Implementing a daily CME at a rural primary care hospital in Nepal

Fostering a culture of continued learning at healthcare facilities is a global priority for healthcare systems performance, patient safety, and quality improvement. In low- and middle-income countries, continuing medical education activities are almost non-existent in rural areas. National professional academies tend to be focused almost exclusively at major teaching hospitals in urban centers. In addition to playing a central role in healthcare provision, rural district-level hospitals are formative for many young healthcare professionals who are posted there for mandatory government service. The district hospital thus represents an important opportunity to be a center for learning.   Methods We conducted a retrospective case study to describe the implementation of a continuing medical education program at a district-level hospital in rural Nepal. The particular modalities of continuing medical education include didactic lectures, case presentations, and morbidity and mortality conferences, presented by physicians and mid-level providers.   Results             During the first twelve months of the program, 155 sessions, or 73% of scheduled sessions, were conducted as planned. Ongoing challenges to the long-term success of the program include dedicated leadership time for session preparation and presenter mentorship, and improving participatory engagement across multiple clinician cadres.   Conclusions             Building a robust continuing medical education program in rural district hospitals is feasible, and has great potential as a mechanism of developing a professional and sustainable cadre of healthcare workers in these settings. Greater investment in these types of programs may improve healthcare worker satisfaction and retention, thereby improving access to care in these remote areas

Production of He-4 and (4) in Pb-Pb collisions at root(NN)-N-S=2.76 TeV at the LHC

Results on the production of He-4 and (4) nuclei in Pb-Pb collisions at root(NN)-N-S = 2.76 TeV in the rapidity range vertical bar y vertical bar <1, using the ALICE detector, are presented in this paper. The rapidity densities corresponding to 0-10% central events are found to be dN/dy4(He) = (0.8 +/- 0.4 (stat) +/- 0.3 (syst)) x 10(-6) and dN/dy4 = (1.1 +/- 0.4 (stat) +/- 0.2 (syst)) x 10(-6), respectively. This is in agreement with the statistical thermal model expectation assuming the same chemical freeze-out temperature (T-chem = 156 MeV) as for light hadrons. The measured ratio of (4)/He-4 is 1.4 +/- 0.8 (stat) +/- 0.5 (syst). (C) 2018 Published by Elsevier B.V.Peer reviewe

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Fabrication of Langmuir-Blodgett film from Polyvinylpyrrolidone stabilized NiCo alloy nanoparticles

The fabrication of monolayer/multilayer films of Polyvinylpyrrolidone (PVP) stabilized NiCo alloy nanoparticles with an average particle size 7 nm via Langmuir–Blodgett method is presented in this paper. The NiCo alloy nanoparticles were synthesized in ethanol using hydrazine hydrate as reducing agent at 60 °C in the presence of PVP and washed with a mixture of chloroform–methanol (1:1) solution to get pure PVP capped alloy nanoparticles. The NiCo alloy suspension was spread to the interface of air/water and transferred to the glass surface. The formation of a Langmuir monolayer/multilayer of PVP stabilized NiCo particles at air/water interface were revealed with the pressure-area isotherm curve. The transfer of nanoparticles on the glass surface was found to be efficient for the first six layers as exhibited by the pressure-area isotherm and increases in absorption intensity in the UV–Vis range. The atomic force microscopy results show that this film has a cubic symmetry in a two dimensional (2D) array. Manish Kumara, Anjali Pathaka, Mandeep Singhb, M.L. Singlaa

Role of the general practitioner in improving rural healthcare access: a case from Nepal

Abstract Background There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. Case presentation We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital’s catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives. Conclusions GPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal’s maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal’s public sector

Enhanced interfacial properties of graphene oxide incorporated carbon fiber reinforced epoxy nanocomposite: a systematic thermal properties investigation

In this study influence of the graphene oxide (GO) inclusion on the thermal properties of carbon fiber reinforced polymer (CFRP) hybrid composite is reported. Different wt% content of GO used for development of epoxy matrix and CFRP hybrid composite was prepared using compression moulding process. The nanocomposites were characterized by various techniques viz. DMA, DSC, TMA, and TGA. It is observed that in GO-epoxy resin composites, storage and loss modulus reached maximum for 0.3wt% of GO. The storage modulus of CFRP hybrid composite is achieved almost double with the addition of 0.3wt% of GO. The glass transition temperature (T-g) calculated from DMA and TMA of GO incorporated CFRP hybrid composites demonstrated the enhancement in T-g by 4 degrees C and 12 degrees C respectively over to CFRP composites at 0.3wt% GO. This improvement at GO loading is because of onstraint effect of GO sheets on the polymer chain mobility in the composite

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

International audienceLow-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal.

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions