; among them were 48 plant species. Each formula treats several symptoms related to rLung imbalance, so the plants may have therapeutic uses distinct from those of the formulas in which they are included. Myristica fragrans, nutmeg, is contained in 100% of the formulas, and its seeds exhibit stimulant and depressant actions affecting the central nervous system. Preclinical and clinical data from the scientific literature indicate that all of the formulas include ingredients with neuropsychiatric action and corroborate the therapeutic use of 75.6% of the plants. These findings indicate a level of congruence between the therapeutic uses of particular plant species in Tibetan and Western medicines.