Burden of injuries in Nepal, 1990–2017: Findings from the Global Burden of Disease Study 2017

Background: Nepal is a low-income country undergoing rapid political, economic and social development. To date, there has been little evidence published on the burden of injuries during this period of transition.Methods: The Global Burden of Disease Study (GBD) is a comprehensive measurement of population health outcomes in terms of morbidity and mortality. We analysed the GBD 2017 estimates for deaths, years of life lost, years lived with disability, incidence and disability-adjusted life years (DALYs) from injuries to ascertain the burden of injuries in Nepal from 1990 to 2017.Results: There were 16 831 (95% uncertainty interval 13 323 to 20 579) deaths caused by injuries (9.21% of all-cause deaths (7.45% to 11.25%)) in 2017 while the proportion of deaths from injuries was 6.31% in 1990. Overall, the injury-specific age-standardised mortality rate declined from 88.91 (71.54 to 105.31) per 100 000 in 1990 to 70.25 (56.75 to 85.11) per 100 000 in 2017. In 2017, 4.11% (2.47% to 6.10%) of all deaths in Nepal were attributed to transport injuries, 3.54% (2.86% to 4.08%) were attributed to unintentional injuries and 1.55% (1.16% to 1.85%) were attributed to self-harm and interpersonal violence. From 1990 to 2017, road injuries, falls and self-harm all rose in rank for all causes of death.Conclusions: The increase in injury-related deaths and DALYs in Nepal between 1990 and 2017 indicates the need for further research and prevention interventions. Injuries remain an important public health burden in Nepal with the magnitude and trend of burden varying over time by cause-specific, sex and age group. Findings from this study may be used by the federal, provincial and local governments in Nepal to prioritise injury prevention as a public health agenda and as evidence for country-specific interventions

Efficacy of Preemptive Gabapentin for Lower Extremity Orthopedic Surgery under Subarachnoid Block

Introduction: Gabapentin is one of the adjuncts when given before surgery as a multi modal analgesia regimen has shown to decrease pain scores and opioid consumption in the first 24 hour after surgery. The aim of the study is to assess total opioid consumption in first 24 hour postoperatively after giving 600 mg of preemptive oral Gabapentin in lower extremity orthopedic surgery done under subarachnoid block. Methods: A randomized single blinded study was conducted for duration of 6 months after approval from institutional review board. A total of 52 American Society of Anesthesiology physical status grade I and II cases were included in the study of which 26 patients received oral Gabapentin two hours prior to surgery and 26 patients in the control group. They were evaluated postoperatively for total opioid consumption in first 24 hours, Visual Analogue Score after 2, 4, 6 and 24 hours at rest.  Results: Total opioid consumption in first 24 hours was 74.13 ± 27.78 mg in Gabapentin group versus 123.53 ± 64.48 mg in Control (p = 0.001). VAS score was 1.23 ± 1.47 in Gabapentin group versus 2.12 ± 1.58 in Control group (p=0.04) at 2 hours and 2.19 ± 0.40 in Gabapentin group versus 2.77 ± 1.17 in control group (p=0.02) at 24 hours postoperatively at rest which were found to be statistically significant. Incidence of sedation was minimal and comparable in both groups.  Conclusions: Oral Gabapentin 600mg given two hours before surgery reduces total opioid consumption in first 24 hours after surgery and also reduces Visual Analogue score for pain postoperatively at rest in 2 and 24 hours with minimum sedation. Keywords: analgesia; gabapentin; opioid; preemptive; sedation; visual analogue score

Ultrasound-Guided Interscalene Brachial Plexus Block for Pathological Humerus Fracture due to Multiple Myeloma with Systemic Manifestation: Useful Option for Management in Low-Income Countries

Anesthetic management of pathological fracture due to multiple myeloma with systemic manifestation poses a perioperative challenge especially in low-resource setups like Nepal. Regional anesthesia using ultrasound-guided block can improve the accuracy, reduce complications, and improve overall perioperative management of pathological fractures due to malignancy with systemic spread in resource-deprived setups. We present a case of a 53-year-old lady with pathological fracture of left humerus shaft, a diagnosed case of multiple myeloma with compression fracture of multiple lumbar spine with chest wall metastasis with resolving acute kidney injury with chest infections. Ultrasound-guided interscalene brachial plexus block with sedation was done for open reduction internal fixation of humerus shaft fracture taking in consideration the overall high perioperative risk of patient. Intraoperative hemodynamic was uneventful, with no neurological sequelae and good recovery status perioperatively. Ultrasound-guided interscalene brachial plexus block if done cautiously can be a very useful alternative technique for better perioperative outcome in patients with malignancy with systemic spread in areas where expertise is scarce and resource is limited

Efcacy of Preemptive Gabapentin for Lower Extremity Orthopedic Surgery Under Subarachnoid Block

Introduction: Gabapentin is one of the adjuncts when given before surgery as a multi modal analgesia regimen has shown to decrease pain scores and opioid consumption in the first 24 hour after surgery. The aim of the study is to assess total opioid consumption in first 24 hour postoperatively after giving 600 mg of preemptive oral Gabapentin in lower extremity orthopedic surgery done under subarachnoid block. Methods: A randomized single blinded study was conducted for duration of 6 months after approval from institutional review board. A total of 52 American Society of Anesthesiology physical status grade I and II cases were included in the study of which 26 patients received oral Gabapentin two hours prior to surgery and 26 patients in the control group. They were evaluated postoperatively for total opioid consumption in first 24 hours, Visual Analogue Score after 2, 4, 6 and 24 hours at rest. Results: Total opioid consumption in first 24 hours was 74.13 ± 27.78 mg in Gabapentin group versus 123.53 ± 64.48 mg in Control (p = 0.001). VAS score was 1.23 ± 1.47 hours in Gabapentin group versus 2.12 ± 1.58 hours in Control group (p=0.04) at 2 hours and 2.19 ± 0.40 hours in Gabapentin group versus 2.77 ± 1.17 hours in control group (p=0.02) at 24 hours postoperatively at rest which were found to be statistically signi cant. Incidence of sedation was minimal and comparable in both groups. Conclusions: Oral Gabapentin 600mg given two hours before surgery reduces total opioid consumption in first 24 hours after surgery and also reduces Visual Analogue score for pain postoperatively at rest in 2 and 24 hours with minimum sedation. Keywords: analgesia; gabapentin; opioid; preemptive; sedation; visual analogue score

Analysis of Health Sector Budget of Nepal

Introduction: Primarily, health sector connects two segments - medicine and public health, where medicine deals with individual patients and public health with the population health. Budget enables both the disciplines to function effectively. The Interim Constitution of Nepal, 2007 has adapted the inspiration of federalism and declared the provision of basic health care services free of cost as a fundamental right, which needs strengthening under foreseen federalism. Methods: An observational retrospective cohort study, aiming at examining the health sector budget allocation and outcome, was done. Authors gathered health budget figures (2001 to 2013) and facts published from authentic sources. Googling was done for further information. The keywords for search used were: fiscal federalism, health care, public health, health budget, health financing, external development partner, bilateral and multilateral partners and healthcare accessibility. The search was limited to English and Nepali-language report, articles and news published. Results: Budget required to meet the population's need is still limited in Nepal. The health sector budget could not achieve even gainful results due to mismatch in policy and policy implementation despite of political commitment. Conclusions: Since Nepal is transforming towards federalism, an increased complexity under federated system is foreseeable, particularly in the face of changed political scenario and its players. It should have clear goals, financing policy and strict implementation plans for budget execution, task performance and achieving results as per planning. Additionally, collection of revenue, risk pooling and purchasing of services should be better integrated between central government and federated states to horn effectiveness and efficiency.  Keywords: health care; budget; financing; unitary system; federalism

Feasibility assessment of an ergonomic baby wrap for kangaroo mother care: A mixed methods study from Nepal.

BACKGROUND:Kangaroo mother care, an evidence based practice and a national policy for management of low birth weight newborns in Nepal, is not widely practiced. This implementation research study aimed to explore the consumer preference and acceptability of the traditional and a new ergonomic wrap on the continuation of kangaroo mother care in the facility and community following discharge. METHODS:A mixed method feasibility study was done from May to October 2015. Ninety-six families of stable low birth weight newborns weighing 1800 to 2499 grams were counseled and taught to practice kangaroo mother care using both wraps. They were randomized into two groups of 48 with one group trying out the traditional wrap for the first six hours and the new wrap for the next six, and vice versa. Mothers were allowed to choose between the wraps for continuation of kangaroo mother care at the facility and post discharge. They were followed up telephonically weekly over 28 days postpartum to ascertain practice of kangaroo mother care. In-depth interviews with mothers (n = 12) and focus group discussions with health workers (n = 16) further evaluated the intervention. Descriptive statistics are presented for the quantitative part of the study. RESULTS:Mothers in the two groups chose the new wrap with no significant difference (81.3% vs 89.6%, p = 0.24). Of the 96 randomized mothers, 85% chose the new wrap. During the hospital stay, six mothers dropped out and remaining 90 mothers who were discharged with the intention of continuing Kangaroo Mother Care, 78 and 12 mothers did so with the new and traditional wrap respectively. New wrap users (429.1 hours, 95% confidence interval [CI]: 351.7-470.3) performed skin-to-skin contact for an extra 77.4 hours overall than traditional wrap (351.7 hours, 95%CI: 259.3-444) users from first day to 28 day postpartum. Health workers and mothers reported positive experience with the new wrap as it was easy to wear without assistance, secure and flexible to move around in kangaroo mother care position. CONCLUSIONS:Involvement of mothers and families with provision of ergonomic wraps showed improvement in kangaroo mother care practice during hospital stay and at home

How positive deviants helped in fighting the early phase of COVID-19 pandemic? A qualitative study exploring the roles of frontline health workers in Nepal.

Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic