35 results on '"Pokharel, Sunil"'
Search Results
2. A Practitioner’s Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel
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Kalra, Sanjay, Bajaj, Sarita, Sharma, Surendra Kumar, Priya, Gagan, Baruah, Manash P., Sanyal, Debmalya, Das, Sambit, Chaudhury, Tirthankar, Gangopadhyay, Kalyan Kumar, Das, Ashok Kumar, Sethi, Bipin, Ayyar, Vageesh, Shaikh, Shehla, Shah, Parag, Jindal, Sushil, Deshmukh, Vaishali, Dave, Joel, Amod, Aslam, Joshi, Ansumali, Pokharel, Sunil, Pathan, Faruque, Afsana, Faria, Prasad, Indrajit, Murad, Moosa, Soelistijo, Soebagijo Adi, Purwoto, Johanes, Hussein, Zanariah, Horn, Lee Chung, Sahay, Rakesh, Somasundaram, Noel, Antonypillai, Charles, Sumanathilaka, Manilka, and Bulugahapitiya, Uditha
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- 2020
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3. Antimicrobial use in food animals and human health: time to implement ‘One Health’ approach
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Pokharel, Sunil, Shrestha, Priyanka, and Adhikari, Bipin
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- 2020
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4. Outbreak of acute undifferentiated febrile illness in Kathmandu, Nepal: clinical and epidemiological investigation
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Pokharel, Sunil, Karki, Manan, Acharya, Bhim, Marasini, Baburam, and Arjyal, Amit
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- 2020
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5. CEBAF Injector Model for K_{L} Beam Conditions
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Pokharel, Sunil, Bruker, Max, Grames, Joseph, Hofler, Alicia, Kazimi, Reza, Krafft, Geoffrey, and Zhang, Shukui
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MC5: Beam Dynamics and EM Fields ,Accelerator Physics - Abstract
The Jefferson Lab KL experiment will run at the Continuous Electron Beam Accelerator Facility with a much lower bunch repetition rate (7.80 or 15.59 MHz) than nominally used (249.5 or 499 MHz). While the proposed average current of 2.5 - 5.0 muA is relatively low compared to the maximum CEBAF current of approximately 180 muA, the corresponding bunch charge is atypically high for CEBAF injector operation. In this work, we investigated the evolution and transmission of low-rep-rate, high-bunch-charge (0.32 to 0.64 pC) beams through the CEBAF injector. Using the commercial software General Particle Tracer, we have simulated and analyzed the beam characteristics for both values of bunch charge. We performed these simulations with the existing injector using a 130 kV gun voltage. We have calculated and measured the transmission as a function of the photocathode laser spot size and pulse length. We report on the findings of these simulations and optimum parameters for operating the experiment., Proceedings of the 13th International Particle Accelerator Conference, IPAC2022, Bangkok, Thailand
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- 2022
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6. Modeling a Nb₃Sn Cryounit in GPT at UITF
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Pokharel, Sunil, Hofler, Alicia, and Krafft, Geoffrey
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MC5: Beam Dynamics and EM Fields ,Accelerator Physics - Abstract
Nb₃Sn is a prospective material for future superconducting RF (SRF) accelerator cavities. The material can achieve higher quality factors, higher temperature operation and potentially higher accelerating gradients (E_{acc} 96 MV/m) compared to conventional niobium. In this work, we performed modeling of the Upgraded Injector Test Facility (UITF) at Jefferson Lab utilizing newly constructed Nb₃Sn cavities. We studied the effects of the buncher cavity and varied the gun voltages from 200-500 keV. We have calibrated and optimized the SRF cavity gradients and phases for the Nb₃Sn five-cell cavities energy gains with the framework of General Particle Tracer (GPT). Our calculations show the beam goes cleanly through the unit. There is full energy gain out of the second SRF cavity but not from the first SRF cavity due to non-relativistic phase shifts., Proceedings of the 13th International Particle Accelerator Conference, IPAC2022, Bangkok, Thailand
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- 2022
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7. Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers.
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Shrestha, Nipun, Mishra, Shiva Raj, Ghimire, Saruna, Gyawali, Bishal, Marahatta, Sujan Babu, Maskey, Smriti, Baral, Sushila, Shrestha, Nilima, Yadav, Rakesh, Pokharel, Sunil, and Adhikari, Bipin
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COVID-19 pandemic ,MEDICAL personnel - Abstract
Background: Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal. Methods: Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches. Results: Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients. Conclusion: Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics. [ABSTRACT FROM AUTHOR]
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- 2022
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8. Prevalence and long-term glucose metabolism evolution of post-transplant diabetes mellitus in Chinese renal recipients
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Xu, Yun, Liang, Jia-xian, Liu, Bin, Yao, Bin, Pokharel, Sunil, Chen, Guo-dong, Wang, Chang-xi, Li, Yan-bing, and Xiao, Hai-peng
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- 2011
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9. Metastatic Esophageal Cancer Presenting as an Orbital Mass
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Pokharel, Sunil, Kabbach, Ghassan, Richter, Seth J., and Chiu, Laura
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- 2016
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10. Status of Anxiety, Depression and Social Discrimination among Quarantined People following Global Pandemic of COVID 19 in Karnali province: A Mixed Method Study Authors name and affiliation Background and Objective
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BC, Udaya Bahadur, Chetan Nidhi Wagle, Pokharel, Sunil, Thapa, Kanchan, Sabika Munikar, Pratik Adhikary, and Bhattarai, Karuna
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- 2020
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11. Trimethoprim-sulfamethoxazole Versus Azithromycin for the Treatment of Undifferentiated Febrile Illness in Nepal: A Double-blind, Randomized, Placebo-controlled Trial.
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Giri, Abhishek, Karkey, Abhilasha, Dangol, Sabina, Arjyal, Amit, Pokharel, Sunil, Rijal, Samita, Gajurel, Damodar, Sharma, Rabi, Lamsal, Kamal, Shrestha, Pradip, Prajapati, Gayatri, Pathak, Saruna, Shrestha, Sita Ram, K. C., Raj Kumar, Pandey, Sujata, Thapa, Abishkar, Shrestha, Nistha, Thapa, Raj Kumar, Poudyal, Buddhi, and Dung Nguyen Thi Phuong
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Background. Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods. We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results. From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions. Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. [ABSTRACT FROM AUTHOR]
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- 2021
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12. Anxiety and depression among people living in quarantine centers during COVID-19 pandemic: A mixed method study from western Nepal.
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B. C., Udaya Bahadur, Pokharel, Sunil, Munikar, Sabika, Wagle, Chetan Nidhi, Adhikary, Pratik, Shahi, Brish Bahadur, Thapa, Chandra, Bhandari, Ram Prasad, Adhikari, Bipin, and Thapa, Kanchan
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COVID-19 pandemic , *QUARANTINE , *ANXIETY , *MEDICAL personnel , *BECK Anxiety Inventory , *RETURN migrants , *MENTAL depression - Abstract
Background: In response to the COVID-19 pandemic, incoming travelers were quarantined at specific centers in Nepal and major checkpoints in Nepal-India border. Nepal adopted a generic public health approaches to control and quarantine returnee migrants, with little attention towards the quality of quarantine facilities and its aftermath, such as the poor mental health of the returnee migrants. The main objective of this study was to explore the status of anxiety and depression, and factors affecting them among returnee migrants living in institutional quarantine centers of western Nepal. Methods: A mixed method approach in this study included a quantitative survey and in-depth interviews (IDIs) among respondents in quarantine centers of Karnali province between 21st April and 15th May 2020. Survey questionnaire utilized Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) tools, which were administered among 441 quarantined returnee migrants. IDIs were conducted among 12 participants which included a mix of six quarantined migrants and healthcare workers each from the quarantine centres. Descriptive and inferential analyses were conducted on quantitative data; and thematic analysis was utilized for qualitative data. Results: Mild depression (9.1%; 40/441) and anxiety (16.1%; 71/441) was common among respondents followed by moderate depression and anxiety {depression (3.4%; 15/441), anxiety (4.1%; 18/441)} and severe depression and anxiety {depression (1.1%; 5/441), anxiety (0.7%; 3/441)}. Anxiety and depression were independent of their socio-demographic characteristics. Perceived fear of contracting COVID-19, severity and death were prominent among the respondents. Respondents experienced stigma and discrimination in addition to being at the risk of disease and possible loss of employment and financial responsibilities. In addition, poor (quality and access to) health services, and poor living condition at the quarantine centres adversely affected respondents' mental health. Conclusion: Depression and anxiety were high among quarantined population and warrants more research. Institutional quarantine centers of Karnali province of Nepal were in poor conditions which adversely impacted mental health of the respondents. Poor resource allocation for health, hygiene and living conditions can be counterproductive to the population quarantined. [ABSTRACT FROM AUTHOR]
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- 2021
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13. Algorithm in the Diagnosis of Febrile Illness Using Pathogen-specific Rapid Diagnostic Tests.
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Pokharel, Sunil, White, Lisa J, Aguas, Ricardo, Celhay, Olivier, Pellé, Karell G, and Dittrich, Sabine
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DIAGNOSIS of fever , *RAPID diagnostic tests , *DISEASE prevalence , *ROUTINE diagnostic tests , *SENSITIVITY & specificity (Statistics) , *ALGORITHMS - Abstract
Background In the absence of proper guidelines and algorithms, available rapid diagnostic tests (RDTs) for common acute undifferentiated febrile illnesses are often used inappropriately. Methods Using prevalence data of 5 common febrile illnesses from India and Cambodia, and performance characteristics (sensitivity and specificity) of relevant pathogen-specific RDTs, we used a mathematical model to predict the probability of correct identification of each disease when diagnostic testing occurs either simultaneously or sequentially in various algorithms. We developed a web-based application of the model so as to visualize and compare output diagnostic algorithms when different disease prevalence and test performance characteristics are introduced. Results Diagnostic algorithms with appropriate sequential testing predicted correct identification of etiology in 74% and 89% of patients in India and Cambodia, respectively, compared with 46% and 49% with simultaneous testing. The optimally performing sequential diagnostic algorithms differed in India and Cambodia due to varying disease prevalence. Conclusions Simultaneous testing is not appropriate for the diagnosis of acute undifferentiated febrile illnesses with presently available tests, which should deter the unsupervised use of multiplex diagnostic tests. The implementation of adaptive algorithms can predict better diagnosis and add value to the available RDTs. The web application of the model can serve as a tool to identify the optimal diagnostic algorithm in different epidemiological settings, while taking into account the local epidemiological variables and accuracy of available tests. [ABSTRACT FROM AUTHOR]
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- 2020
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14. Antimicrobial resistance and over the counter use of drugs in Nepal.
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Pokharel, Sunil and Adhikari, Bipin
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CULTURE ,DRUG resistance in microorganisms ,DRUG laws ,NONPRESCRIPTION drugs ,DRUGSTORES ,MEDICAL care costs ,SOCIOECONOMIC factors - Published
- 2020
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15. Novel Roles of Chloroquine and Hydroxychloroquine in Graves’ Orbitopathy Therapy by Targeting Orbital Fibroblasts.
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Yan Guo, Hai Li, Xueying Chen, Huasheng Yang, Hongyu Guan, Xiaoying He, Yuxin Chen, Pokharel, Sunil, Haipeng Xiao, and Yanbing Li
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- 2020
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16. Quiz Page March 2016: A 60-Year-Old Man With Fever, Night Sweats, and Acute Kidney Injury
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Tobin, Ellis, Pokharel, Sunil, Haqqie, Syed, and Asif, Arif
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- 2016
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17. Co-trimoxazole versus azithromycin for the treatment of undifferentiated febrile illness in Nepal: study protocol for a randomized controlled trial.
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Pokharel, Sunil, Basnyat, Buddha, Arjyal, Amit, Pathak Mahat, Saruna, Raj Kumar, K. C., Bhuju, Abhusani, Poudyal, Buddhi, Kestelyn, Evelyne, Shrestha, Ritu, Dung Nguyen Thi Phuong, Thapa, Rajkumar, Karki, Manan, Dongol, Sabina, Karkey, Abhilasha, Wolbers, Marcel, Baker, Stephen, Thwaites, Guy, Mahat, Saruna Pathak, Kc, Raj Kumar, and Phuong, Dung Nguyen Thi
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TYPHOID fever treatment , *CO-trimoxazole , *AZITHROMYCIN , *FLUOROQUINOLONES , *RANDOMIZED controlled trials , *DIAGNOSIS of fever , *ANTIBIOTICS , *CLINICAL trials , *COMPARATIVE studies , *DRUG resistance in microorganisms , *EXPERIMENTAL design , *FEVER , *RESEARCH methodology , *MEDICAL cooperation , *RESEARCH protocols , *ORAL drug administration , *RESEARCH , *RESEARCH funding , *TIME , *TYPHOID fever , *EVALUATION research , *TYPHUS fever , *TREATMENT effectiveness , *BLIND experiment , *DIAGNOSIS ,TYPHOID fever diagnosis - Abstract
Background: Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI.Methods/design: This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients.Discussion: Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever.Trial Registration: ClinicalTrials.gov, ID: NCT02773407 . Registered on 5 May 2016. [ABSTRACT FROM AUTHOR]- Published
- 2017
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18. Diffusion coefficients of nitric oxide in water: A molecular dynamics study.
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Pokharel, Sunil, Pantha, Nurapati, and Adhikari, N. P.
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NITRIC oxide , *DIFFUSION coefficients , *SELF-diffusion (Solid state physics) , *SOLVENTS , *MOLECULAR dynamics , *RADIAL distribution function - Abstract
Self-diffusion coefficients along with the mutual diffusion coefficients of nitric oxide (NO) and SPC/E water (H2O) as solute and solvent of the mixture, have been studied within the framework of classical molecular dynamics level of calculations using GROMACS package. The radial distribution function (RDF) of the constituent compounds are calculated to study solute-solute, solute-solvent and solvent-solvent molecular interactions as a function of temperature. A dilute solution of five NO molecules (mole fraction 0.018) and 280 H2O molecules (mole fraction 0.982) has been taken as the sample. The self-diffusion coefficient of the solvent is calculated by using mean square displacement (MSD) where as that for solute (NO) is calculated by using MSD and velocity auto-correlation function (VACF). The results are then compared with the available experimental values. The results from the present work for water come in good agreement, very precise at low temperatures, with the experimental values. The diffusion coefficients of NO, on the other hands, agree well with the available theoretical studies, and also with experiment at low temperatures (up to 310 K). The results at the higher temperatures (up to 333 K), however, deviate significantly with the experimental observations. Also, the mutual diffusion coefficients of NO in water have been calculated by using Darken's relation. The temperature dependence of the calculated diffusion coefficients follow the Arrhenius behavior. [ABSTRACT FROM AUTHOR]
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- 2016
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19. An Unusual Presentation of Granulomatosis with Polyangiitis (GPA).
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Pokharel, Sunil, Singh, Sukhraj, and Shaukat, Muhammad Saad
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GANGRENE , *HAND diseases , *ISCHEMIA , *BLOOD vessels , *MULTIPLE organ failure - Abstract
Patient: Female, 72 Final Diagnosis: Granulomatosis with polyangiitis Symptoms: Finger pain • gangrene Medication: -- Clinical Procedure: -- Specialty: Rheumatology Objective: Unusual clinical course Background: This is a very interesting case of Granulomatosis with Polyangiitis (GPA) presenting with hand ischemia which rapidly evolved into dry gangrene from the involvement of digital arteries. GPA usually affects the small and medium sized blood vessels. GPA affecting muscular artery causing limb ischemia is a rare manifestation. Case Report: A 72 years old Caucasian female was sent to our hospital for the evaluation of left hand pain and bluish discoloration, which she noticed for few days. Physical examination was notable for bluish discoloration of left 2nd to 5th fingers, which later evolved, into dry gangrene at the tips. Angiogram revealed ischemia with no evidence of thrombosis. Administration of intra-arterial nitroglycerin resulted in improved blood flow through the radial artery. Labs revealed ESR of 142 mm/hr. C-ANCA titer was 5120, (normal <20) and antiproteinase 3 was 1117 (normal <20) consistent with GPA. Conclusions: GPA usually affects the small and medium sized blood vessels. This case highlights an unusual presentation of GPA manifesting as critical limb ischemia. Given the rarity of this circumstance, a high index of suspicion is necessary in order to initiate proper treatment and limb salvaging intervention. [ABSTRACT FROM AUTHOR]
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- 2018
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20. Coronavirus Disease 2019 Pandemic – Public Health Preparedness in Nepal and One Health Approach.
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Pokharel, Sunil, Raut, Shristi, Rijal, Komal Raj, and Adhikari, Bipin
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SARS disease ,COVID-19 pandemic ,PUBLIC health ,EMERGENCY management ,MIDDLE-income countries ,LIFE support systems in critical care - Published
- 2021
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21. Duodenal perforation by an inferior vena cava filter with staphylococcal bacteremia: a case report.
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Pokharel, Sunil, Bartholomew, Catherine, Zing Zau, and Zau, Zing
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DUODENAL ulcers , *VENA cava inferior , *BACTEREMIA , *ABDOMINAL pain , *INTRAVENOUS injections , *METHICILLIN-resistant staphylococcus aureus , *PATIENTS - Abstract
Background: Inferior vena cava filter complications can range from dislodgement to perforation. Patients who present with concomitant bacteremia have rarely been reported. Persistent bacteremia usually results from direct bacterial seeding from a source other than perforation of surrounding viscus. It is unclear if the risk of perforation is higher in patients who are bacteremic due to other causes.Case Presentation: We report an interesting case of a 67-year-old white woman who presented with fever, chills, and right upper quadrant abdominal pain. Her blood cultures were positive for methicillin-sensitive Staphylococcus aureus with no obvious source. Upon further investigation, she was found to have an inferior vena cava filter perforating her duodenum. The cause of her abdominal pain was explained by the inferior vena cava filter penetrating the duodenum; however, the source of bacteremia could not be ascertained. The inferior vena cava filter was removed successfully, and she was discharged on an intravenous antibiotic. Her symptoms resolved soon after the filter was removed.Conclusions: The use of inferior vena cava filters has increased significantly in recent years. This is likely due to their wider availability and safer placement techniques. With increasing use, the complications arising from these filters have been on the rise as well. It is very important for clinicians to be aware of these complications to avoid delays in diagnosis and patient care. [ABSTRACT FROM AUTHOR]- Published
- 2016
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22. Novel Roles of Chloroquine and Hydroxychloroquine in Graves' Orbitopathy Therapy by Targeting Orbital Fibroblasts.
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Guo, Yan, Li, Hai, Chen, Xueying, Yang, Huasheng, Guan, Hongyu, He, Xiaoying, Chen, Yuxin, Pokharel, Sunil, Xiao, Haipeng, and Li, Yanbing
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- 2020
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23. 0943 PAP Adherence in Veterans with Moderate to Severe Traumatic Brain Injury (TBI).
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Pokharel, Sunil, Schwartz, Daniel J, Anderson, William Mc Dowell, Wittine, Lara, Nakase-Richardson, Risa, Silva, Marc A, and Drasher-Philips, Leah
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- 2019
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24. Interventions to address antimicrobial resistance: an ethical analysis of key tensions and how they apply in low- income and middle-income countries.
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Pokharel S, Adhikari B, Johnson T, and Cheah PY
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- Humans, Drug Resistance, Bacterial, Developing Countries, Ethical Analysis, Anti-Bacterial Agents therapeutic use, Anti-Infective Agents
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Antimicrobial resistance (AMR) is a global health and one health problem. Efforts to mitigate the problem of AMR are challenging to implement due to unresolved ethical tensions. We present an in-depth ethical analysis of tensions that might hinder efforts to address AMR. First, there is a tension between access and excess in the current population: addressing lack of access requires facilitating use of antimicrobials for some populations, while addressing excessive use for other populations. Second, there is a tension between personal interests and a wider, shared interest in curbing AMR. These personal interests can be viewed from the perspective of individuals seeking care and healthcare providers whose livelihoods depend on using or selling antimicrobials and who profit from the sales and use of antimicrobials. Third, there is a tension between the interests of current populations and the interests of future generations. Last, there is a tension between addressing immediate health threats such as pandemics, and AMR as a 'silent', chronic threat. For each of these tensions, we apply 'descriptive ethics' methods that draw from existing evidence and our experiences living and working in low-income and middle-income countries to highlight how these ethical tensions apply in such settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)
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- 2024
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25. Use of antimicrobials during the COVID-19 pandemic: A qualitative study among stakeholders in Nepal.
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Dhungel B, Thapa Shrestha U, Adhikari S, Adhikari N, Bhattarai A, Pokharel S, Karkey A, Limmathurotsakul D, Ghimire P, Rijal KR, Cheah PY, Pell C, and Adhikari B
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The COVID-19 pandemic was a major public health threat and the pressure to find curative therapies was tremendous. Particularly in the early critical phase of the pandemic, a lot of empirical treatments, including antimicrobials, were recommended. Drawing on interviews with patients, clinicians and drug dispensers, this article explores the use of antimicrobials for the management of COVID-19 in Nepal. A total of 30 stakeholders (10 clinicians, 10 dispensers and 10 COVID-19 patients) were identified purposively and were approached for an interview. Clinicians and dispensers in three tertiary hospitals in Kathmandu assisted in the recruitment of COVID-19 patients who were undergoing follow-up at an out-patient department. Interviews were audio recorded, translated and transcribed into English, and were analyzed thematically. The respondents report that over-the-counter (OTC) use of antibiotics was widespread during the COVID-19 pandemic in Nepal. This was mostly rooted in patients' attempts to mitigate the potential severity of respiratory illnesses, and the fear of the stigmatization and social isolation linked to being identified as a COVID-19 patient. Patients who visited drug shops and physicians reportedly requested specific medicines including antibiotics. Clinicians reported uncertainty when treating COVID-19 cases that added pressure to prescribe antimicrobials. Respondents from all stakeholder groups recognized the dangers of excessive use of antimicrobials, with some referring to the development of resistance. The COVID-19 pandemic added pressure to prescribe, dispense and overuse antimicrobials, accentuating the pre-existing OTC use of antimicrobials. Infectious disease outbreaks and epidemics warrant special caution regarding the use of antimicrobials and specific policy response., Competing Interests: The authors declare that they do have no competing interests. Bipin Adhikari serves as an associate editor at PloS Global Public Health., (Copyright: © 2023 Dhungel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
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- 2023
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26. Correction: Two-test algorithms for infectious disease diagnosis: Implications for COVID-19.
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Pokharel S, White LJ, Sacks JA, Escadafal C, Toporowski A, Mohammed SI, Abera SC, Kao K, Freitas MM, and Dittrich S
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[This corrects the article DOI: 10.1371/journal.pgph.0000293.]., (Copyright: © 2023 Pokharel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
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- 2023
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27. Arterial hypertension and its covariates among nomadic Raute hunter-gatherers of Western Nepal: a mixed-method study.
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Koirala T, B C UB, Shrestha C, Paudel U, Dhital R, Pokharel S, and Subedi M
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- Male, Adolescent, Humans, Female, Aged, Adult, Nepal epidemiology, Cross-Sectional Studies, Alcohol Drinking epidemiology, Tobacco Use, Prevalence, Risk Factors, Hypertension epidemiology
- Abstract
Objectives: To determine the prevalence of, and understand the factors associated with, hypertension among the nomadic Raute hunter-gatherers of Western Nepal., Design: A mixed-method study., Setting: The study was carried out at Raute temporary campsites in the Surkhet District of Karnali Province between May and September 2021., Participants: The questionnaire-based survey included all males and non-pregnant females of the nomadic Raute group aged 15 years and above. In-depth interviews were conducted among purposively selected 15 Raute participants and four non-Raute key informants to help explain and enrich the quantitative findings., Outcome Measures: The prevalence of hypertension (defined as brachial artery blood pressure of systolic ≥140 mm Hg and/or diastolic ≥90 mm Hg) and its sociodemographic, anthropometric and behavioural covariates., Results: Of the 85 eligible participants, 81 (median age 35 years (IQR: 26-51), 46.9% female) were included in the final analysis. Hypertension was found in 10.5% of females, 48.8% of males and 30.9% of the total population. Current alcohol and tobacco use were high (91.4% and 70.4%, respectively), with concerning high rates among youths. Males, older people, current drinkers and current tobacco users were more likely to have hypertension. Our qualitative analysis suggests that the traditional forest-based Raute economy is gradually transitioning into a cash-based one that heavily relies on government incentives. Consumption of commercial foods, drinks and tobacco products is increasing as their market involvement grows., Conclusion: This study found a high burden of hypertension, alcohol and tobacco use among nomadic Raute hunter-gatherers facing socioeconomic and dietary transitions. Further research is needed to assess the long-term impact of these changes on their health. This study is expected to help appraise concerned policymakers of an emerging health concern and formulate context-specific and culturally sensitive interventions to limit hypertension-related morbidities and mortalities in this endangered population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
- Published
- 2023
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28. Usability, acceptability and feasibility of a novel technology with visual guidance with video and audio recording during newborn resuscitation: a pilot study.
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Kc A, Kong SYJ, Basnet O, Haaland SH, Bhattarai P, Gomo Ø, Gurung R, Ahlsson F, Meinich-Bache Ø, Axelin A, Malla H, Basula YN, Pathak OK, Pokharel SM, Subedi H, and Myklebust H
- Subjects
- Infant, Infant, Newborn, Humans, Pilot Projects, Cross-Sectional Studies, Feasibility Studies, Technology, Health Personnel
- Abstract
Objective: Inadequate adherence to resuscitation for non-crying infants will have poor outcome and thus rationalise a need for real-time guidance and quality improvement technology. This study assessed the usability, feasibility and acceptability of a novel technology of real-time visual guidance, with sound and video recording during resuscitation., Setting: A public hospital in Nepal., Design: A cross-sectional design., Intervention: The technology has an infant warmer with light, equipped with a tablet monitor, NeoBeat and upright bag and mask. The tablet records resuscitation activities, ventilation sound, heart rate and display time since birth. Healthcare providers (HCPs) were trained on the technology before piloting., Data Collection and Analysis: HCPs who had at least 8 weeks of experience using the technology completed a questionnaire on usability, feasibility and acceptability (ranged 1-5 scale). Overall usability score was calculated (ranged 1-100 scale)., Results: Among the 30 HCPs, 25 consented to the study. The usability score was good with the mean score (SD) of 68.4% (10.4). In terms of feasibility, the participants perceived that they did not receive adequate support from the hospital administration for use of the technology, mean score (SD) of 2.44 (1.56). In terms of acceptability, the information provided in the monitor, that is, time elapsed from birth was easy to understand with mean score (SD) of 4.60 (0.76)., Conclusion: The study demonstrates reasonable usability, feasibility and acceptability of a technological solution that records audio visual events during resuscitation and provides visual guidance to improve care., Competing Interests: Competing interests: HMyklebust, ØM-B, SHH, ØG and SYJK are employed at Laerdal Medical., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
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- 2022
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29. Two-test algorithms for infectious disease diagnosis: Implications for COVID-19.
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Pokharel S, White LJ, Sacks JA, Escadafal C, Toporowski A, Mohammed SI, Abera SC, Kao K, Melo Freitas M, and Dittrich S
- Abstract
Diagnostic assays for various infectious diseases, including COVID-19, have been challenged for their utility as standalone point-of-care diagnostic tests due to suboptimal accuracy, complexity, high cost or long turnaround times for results. It is therefore critical to optimise their use to meet the needs of users. We used a simulation approach to estimate diagnostic outcomes, number of tests required and average turnaround time of using two-test algorithms compared with singular testing; the two tests were reverse transcription polymerase chain reaction (RT-PCR) and an antigen-based rapid diagnostic test (Ag-RDT). A web-based application of the model was developed to visualise and compare diagnostic outcomes for different disease prevalence and test performance characteristics (sensitivity and specificity). We tested the model using hypothetical prevalence data for COVID-19, representing low- and high-prevalence contexts and performance characteristics of RT-PCR and Ag-RDTs. The two-test algorithm when RT-PCR was applied to samples negative by Ag-RDT predicted gains in sensitivity of 27% and 7%, respectively, compared with Ag-RDT and RT-PCR alone. Similarly, when RT-PCR was applied to samples positive by Ag-RDT, specificity gains of 2.9% and 1.9%, respectively, were predicted. The algorithm using Ag-RDT followed by RT-PCR as a confirmatory test for positive patients limited the requirement of RT-PCR testing resources to 16,400 and 3,034 tests when testing a population of 100,000 with an infection prevalence of 20% and 0.05%, respectively. A two-test algorithm comprising a rapid screening test followed by confirmatory laboratory testing can reduce false positive rate, produce rapid results and conserve laboratory resources, but can lead to large number of missed cases in high prevalence setting. The web application of the model can identify the best testing strategies, tailored to specific use cases and we also present some examples how it was used as part of the Access to Covid-19 Tools (ACT) Accelerator Diagnostics Pillar., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: SD, JS, CE, AT, KK, MSMF declare that they are employed by Foundation for Innovative New Diagnostics (FIND). SP, LJW, SIM, SCA declare no conflict of interest., (Copyright: © 2022 Pokharel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
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- 2022
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30. Tuberculosis among Patients Admitted to the Department of Medicine of a Tertiary Care Center in Nepal: A Descriptive Cross-sectional Study.
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Thapa S, Bista A, Subedi P, Adhikari A, and Pokharel S
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- Cross-Sectional Studies, Humans, Male, Middle Aged, Nepal epidemiology, Prevalence, Tertiary Care Centers, Tuberculosis diagnosis, Tuberculosis epidemiology
- Abstract
Introduction: Tuberculosis has high burden in developing countries like Nepal. This study aims to determine the prevalence of tuberculosis among patients admitted in the department of medicine of a tertiary hospital., Methods: A descriptive cross-sectional study of all the patients admitted to the tertiary care hospital from 1st January 2017 to 31st December 2019 was done. Ethical approval was obtained from Institutional Review Committee (Ref: drs2006181387). Convenience sampling method was used. A descriptive analysis of demographic, clinical and laboratory profile of patients was made using Microsoft Excel version 2016. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data., Results: Among 6829 patients admitted to the department of medicine, 209 (3.06%) (2.65-3.47 at 95% CI) patients were diagnosed with tuberculosis. Among them, 147 (70.33%) were males and the mean age was 49.77 years. Pulmonary and extra-pulmonary tuberculosis were present in 153 (73.20%) and 56 (26.79%) patients, respectively. Bacteriological confirmation was limited to 107 (70%) of pulmonary tuberculosis and 3 (5%) of extrapulmonary tuberculosis. Fever was the commonest presentation in 166 (79.42%) followed by cough in 164 (78.46%), anorexia in 108 (51.67%), weight loss 104 (49.76%), and others., Conclusions: The study showed that the prevalence of tuberculosis among admitted patients was higher than national prevalence.
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- 2021
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31. Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers.
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Shrestha N, Mishra SR, Ghimire S, Gyawali B, Marahatta SB, Maskey S, Baral S, Shrestha N, Yadav R, Pokharel S, and Adhikari B
- Abstract
Background: Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal., Methods: Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches., Results: Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients., Conclusion: Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.
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- 2021
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32. Why do people purchase antibiotics over-the-counter? A qualitative study with patients, clinicians and dispensers in central, eastern and western Nepal.
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Adhikari B, Pokharel S, Raut S, Adhikari J, Thapa S, Paudel K, G C N, Neupane S, Neupane SR, Yadav R, Shrestha S, Rijal KR, Marahatta SB, Cheah PY, and Pell C
- Subjects
- Humans, Microbial Sensitivity Tests, Nepal, Qualitative Research, Anti-Bacterial Agents therapeutic use, Mycobacterium tuberculosis
- Abstract
Introduction: Over-the-counter (OTC) use of antibiotics contributes to the burgeoning rise in antimicrobial resistance (AMR). Drawing on qualitative research methods, this article explores the characteristics of OTC sales of antibiotic in Nepal, its drivers and implications for policy., Methods: Data were collected in and around three tertiary hospitals in eastern, western and central Nepal. Using pre-defined guides, a mix of semi-structured interviews and focus group discussions were conducted with dispensers at drug stores, patients attending a hospital and clinicians. Interviews were audio-recorded, translated and transcribed into English and coded using a combination of an inductive and deductive approach., Results: Drug shops were the primary location where patients engaged with health services. Interactions were brief and transactional: symptoms were described or explicit requests for specific medicine made, and money was exchanged. There were economic incentives for clients and drug stores: patients were able to save money by bypassing the formal healthcare services. Clinicians described antibiotics as easily available OTC at drug shops. Dispensing included the empirical use of broad-spectrum antibiotics, often combining multiple antibiotics, without laboratory diagnostic and drug susceptibility testing. Inappropriately short regimens (2-3 days) were also offered without follow-up. Respondents viewed OTC antibiotic as a convenient alternative to formal healthcare, the access to which was influenced by distance, time and money. Respondents also described the complexities of navigating various departments in hospitals and little confidence in the quality of formal healthcare. Clinicians and a few dispensers expressed concerns about AMR and referred to evadable policies around antibiotics use and poor enforcement of regulation., Conclusions: The findings point to the need for clear policy guidance and rigorous implementation of prescription-only antibiotics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)
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- 2021
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33. Tackling antimicrobial resistance in low-income and middle-income countries.
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Pokharel S, Raut S, and Adhikari B
- Abstract
Competing Interests: Competing interests: None declared.
- Published
- 2019
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34. Erratum to: Duodenal perforation by an inferior vena cava filter with staphylococcal bacteremia: a case report.
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Pokharel S, Bartholomew C, and Cheng ZA
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- 2016
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35. A boy wearing two different sized slippers in his two feet.
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Shrestha S, Pokharel S, and Chalise SN
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- Adolescent, Hemangioma diagnosis, Humans, Leg physiopathology, Male, Pain, Arteriovenous Malformations diagnosis, Klippel-Trenaunay-Weber Syndrome diagnosis, Leg abnormalities, Shoes, Spinal Diseases diagnosis
- Abstract
A rare case of Klippel Trenaunay Weber Syndrome (KTWS) in a 13-year-old boy with lower limb asymmetry and lower motor lesion of left lower limb is presented along with a brief review of literature.
- Published
- 2006
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