Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Background: Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions – availability, affordability, accessibility, acceptability, and quality – is crucial yet rarely performed, especially in low- and middle-income countries. Objective: To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal. Methods: We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public sector: 11; private sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during May–July 2017. Data for 13 routine diagnostics were obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 day’s wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepal’s adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality. Results: We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHO’s availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public sector) and 1.26 (private sector) days’ wages to purchase a monthly medicine supply. For a person undergoing CVD secondary-prevention interventions in the private sector, the associated expenditure would be 7.5–11.2% of monthly household income. Exit interviews suggest that a long/expensive commute to health facilities and poor medicine affordability constrain access. Conclusions: This study highlights critical gaps in Nepal’s health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability and poor affordability and accessibility. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics

Dengue and Scrub Typhus Coinfection in a Patient Presenting with Febrile Illness

Dengue fever and scrub typhus are common causes of acute febrile illness of unclear origin in Asia. Though coinfections of many vector-borne diseases have been described, articles on dengue and scrub typhus coinfection are distinctly limited. In case of coinfection with dengue and scrub typhus, vigilant monitoring of vitals, platelets transfusion, and timely treatment with doxycycline are necessary. High degree of suspicion has to be made for coinfection in a patient presenting with febrile illness with thrombocytopenia and deranged laboratory parameters in postmonsoon season in endemic regions in Asia

Do Not Ignore Those Raccoon Eyes; They May Indicate Lethal AL Amyloidosis

Light chain (AL) amyloidosis is a lethal form of systemic amyloidosis that arises from the clonal expansion of CD38+ plasma cells. Organ damage occurs when these plasma cells produce misfolded immunoglobulin light chains, which form amyloid fibrils and deposit in tissues. A minority of patients with AL amyloidosis show “raccoon eyes” caused by increased vascular fragility from accumulation of amyloid fibrils. Amyloidosis can be directly associated with bleeding diathesis due to factor X deficiency as factor X binds to amyloid fibrils primarily in the liver and spleen. A 65-year-old Caucasian male presented with random bruising in the upper chest and around the eyes for 1.5 years. Physical examination was unremarkable, except for neck bruising. Pertinent workup showed protein electrophoresis with a faint M spike, increased serum lambda light chains, a kappa to lambda ratio of 0.06, increased Bence-Jones proteins, reduced factor X activity, elevated NT-proBNP. The bone marrow biopsy was positive for Congo red stain for amyloid protein. Magnetic resonance imaging revealed diffuse enhancement of the right and left ventricle subendocardial late gadolinium, consistent with cardiac amyloidosis. The patient started systemic therapy with a regimen of daratumumab, cyclophosphamide, bortezomib, and dexamethasone. After one cycle of therapy, lambda light chains normalized with an improvement in bruising. Diagnostic delays for cardiac patients are concerning as the median survival rate among these patients, when not treated, is approximately 6 months after the onset of symptoms. Since timely treatment can prevent organ damage, clinicians should be aware of specific clinical signs such as raccoon eyes and the importance of systemic evaluation for a prompt diagnosis

Fusobacterium bacteremia presenting with inferior mesenteric vein thrombosis

Key Clinical Message Isolated mesenteric vein thrombosis associated with Fusobacterium is rare. Physicians should be aware regarding the association of Fusobacterium with thrombosis at various sites

Strategy for Prioritization of Storage Hydropower Projects - A Case from Nepal

Purpose: This research aims to analyze the Sensitivity for Prioritization of Storage Hydropower Projects of Nepal. Design/Methodology/Approach: Analytical Hierarchy Process (AHP) based on Multi-Criteria Decision Making (MCDM) has been used for analyzing the Technical, Financial, Policy, Environment factors Sensitivity with pairwise comparison in different multiple criteria. Additionally, the response from the client and expert opinion was conducted. Findings/Result: Technical on first (weightage of 34%), financial on the second (weightage of 25%), environmental on third (weightage of 16%), policy and political on fourth (weightage of 11%), uncertainties on fifth (weightage of 9%), and respondents on sixth (weightage of 5%) are the main the factors. The impact can be explained at 50 % change in weight of respondent Nalsaugad Storage Hydropower Project stands at first rank. If the weightage of respondents changes by 100% then Uttarganga Storage Hydropower Project stands at first rank with respect to respondent factor. The sensitivity analysis with respect to factors was done, which shows no significant difference in the ranking of projects at the base case and at the case of change in weight of factors. Originality/Value: It is action research to assure factors weights Paper Type: Analytical Policy Researc

Adrenal infarction secondary to methamphetamine use: a case report and review of the literature.

BACKGROUND: An acute abdomen can have a variety of causes. A commonly missed cause of abdominal pain is direct substance abuse and its sequelae. The use of methamphetamine is rising in the United States resulting in significant morbidity and mortality. There has been no reported case of methamphetamine-induced adrenal infarction based on an extensive review of available literature. CASE PRESENTATION: We present a case of a 34-year-old Hispanic man who presented with acute abdominal pain secondary to adrenal infarction in the setting of methamphetamine use. Left paraumbilical tenderness was present on abdominal examination. Contrast-enhanced CT of the abdomen and pelvis revealed internal hypoenhancement of the left adrenal gland, consistent with acute left adrenal infarction. The patient was managed with enoxaparin and apixaban. CONCLUSION: Substance abuse, especially among young patients, can at times present with acute abdomen. This mandates physicians to be vigilant and take into consideration the history of substance abuse and relevant investigations. Timely diagnosis and management can prevent life-threatening complications

Antibody-Drug Conjugates in Solid Tumor Oncology: An Effectiveness Payday with a Targeted Payload

Antibody–drug conjugates (ADCs) are at the forefront of the drug development revolution occurring in oncology. Formed from three main components—an antibody, a linker molecule, and a cytotoxic agent (“payload”), ADCs have the unique ability to deliver cytotoxic agents to cells expressing a specific antigen, a great leap forward from traditional chemotherapeutic approaches that cause widespread effects without specificity. A variety of payloads can be used, including most frequently microtubular inhibitors (auristatins and maytansinoids), as well as topoisomerase inhibitors and alkylating agents. Finally, linkers play a critical role in the ADCs’ effect, as cleavable moieties that serve as linkers impact site-specific activation as well as bystander killing effects, an upshot that is especially important in solid tumors that often express a variety of antigens. While ADCs were initially used in hematologic malignancies, their utility has been demonstrated in multiple solid tumor malignancies, including breast, gastrointestinal, lung, cervical, ovarian, and urothelial cancers. Currently, six ADCs are FDA-approved for the treatment of solid tumors: ado-trastuzumab emtansine and trastuzumab deruxtecan, both anti-HER2; enfortumab-vedotin, targeting nectin-4; sacituzuzmab govitecan, targeting Trop2; tisotumab vedotin, targeting tissue factor; and mirvetuximab soravtansine, targeting folate receptor-alpha. Although they demonstrate utility and tolerable safety profiles, ADCs may become ineffective as tumor cells undergo evolution to avoid expressing the specific antigen being targeted. Furthermore, the current cost of ADCs can be limiting their reach. Here, we review the structure and functions of ADCs, as well as ongoing clinical investigations into novel ADCs and their potential as treatments of solid malignancies

Parasitic mature cystic ovarian teratoma: A rare case of autoimplantation of a twisted dermoid cyst

Key Clinical Message Extragonadal parasitic dermoid cysts are rare. Diagnosis of such extragonadal parasitic teratoma is often done intraoperatively during surgical exploration of abdominal mass