Strengthening Nepal's Female Community Health Volunteer network: a qualitative study of experiences at two years.

BACKGROUND: Nepal's Female Community Health Volunteer (FCHV) program has been described as an exemplary public-sector community health worker program. However, despite its merits, the program still struggles to provide high-quality, accessible services nation-wide. Both in Nepal and globally, best practices for community health worker program implementation are not yet known: there is a dearth of empiric research, and the research that has been done has shown inconsistent results. METHODS: Here we evaluate a pilot program designed to strengthen the Nepali government's FCHV network. The program was structured with five core components: 1) improve local FCHV leadership; 2) facilitate structured weekly FCHV meetings and 3) weekly FCHV trainings at the village level; 4) implement a monitoring and evaluation system for FCHV patient encounters; and 5) provide financial compensation for FCHV work. Following twenty-four months of program implementation, a retrospective programmatic evaluation was conducted, including qualitative analysis of focus group discussions and semi-structured interviews. RESULTS: Qualitative data analysis demonstrated that the program was well-received by program participants and community members, and suggests that the five core components of this program were valuable additions to the pre-existing FCHV network. Analysis also revealed key challenges to program implementation including geographic limitations, literacy limitations, and limitations of professional respect from healthcare workers to FCHVs. Descriptive statistics are presented for programmatic process metrics and costs throughout the first twenty four months of implementation. CONCLUSIONS: The five components of this pilot program were well-received as a mechanism for strengthening Nepal's FCHV program. To our knowledge, this is the first study to present such data, specifically informing programmatic design and management of the FCHV program. Despite limitations in its scope, this study offers tangible steps forward for further research and community health worker program improvement, both within Nepal and globally.

Thoraco- abdominal impalement injury: a case report.

BACKGROUND: Impalement injury is an uncommon presentation in the emergency department (ED), and penetrating thoraco-abdominal injuries demand immediate life-saving measures and prompt care. Massive penetrating trauma by impalement in a pediatric case represents a particularly challenging presentation for emergency providers in non-trauma center settings. CASE PRESENTATION: We report a case of 10 year old male who presented in our ED with an alleged history of fall from an approximately 15 foot tall coconut tree, landing over an upright bamboo stake approximately 50 centimeter long, resulting in a trans-abdomino, trans-thoracic injury. In addition to prompt resuscitation and hospital transfer, assessment of damage to vital structures in conjunction with surgical specialty consultation was an immediate goal. CONCLUSION: This article describes a case study of an impalement injury, relevant review of the available literature, and highlights the peculiar strategies required in the setting of a resource limited ED.

Subarachnoid hemorrhage mimicking an acute migraine attack: A case report.

Subarachnoid hemorrhage is a neurological emergency in which arterial blood accumulates in the subarachnoid space with cerebral aneurysmal rupture being the most common cause. Subarachnoid hemorrhage is often misdiagnosed in the emergency department and mortality rates range from 8% to 67%. It may be the manifestation of the chronicity of the migraine. The difference in severity or quality compared to previous headaches, and other symptoms, particularly neck stiffness, but also seizure, syncope, focal neurological deficit, and vomiting are the key factors differentiating subarachnoid hemorrhage from the migraine. We report a case of a 37-year-old female with a previous history of migraines who presented with acute onset of excruciating headaches in the occiput associated with nausea, vomiting, and photophobia in whom a non-contrast computed tomography scan of the head showed hyper-densities involving the bilateral cerebral cortical sulcus and Sylvian fissure and the cerebral angiography showed a complex aneurysm in anterior communicating artery.

A Rare Case of Thrombotic Thrombocytopenic Purpura (TTP) With Concurrent Renal Cell Carcinoma: Diagnostic and Therapeutic Challenges.

Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening thrombotic microangiopathy (TMA) that needs prompt identification and treatment. Disseminated malignancy-related TMA can potentially be misdiagnosed as TTP, and patients may be inappropriately subjected to therapeutic plasma exchange (TPE) with serious implications. Likewise, the presence of a concurrent cancer diagnosis in a patient with microangiopathic hemolytic anemia and thrombocytopenia may lead to suspicion of disseminated malignancy as the cause, delaying the TPE with serious outcomes. Testing for ADAMTS13 activity is diagnostic of TTP, but the results may take time. This poses a diagnostic and therapeutic dilemma that includes weighing the benefits of TPE for treating TTP and cancer treatment. We describe a rare case of immune-mediated TTP in a patient concurrently diagnosed with metastatic renal cell cancer. To our knowledge, this is the first case of TTP reported in patients with metastatic renal cell carcinoma (RCC) in a non-treatment-naive patient.

Cutaneous drug reaction secondary to antitubercular regimen: A case report from Nepal.

Cutaneous adverse drug reactions are known side effects of first-line antitubercular therapy, which ranges from mild pruritus to life-threatening toxic epidermal necrolysis. Severe cutaneous adverse drug reactions can lead to antitubercular therapy discontinuation and further complicates tuberculosis treatment. Here we present the case of a 49-year-old obese male who developed a generalized maculopapular rash within 24 hours of initiation of therapy followed by bullae over palms in 3 days. Antitubercular therapy was immediately discontinued, and he was managed with antihistamines, intravenous fluid, and electrolyte supplementation. He was discharged on antihistamines, a short course of systemic steroids, moxifloxacin, and bedaquiline (second-line antitubercular therapy (ATT)). Proper guidelines about rechallenge therapy will enormously aid in managing cutaneous adverse drug reactions, and efficient treatment of tuberculosis in these patients, and ceasing its progression to multisystemic complications. This article aims to discuss the presentation and management of cutaneous adverse drug reactions in the setting of Nepal.

Unilateral proptosis in a patient with thyroid eye disease: A case report.

Unilateral proptosis is an abnormality in which one eye sticks out forward more than the other. Bulging of the eye is commonly seen in Graves' ophthalmopathy, but it's mostly bilateral. Thyroid eye disease presents as the most common extrathyroidal manifestation of Graves' disease, and rarely leads to unilateral proptosis. A 25-year-old female with a history of weight loss, menstrual irregularities, and palpitations presented with progressive right eye bulging, which was further confirmed by magnetic resonance imaging and biochemical investigations. Magnetic resonance imaging of the orbit revealed unilateral extraocular muscle enlargement and enhancement with sparing of the tendons. Timely therapy is crucial for reversing the ocular manifestations of thyroid eye disease.

Diagnostic pitfalls in young onset parkinsonism and its unique challenges: A case report from rural Nepal.

Parkinson's disease is a neurodegenerative disease resulting from the loss of dopamine-secreting neurons present in the substantia nigra of the brain. Parkinson's disease is classified as early-onset and late-onset disease based on the time of its presentation. Since young patients with Parkinson's disease have an atypical clinical presentation and have to deal with their careers, raising families, or both at the time of diagnosis and also have a higher risk of drug-related side effects, it poses unique challenges for the patient, clinical team, and community. We present the case of a 40-year-old female with young onset Parkinson's disease from rural Nepal and the challenges faced during and after the disease in a resource-limited setting.

Intestinal tuberculosis can masquerade as Crohn's disease: A teachable moment.

Intestinal tuberculosis and Crohn's disease are chronic granulomatous diseases with similar clinical presentations and can mimic one another. Their treatment modalities are completely different; however, sometimes it is challenging to differentiate them. We report a case of a 51-year-old female presenting with abdominal pain and on-and-off diarrhea for 4 years with weight loss. Clinical symptoms along with multiple aphthous ulcers in the terminal ileum and negative tuberculin test favored the diagnosis of Crohn's disease. The patient did not respond to steroids. A repeat colonoscopy with acid-fast bacilli stain showed Mycobacterium tuberculosis. This case highlights that acid-fast bacilli culture and tuberculosis polymerase chain reaction to confirm or rule out the diagnosis of intestinal tuberculosis in all patients suspected of Crohn's disease.

Use of Venous Thromboembolism Prophylaxis in Hospitalized Patients: Knowledge and Practice Among Physicians in Nepal.

Introduction: Despite the importance of Venous Thromboembolism (VTE) prophylaxis in hospitalized patients, audits have shown inadequate use of VTE prophylaxis methods around the world. We aimed to assess knowledge, attitudes, and behaviors regarding VTE prophylaxis among clinicians in Nepal. Methodology: A cross-sectional questionnaire-based survey was conducted using an online survey platform. Results: 199 (60.7%) of the respondents were aware of the risk factors-based risk stratification approach to VTE prophylaxis in hospitalized patients. Only 154 (47%) of the physicians reported institute-based protocols for VTE prophylaxis. Conclusion: We found a significant lack of awareness on risk factors-based stratification strategy for VTE prevention practices among Nepalese physicians. We recommend educational efforts for Nepalese physicians on the overall impact of VTE on mortality and morbidity of hospitalized patients. Our study highlights the needs for adoption of institution-based protocols for VTE prophylaxis and prevention.

Quality of YouTube patient information on prostate cancer screening.

Social media is used by patients for health care information. We analyzed the quality of YouTube videos on prostate cancer screening. Most videos (71.1%) mentioned the potential harms of prostate cancer screening. There was no significant difference in risk-related information between videos published before and after the publication of US Preventive Services Task Force 2012 guidelines for prostate cancer screening. In conclusion, the quality of information of YouTube videos on prostate cancer screening is low and the content is potentially misleading.

YouTube lens to attention deficit hyperactivity disorder: a social media analysis.

OBJECTIVE: Social media has provided an online environment for patients to discuss regarding their health and seek medical information. The primary aim of our study was to analyze the quality of information shared on YouTube regarding attention deficit hyperactivity disorder (ADHD). RESULTS: More than half of the videos, 91 (57.23%) had duration of fewer than 5 min. Only 8 (5.03%) videos were rated as highly useful whereas 61 (38.36%) videos were misleading. Interestingly, there was a significant higher (1203.38 ± 395) likes in the misleading group of videos, compared to 162.13 ± 169.63 likes in the very useful group, P = 0.012. Only a small fraction of videos had very useful information on ADHD. There is a need for high-quality, evidence-based, educational videos on ADHD for patient education.

Exercise-induced acute compartment syndrome in a young man, occurring after a short race.

We describe a case of exercise-induced acute compartment syndrome (ACS) in a 23-year-old man who presented to his primary care physician 48 hours after he attempted to run a 5K race. He noticed searing pain in his left leg after the first half mile but had no other symptoms. He was referred to the emergency department and diagnosed with ACS, and a fasciotomy was done. A presentation of limb pain that is out of proportion to a known or suspected injury should prompt consideration of ACS. Early recognition and surgical management are essential to achieving the best possible outcome.

Road traffic accidents in Kathmandu--an hour of education yields a glimmer of hope.

After the Metropolitan Traffic Police, Kathmandu initiated a "No Drinking and Driving" policy in 2011 in which a major intervention for intoxicated drivers was mandatory 1-hour class to modify drunk driving behaviors, reports show that the number of road traffic accidents in the year 2012 decreased by 23 percent from the year 2011. The injury to fatality ratio decreased by 21 percent in this period. We remain encouraged by these statistics which confirm that increased enforcement of road traffic rules, combined with behavioral change programs, can have positive changes in LMICs which suffer considerably from the global burden of trauma.

Parenteral organophosphorus poisoning in a rural emergency department: a case report.

BACKGROUND: Poisoning is a common presentation in the emergency department. Oral exposures to organophosphorus compounds are especially frequent in rural and agricultural regions of South Asia and throughout the developing world. CASE PRESENTATION: Here we report a case of deliberate self-harm with an organophosphorus pesticide via the relatively uncommon parenteral route. A young woman injected herself with chlorpyriphos. Although the cholinergic effects were mild, cellulitis and abscess development were noted as a result. CONCLUSION: Resource limited agricultural countries like Nepal present health care workers with numerous challenges in poisoning management. This case represents a rare but potentially morbid method of agrochemical poison exposure.

Initial resuscitation for Australasian Triage Scale 2 patients in a Nepalese emergency department.

OBJECTIVES: Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken. METHODS: We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded. RESULTS: The mean waiting time was 2.1 ± 1.7 min with a range of 1-10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients. CONCLUSION: Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden.