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The Himalayan Kingdom of Bhutan, where images of magical splendor obscure its challenges, provides a viewpoint from which to understand the contradictions that emerging economies face as they move towards mass education. Isolated from the outside world in every sense except for the mythologies that surround it, Bhutan is attempting to move from a basic agrarian societal framework as found in the feudal 1800s into the whirl of a technologically savvy twenty-first century. The demands for such a transition require educators and politicians at all levels to rethink the role of schooling and what it means to be educated in this country at this point in time. To provide guidance, the government set up a special task force, the Royal Education Council, to devise a curriculum and pedagogy that would equip young people with the skills to move into the future without forsaking their past. This ethnographic piece of research explores the challenges faced by teachers and principals in nine designated Beacon schools as they grapple within a historical context which views teachers as labourers, working under difficult conditions with minimal support. The work ends with the question of whether mass education might in fact move this country away from the traditional values that are perceived as making Bhutan special, if not unique.

In 2006, Bhutan changed the secondary school curriculum. This study examines the washback effect of the English assessment system associated with this new curriculum. Based on questionnaire responses from 56 EFL secondary school teachers in Bhutan, the study suggests the new curriculum produces both positive and also negative washback. In order for the new curriculum's benefit to outweigh any harm it may cause, teachers should receive proper guidance and support during this transition.

Science education in a developing country is pivotal in the developmental process. Bhutan, like other developing countries, places great importance in institutionalising a relevant and challenging science curriculum for all of its school-aged children. A number of factors have made the review of the science curriculum in Bhutan a priority including international debates about scientific literacy and the changing time and needs of Bhutanese society and its students. This article reports on the findings of a study to investigate the present status and challenges of the current science curriculum from interviews with teachers, students, and other key stakeholders such as higher education lecturers and employers. The study also draws on observations of science classes and key curriculum documents. This study was conducted as a prelude to the major science curriculum reform prioritised in the government's 10th Five Year Plan (2008-2012) in order to provide a research informed perspective for science curriculum development. The findings from the research are reported here and show a number of positive issues in science education including good student motivation in lower classes. Challenges are identified including issues of teacher development, resourcing, and fragmentation and discontinuity in the current curriculum. These issues and challenges are discussed in the light of literature on science education in developing countries. (Contains 1 table and 2 figures.)

This purpose of the study was to ascertain the level of ethnic identity formation and its perceived role on school engagement for Tibetan adolescents enrolled in public schools in two Midwestern states in the USA. The journey of these students from culturally encapsulated schools from Nepal, Bhutan, and India to multiculturally diverse settings was one of the most fascinating facets of the Tibetan Diaspora. Subjects included 16 girls, 25 boys, and 2 who did not identify their gender. The multigroup ethnic identity measure was used to determine the level of ethnic identity formation of Tibetan students while a questionnaire gathered information on school engagement. The overall ethnic identity measure for this sample was high with a mean of 3.58, while the cognitive and affective aspect of the measure was also high with a mean of 3.56 and 3.74, respectively. The girls showed more emotional commitment to ethnic identity, as their mean score was 3.92, while boys scored 3.62. The results clearly corroborated findings and conclusions drawn by other scholars. School and community partnership contributed to the healthy ethnic identity development of adolescents who were thus encouraged to be more engaged in meaningful school activities. (Contains 2 tables.)

This qualitative study examines the use of digital storytelling as an instructional intervention for bridging the digital divide among public school students in rural Bhutan. Primary participants for the study included elementary school children who had never been previously exposed to computer technology and were recipients of a donated classroom set of laptops. Results demonstrated how technology instruction and infrastructure inherently positions ethical and cultural differences between researchers, education personnel, school children and their families. The use of English became an inadvertent gatekeeper for who was chosen to participate in the classroom laptop program. Another major finding examines how Bhutan's social awareness for "Gross National Happiness" is inherently juxtaposed in contrast to Western perceptions of modernity and progress. Educators and administrators concerned about initial technology instruction in developing regions should find this study informative. (Contains 4 figures.)

Interrupted formal education is a barrier that makes learning English as an adult an extremely challenging commitment. Besides the many work and family responsibilities that most adult English as a second language (ESL) learners face, students with interrupted formal education (SIFE) often lack familiarity with school-based skills and typical classroom activities that develop over years of formal schooling (Florez & Burt, 2001; Wrigley, 2004). Their limited reading skills also effectively shut off a major source of input for learning, especially learning in school. This article describes how an ESL family literacy program serving refugee SIFE in Pittsburgh, Pennsylvania, uses learner narratives to create an engaging, productive classroom experience. (Contains 1 footnote.)

Nestled in the Himalayan Mountains, Bhutan, a Buddhist country, is one of the most isolated nations in the world. After spending a month there, the authors all agreed it deserved its title of "The Last Shangri-La." Their team of professional development specialists spent the summer of 2010 providing professional development in the basic principles of special education to teachers, administrators, and government officials. At the end of their visit, they left with a new appreciation of the need for all professional developers to become more aware of cultural differences both overt and subtle. In the process, they sharpened their skills, increased their cultural sensitivities, and came back to the United States as more effective and more broadly engaged staff developers.

During a six month contract with the Royal University of Bhutan, the author was required to develop the initial stages of a first library qualification to be offered in Bhutan. Questions raised by this project included: is a first qualification in librarianship needed in Bhutan? What are the potential student numbers in such a programme? What structure should such a programme take? What guidance exists for developing diploma programmes at the royal university of Bhutan? Does the country contain the expertise to run the programme? The author utilised situational analysis to gather data for the programme, building on a number of existing but unpublished documents relating to training library staff in Bhutan. Using the guidelines in existence, and the knowledge gained from the data gathered it was possible to answer the research questions. A three year, part time diploma of library management to be offered by mixed mode (distance education) was designed, and supporting documentation written. There is no doubt that appropriate, relevant library training is needed for library staff in Bhutan. It is less clear that the resources currently exist to fully develop and present an initial diploma level qualification. (Contains 1 table.)

Setting international benchmarks for education systems of the Organisation for Economic Co-operation and Development (OECD) countries is one of the goals of the OECD's Programme for International Student Assessment (PISA). However, some countries are not able to participate in PISA, despite their desire to set international benchmarks for their education systems. This article presents a method of setting international benchmarks for a country's school education system, without necessarily participating in PISA, by designing a test using the test items released by PISA for public consumption. The method has been implemented in a study that involved 1,500 Grade 10 students across 60 schools in Bhutan. The students were administered a mathematics test constructed from the PISA Mathematical Literacy test items. The study showed that the performance of Bhutanese students was comparable with the performance of the students from the countries that participated in PISA 2003 and that Bhutan could learn from both high- and low-performing school education systems of those countries. (Contains 5 tables and 1 figure.)

This study explores the validity of school-based assessments when they serve to supplement scores on central tests in high-stakes examinations. The school-based continuous assessment (CA) marks are compared to the marks scored on the central written Bhutan Certificate of Secondary Education (BCSE) examination, to detailed teacher ratings of student competencies, and to student self-ratings. A survey was undertaken in 10 higher secondary schools, involving 26 English teachers and 365 graduates. Though results indicate moderate conformity among measurements within schools, results between schools indicate that schools with high average scores on the BCSE exam tend to score relatively low CA averages and vice versa. Compared to the CA marks for student performance in English listening and speaking skills, the detailed teacher ratings of students on the same skills correlate more strongly with the BCSE exam marks and the student self-ratings. (Contains 4 tables.)

The purpose of this paper is to trace the evolution of school assessment in Bhutan, briefly, as a background to considering the present and future school assessment issues especially as they relate to quality concerns and educational improvement in Bhutan. A benchmark for Bhutan, the National Educational Assessment (NEA) programme in Bhutan was inspired by a 2002 initiative in South Asia funded by the World Bank. In this paper, we address how the 2003 NEA was developed. Emerging issues are discussed including methods of reporting and the concept of "benchmarking" in three senses of that term. Technical issues are also addressed in the context of the desire to administer another comparative NEA in 2010. Out of these developments, the Bhutan Board of Examinations has developed ideas about expanding access to system-wide assessment data to different levels of stakeholders in order to achieve improvements. A 2x2 matrix is provided identifying four key questions around judgments of educational achievement at two key levels (system and school) within and between these levels. This matrix represents a model of the evolution of assessment in Bhutan. This paper should be of interest to education systems in developing countries that have undertaken or intend to undertake national educational assessment programmes. (Contains 3 tables and 5 notes.)

Bhutan is embarking on a comprehensive education reform process, with teachers and teacher education at the centre of a number of initiatives. This study describes the current state of affairs based on interviews with key informants and semi-structured focus groups in Bhutan. Several major themes emerged, including issues of quality of students and teaching, the integration of theory and practice, organizational structure and culture, and working conditions at the present Colleges of Education, and in the broader education sector.

This study examines the multilingual and multiliteracy practices of a group of Tibetan female youths from South Asia (India, Bhutan, Nepal) newly arrived in Toronto, Canada (N = 24). The main data are derived from a questionnaire surveying their language practices across contexts indicating the roles of education, community, and society in multilingual maintenance and loss. In addition, this study considers how language ideology and the other sociocultural factors have impacted on participants' language and literacy preferences and practices. The results indicate specific multilingual and multiliterate patterns within the diaspora with differences between South Asia and North America. As female youths, the participants offer an indication of future trends in cultural and linguistic participation given the unequal influence of women on family language practices. (Contains 10 tables and 4 footnotes.)

In the 1960s, the Royal Government of Bhutan began developing its modern educational system. Over time, a strategic plan was formulated to meet Education for All and Millennium Development Goals. In 2003, the Royal University of Bhutan, the country's first university, opened its doors. This paper uses comparative analysis to describe and explore the impact on the development of The Royal University of Bhutan of the national consciousness termed "Gross National Happiness". It is proposed that the university is likely to become a catalyst for development, and an influential representative of and for a cultural identity. Will it become an elite institution? Will the institution offer formal degrees for all who qualify? It is suggested that the issues considered in Bhutan may be of significance for other new universities attempting to establish themselves in the developing world.

Context is a key factor in designing and delivering adult learning programmes, and in multilingual environments the choice of language plays a decisive role. Four programmes, two in Asia (Bhutan Myanmar) and two in Africa (Ghana and Uganda), which focus on learning for development, integrate language considerations in different ways, related both to the broader socio-political contest and to the purposes and assumptions of the programmers themselves. Both the functional and the symbolic roles affect the choice of language, and its impact, and must be factored into the design and implementation of adult learning programmes.

Since 2004, the National Institute of Education (NIE) in Samtse, Bhutan, has made systematic efforts to introduce information and communication technology (ICT) for learning support into its distance teacher education program. This article describes the early experiences of using ICT for distance education in Bhutan by teachers and students with relatively limited ICT background. It discusses the challenges of providing student support for a distance teacher education program in Bhutan and it explores the use of ICT for student support. The article also reports an assessment of student perceptions and readiness for ICT use, the introduction of a learning management system and regional study centers as ICT access points, and the experiences and challenges encountered in the process of ICT introduction in its early stages. The use of ICT by distance students based on log data from the learning management system Moodle[TM] and regional study centers are discussed, as well as the challenges of ICT use under infrastructure and technological support limitations.

The purpose of this article is to look at the experience of Bhutan in using examinations as a tool for assessing and systematically monitoring the health of the education system. The strategy in both school-based and nationwide examinations is three-fold: (1) monitoring of standards for the formally prescribed national curriculum across the country; (2) the selection of students to proceed to higher grades; and (3) the screening of under-achievers. This article discusses the practice of employing examination results to motivate policy decisions and to launch intervention measures to improve performance. The article begins with a brief introduction to the country and its education system. It follows the evolution and institutionalization of examinations in the Bhutanese education system, introduces the practice of continuous assessment and addresses strategies for disseminating examination results. The impact of examination results on pedagogy and decision-making is discussed next, followed by a look at the key features of examinations for monitoring purposes.

With the blooming of information in digital format, dissemination of information is becoming a big challenge for developing countries. It is not only due to the limited provision of personal computers--in addition, the technological infrastructure and the ability to access information are also becoming major concerns in developing countries. This paper examines the situation in the Asian developing countries as an example to illustrate the difficulties with the dissemination of information. The availability of personal computers is not the only difficulty facing developing countries. The availability and popularity of the Internet, the telecommunication policies and environment of the countries concerned, the information literacy level of the users and the librarians, the popularity of the English language, the knowledge of searching information on the Internet, and the maturity of the electronic publishing market are all inter-related and have affected the success of information dissemination. Recent developments in tackling the problems are also described. (Contains 1 table and 15 notes.)

Discusses increased advocacy for community participation in education. Points out that policies often fail to differentiate between different types of communities. Recognizes that community knowledge bases and motives for supporting education can differ from the governments. Stresses the need for policies to account for diversity of circumstances. (CAJ)

This article was written by a group from different language backgrounds who shared an interest in the languages and biodiversity of Bhutan and a curiosity about how these are interrelated and impact on each other. (Author/VWL)

Describes the structure of science education in Bhutan, a kingdom in the Eastern Himalayas. (YDS)

American educators in cities such as Syracuse, NY, Burlington, VT, and St. Paul, MN, for reasons including civic culture, existing ethnic communities, availability of jobs, and the location of refugee-resettlement organizations, periodically receive waves of resettling immigrants. Officials in those communities have become adept at educating themselves on the cultures and educational needs of newly arriving groups, which in recent years have included refugees from Burundi, Burma, Somalia, and now Bhutan. School administrators and teachers who work with English-language learners browse the Web sites of the United Nations High Commissioner for Refugees, the State Department, or the Cultural Orientation Resource Center of the Washington-based Center for Applied Linguistics to learn more about what to expect. Educators say they typically do not know what specific needs they will have to address until the children of refugee families arrive at the schoolhouse door, however. The Bhutanese Lhotshampas ("People of the South") are members of an ethnic group that retained its Nepalese culture and language while living in Bhutan for generations. The government of Bhutan enacted policies in the early 1990s that has made it increasingly difficult for the Lhotshampas to live and work legally in that country.

In December 2009, the author traveled to the Himalayan kingdom of Bhutan for a week-long workshop, "Educating for Gross National Happiness." At the invitation of the royal government, international participants joined with local teachers, principals, and students to discover ways that Bhutanese schools could better support the country's commitment to Gross National Happiness (GNH). Bhutan's commitment to the well-being of its people is built on four pillars: (1) economic development, sustainable over generations; (2) conservation of the environment; (3) good governance that is transparent (the Fourth King introduced democracy and Bhutanese now vote for a parliament); and (4) preservation of cultural values. It is not clear to the author whether the U.S. has had a "big dream" since President Kennedy challenged the Americans to land on the moon. If America were to be guided by that vision, how might their education system "promote and advance that dream?" Perhaps some answers lie in the large heart and mindful approach of the Dragon Kingdom of Bhutan. (Contains 7 notes.)

Classrooms in Bhutan overflow with eager students; however, the teacher supply is often not enough to meet demand. The Bhutan Canada Foundation (BCF) is a Canadian charity working with the Ministry of Education in Bhutan, providing Canadian teachers to remote areas, where they work for a local salary and live in basic conditions The feature of Bhutanese education that these Canadian teachers find most unique is integrating the concept of Gross National Happiness (GNH) into both curriculum and school culture. The goal is "to see young people graduate from our educational system with a deeply felt care for nature and for each other, steeped in their culture, seeing reality clearly, living in harmony with the natural world and with their neighbors, and acting wisely for the benefit of all beings." This concept takes shape in classrooms through weekly themes integrated with GNH philosophy, school-wide meditation, and GNH-infused curriculum and lesson plans.

Background: Star anise fruit has been used in spice in Asian cuisine, ingredient for traditional medicines, component for antiviral drugs and as parts of tea and beverage across the globe. Toxicity from these plants has been reported due to adulteration with similar toxic species and from consumption with high toxic dose. Most physician and public are unaware of these adverse effects. Cases: We present two cases of star anise toxicity. Both of the patients presented with gastrointestinal and neurological symptoms after consumption of the said fruit. All of the labs and imaging test was negative for other causes and star anise toxicity diagnosis was made after detailed history, events and related symptoms. They were managed supportively and discharged after 24 h of observation. Conclusion: Emergency department doctors should be vigilant about possible star anise toxicity in patient presenting with suggestive symptoms, negative investigation for other possible cause and in area where these plant species is available. A detailed drug and ingestion history is essential. [ABSTRACT FROM AUTHOR]

We describe the bias adjustment and downscaling to a resolution of 1 × 1 km of daily temperature, precipitation and solar radiation of a multimodel ensemble of Coupled Model Intercomparison Project Phase 6 (CMIP6) GCMs with the local observational data set BhutanClim for Bhutan and an analysis of the results for 1996–2100. The GCMs were selected based on their ability to reproduce local temporal and spatial precipitation patterns, resulting in a total of 14 models for each shared socioeconomic pathway (SSP). The results are shown for five global warming levels (GWLs) 1.5, 2, 3, 4 and 5°C, providing insight into the projected impacts of climate change at different warming levels. The daily temperature and precipitation data are publicly available, which is of great benefit for climate impact studies, such as ecological, hydrological or infrastructure‐related studies. In this paper, we discuss showcase climate indicators. Peak‐over‐threshold climate indicators such as hot days above 30°C are relevant for human health. In the capital city of Thimphu, these are currently rare, at 4 days per year, but might increase to more than 80 for GWL5.0. Precipitation increases in the summer months, but slightly decreases in the drier winter months. Accordingly, the 3‐month SPEI drought index is projected to increase in summer, but strongly decreases in the winter months, mostly pronounced in February. The increasing severity of late‐winter and spring droughts might have a negative impact on vegetation, wildfires and water supply. [ABSTRACT FROM AUTHOR]

In 2020, Bhutan pioneered a school-based gender-neutral human papillomavirus (HPV) vaccination program, achieving an impressive 96% vaccination coverage rate by 2021. This study, conducted through 49 in-depth interviews with community leaders, policymakers, parents, teachers, and health workers, and 12 focus group discussions with boys who received HPV vaccination. We used conventional content analysis to analyze the data. Enablers of the extension of gender-neutral HPV vaccination included social mobilization and advocacy efforts, which encompassed community engagement and leadership and collaborations with schools. Equally crucial were proficient program management and the strategic use of digital interventions. Challenges included tracking and reaching eligible adolescents. Vaccinated boys perceived school-based vaccination to be a key enabler of vaccine update. The study concludes that extending a girls-only HPV vaccination program to gender-neutral is feasible and acceptable in Bhutan. Findings related to challenges and ways for overcoming them can support other countries interested in gender-neutral HPV vaccination program. [ABSTRACT FROM AUTHOR]

The authors conducted a comprehensive review of Hesperiidae species in Bhutan, scrutinizing three existing checklists and 25 new records presented by Van der Poel et al. (2023). A thorough examination of all available documents and evidence confirmed 145 Hesperiidae species in Bhutan, with four additional species listed as tentative and one as "cf." (requiring further research). The updated checklist excludes 14 species that were listed in one or more of the three existing checklists and provides justifications for not including these species. Additionally, 11 unverifiable or wrongly identified species presented by non-peer-reviewed sources were not included in the checklist. Sixteen species with no verifiable records in the last 70 years were also identified. This review provides a comprehensive and authoritative checklist of Hesperiidae species in Bhutan. [ABSTRACT FROM AUTHOR]

Background: The need for palliative care is ever-increasing globally. However, it is least developed or not available in most low-and-middle-income-countries including Bhutan. Objective: This study was aimed at exploring the perspectives of Bhutanese healthcare professionals on the need for palliative care in the country. Design: This is a cross-sectional, mixed-method study. Setting/subjects: The study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. Results: While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from 1 day to 6 weeks. Ninety-five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Conclusion: Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan. Plain language summary: 'There is no such word as palliative care for us at the moment': A study exploring the perceptions of healthcare professionals on the need for palliative care in Bhutan Palliative care is least developed in most low-and-middle-income-countries. This study was aimed at exploring the perspectives of healthcare professionals on the need for palliative care in Bhutan. Utilising both quantitative and qualitative approaches, the study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from one day to six weeks. Ninety five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan. [ABSTRACT FROM AUTHOR]

During continental collision, crustal rocks are buried, deformed, transformed and exhumed. The rates, timescales and tectonic implications of these processes are constrained through the sequence and conditions of metamorphic reactions in major and accessory phases. Petrographic, isotopic and elemental data from metabasite samples in NW Bhutan, eastern Himalaya, suggest initial equilibration under high‐pressure (plagioclase‐absent and rutile‐present) conditions, followed by decompression to lower pressure conditions at high‐temperatures that stabilized plagioclase, orthopyroxene and ilmenite. Field observations and chemical indicators suggest equilibration under the lower pressure conditions is likely linked to the infiltration of melt from the host metasedimentary rocks. The metabasites preserve two metamorphic growth stages of chemically‐and petrographically distinct allanite that temporally overlap two stages of zircon growth. Allanite cores and zircon mantles grew at c. 19 ± 2 and 17–15.5 Ma respectively, linked texturally and chemically to the high‐pressure evolution. Symplectitic rims on embayed allanite cores, wholly symplectized Aln–Ilm and Aln–Cpx grains, and high U zircon rims grew at c. 15.5–14.5 Ma, linked chemically to the presence of melt and lower pressure, high‐temperature conditions. A single garnet Lu–Hf date is interpreted as geologically meaningless, with the bulk rock composition modified by melt infiltration after garnet formation. The open system evolution of these rocks precludes precise determination of the reactive bulk composition during metamorphic evolution and thus absolute conditions, especially during the early high‐pressure evolution. Despite these limitations, we show that combined geochemical and petrographic datasets are still able to provide insights into the rates and timescales of deep orogenic processes. The data suggest a younger and shallower evolution for the NW Bhutan metabasites compared to similar rocks in the central and eastern Himalayas. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative nausea and vomiting (PONV) are common distressing symptoms experienced after laparoscopic cholecystectomy. We report the rate, and the factors associated with postoperative nausea and vomiting, the patterns of prophylactic antiemetic prescription, and the anesthetic techniques used among patients who underwent laparoscopic cholecystectomy at the Jigme Dorji Wangchuck (JDW) National Referral Hospital, Bhutan. Methods: A cross-sectional study was conducted at the JDW National Referral Hospital, from January to December 2018. All the patients who underwent laparoscopic cholecystectomy under general anesthesia were included in the study. The demographic variables, premedication, induction agents, muscle relaxants, inhalational agents for maintenance, opioid and adjuvant analgesics, the reversal agents used, and the occurrence of PONV within 24 h were recorded. Data were analyzed using SPSS (version 23). Continuous variables were compared using a t-test or Mann-Whitney test, categorical variables were tested using chi-square or Fisher's exact tests. Binary logistic regression analysis was performed to determine the factors associated with postoperative nausea and vomiting. Results: 190 patients underwent laparoscopic cholecystectomy under general anesthesia. The rate of PONV after laparoscopic cholecystectomy was 31.1% (59/190). Over half (53.7%, 102/190) of the study population were within 21–40 years of age, over 80% (157/190) were female, and 2/3rd were overweight and obese. The most frequently used premedication was ranitidine (39%, 34/87) and metoclopramide (31%, 27/87). More than half (57.4%, 109/190) of the patients received morphine as an opioid analgesic before induction. Sodium thiopentone was a commonly used induction agent (65.8%, 125/190). Succinylcholine and atracurium were mostly preferred muscle relaxants. Isoflurane and air were the most used inhalational anesthetic agents for the maintenance of anesthesia. Ondansetron was the most preferred anti-emetics during the intraoperative period. Previous history of motion sickness (OR 5.8, 95%CI 2.9–11.2, p < 0.001), and use of sodium thiopental (OR 4.1, 95%CI 1.9–9.1, p < 0.001) were independent risk factors for PONV. The use of antiemetics (OR 0.1, 95%CI 0.0-0.4, p = 0.002), propofol (OR 0.2, 95%CI 0.1–0.5, p < 0.001), adjuvant analgesic paracetamol (OR 0.4, 95%CI 0.2–0.8, p = 0.026), and adequate hydration with IV fluids (OR 0.9, 95%CI 0.9-1.0, p = 0.042) were preventive factors for PONV. Conclusion: The rate of PONV after laparoscopic cholecystectomy was high. History of motion sickness and use of sodium thiopental for induction were independent risk factors of PONV. The use of multimodal prophylactic antiemetics was robust and superior to monotherapy in preventing PONV. This finding re-emphasizes the need for risk stratification and appropriate use of antiemetics and anesthetic agents to prevent PONV. [ABSTRACT FROM AUTHOR]

School teaching is widely acknowledged to be a highly demanding profession. Consequentially, an emerging academic literature deals with the stress levels teachers face. While existing studies predominantly focus on quantifying relevant stressors, this study investigates the subjective perceptions and interpretations of stressors by teachers. Data comes from Bhutan, a country with a high teacher resignation rate primarily due to teacher stress, despite being one of the highest-paid occupations. The results show that teacher stress in Bhutan predominantly emanates from heightened job demands. These demands are perceived differently in terms of how individuals view teaching responsibilities and non-academic obligations (e.g., Class Teacher). The pervasive impact of inadequate leadership and management exacerbates stress levels, directly encroaching upon psycho-social wellbeing. Ten teachers in Bhutan were interviewed using a semi-structured format. The interview data was recorded, transcribed, and coded using MAXQDA. Thematic analysis was then conducted based on the generated codes. By adopting a qualitative lens, this research enriches our understanding of teacher stress by unraveling how stressors are interconnected and how different teachers perceive the same stressor differently, providing insights on targeted interventions and support mechanisms. The results also show that supportive leadership can sometimes be viewed as a source of stress as opposed to the popular notion of perceiving it entirely as a stress-mitigating factor. [ABSTRACT FROM AUTHOR]

Aflatoxins are mycotoxins that contaminate staple foods globally and pose a significant health risk. To the best of our knowledge, information on the occurrence of aflatoxins in Bhutanese diets is scarce. This study aimed to estimate the aflatoxin levels in selected foodstuffs in Bhutan and determine the health risk associated with aflatoxin exposure. Ten different types of food commodities were randomly collected from farmers’ markets, shelves of supermarkets, and wholesale and retail shops from 20 districts of the country. The samples were subjected to analysis by an enzyme-linked immunosorbent assay for both total aflatoxins (B1, B2, G1 and G2) and aflatoxin B1. Among the 315 samples included, 48.81% and 79.35% were positive for total aflatoxins and aflatoxin B1, respectively. The overall mean total aflatoxin concentration was 11.49 ± 12.83 µg/kg, and that for B1 was 17.62 ± 23.99 µg/kg. The most prevalent food commodity with the highest aflatoxin contamination was chili products. In addition, the estimated daily intake and margin of exposure to aflatoxin B1 via the consumption of chili products ranged from 0.98 to 5.34 ng kg−1 bw day−1 and from 74.90 to 408.10, indicating a risk for public health. The liver cancer risk was estimated to be 0.01 and 0.007 cancers per year per 100,000 population resulting from the consumption of chili products. The present findings revealed the presence of total aflatoxins and aflatoxin B1 in the selected samples. The margin of exposure values was exorbitant, demanding a stringent public health measure. Notably, these results suggest the need for routine monitoring of aflatoxin contamination in the region and stress rigorous safety management strategies to reduce exposure. [ABSTRACT FROM AUTHOR]

Objectives This article describes Pathologists Overseas (PO) experience supporting external quality assessment (EQA) programs in 10 clinical laboratories across 3 countries between 2009 and 2017. Methods Laboratories were enrolled in the condensed chemical pathology EQA program provided by the Royal College of Pathologists of Australasia Quality Assurance Program. Participants were given an initial 2- to 4-day in-person training, followed by 1 year of active feedback on performance via emails or phone calls by a PO volunteer. Results There were 2 performance metrics: percentage of reported results as a measure of compliance and percentage of acceptable reported results as a measure of accuracy. Laboratories demonstrated high compliance with result reporting, with medians of 69.9%, 71.7%, and 81.3% before, during, and after feedback, respectively. Concomitant medians for the percentage of acceptable reported results were 41.2%, 57.3%, and 53.5%, respectively. Six laboratories had low performance in terms of accuracy at baseline (<60%). Active feedback improved the percentage of acceptable reported results for these lower-performing laboratories. Conclusions External quality assessment programs can be successfully adopted long term by laboratories in low-resource settings. Active feedback requires significant time and effort but could be especially beneficial for laboratories with poor baseline performance. [ABSTRACT FROM AUTHOR]

Action research has gained widespread recognition as a tool to improve teaching practices in many countries, and action research based on Kemmis and McTaggart's model was recently introduced in Bhutan to raise teaching quality. This study explored how Bhutanese secondary science teachers carried out the process of action research and the factors which supported or constrained them. Focusing on one case study school in Bhutan, data were collected progressively, using interviews, teachers' diaries, and classroom observations, as three science teachers carried out their first action research project over a period of seven weeks. Data were analysed using the coding procedures of grounded theory. The findings showed that the teachers used a messy process of action research which was not consistent with the linear process depicted in Kemmis and McTaggart's model. The constraints they faced included concerns about science curriculum coverage, lack of time, inadequate knowledge, the hierarchical education system, and the Buddhist value of Driglam Namzha. However, teachers' collaboration, motivation, and Buddhist values of Tha Dam Tshig and Zhenphen facilitated their progress. In response to the influence of cultural factors on action research in Bhutan, the study proposes a new context-sensitive model called the Sherig Action Research (SAR) model for Bhutanese teachers. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Rheumatic heart disease is a preventable disease. Patients may not present with a typical history of sore throat and polyarthritis but may present with Sydenham's chorea. We should not rely completely on clinical findings to rule out carditis. Echocardiography should be done to rule out subclinical carditis. Sydenham's chorea is a major manifestation of rheumatic fever. It occurs primarily in children and is seen rarely after the age of 20 years. We describe a 16‐year‐old girl who presented with purposeless involuntary movements of her upper and lower limbs. Laboratory blood reports showed raised erythrocyte sedimentation rate and anti‐streptolysin O. 2D Doppler Echocardiography confirmed subclinical carditis, thickened mitral and aortic valve with mild mitral regurgitation. She was managed as Acute Rheumatic Fever with oral Phenoxymethyl penicillin and Carbamazepine. At the latest follow‐up interviewing the caregiver, the patient had no sequelae. Early diagnosis is key to preventing late consequences of acute rheumatic fever and rheumatic heart disease. Sydenham's chorea is a rare presentation of acute rheumatic fever. The absence of clinical carditis does not rule out carditis. [ABSTRACT FROM AUTHOR]

Societal Impact Statement: Bhutan is an ancient kingdom in the Himalayan range and one of the most rugged, geodiverse, and mountainous agricultural countries in the world. Historically secluded and geographically isolated, Bhutan is a hotspot for Himalayan agrobiodiversity where small‐scale agriculture supports the livelihoods of a large share of the resident population. Here, Bhutanese maize agrobiodiversity is explored to unlock its adaptation potential using genomics and participatory variety selection in combination with climate research. We show that Bhutanese traditional farmers maintain a wealth of diversity that may support the sustainable intensification of maize cropping in the Himalayas and beyond. Summary: Bhutan, an ancient kingdom enshrouded in the Himalayas, hosts largely untapped agrobiodiversity that may harness genetic variation useful for adaptation to local climates and user needs.Here, we genotyped‐by‐sequencing 351 pooled samples of local maize (Zea mays L.) landraces, the entire collection of the Bhutan National Gene Bank, comparing their genomic diversity with maize from other countries in the Himalayan range. We reconstructed the adaptation of Bhutanese maize to historical and projected climates, identifying areas of future maladaptation. We then run a common garden experiment involving local smallholder farmers in a participatory evaluation of landraces' performance, aiming at the identification of quantitative trait nucleotides (QTNs) contributing to adaptation, performance, and farmers' choice.We found that Bhutanese maize agrobiodiversity is unique in the Himalayan range, and a locus on Chromosome 5 supports the differentiation of three distinct genetic clusters. We found that a portion of current genomic diversity can be associated with the Bhutanese landscape and that maize cultivation in the southwest of the country may be negatively impacted by projected climates. We also found that Bhutanese maize agrobiodiversity is large and may contribute to adaptation and improvement. A genome‐wide association study identified 117 QTNs for climatic adaptation, agronomic performance, and farmers' preferences.Our results show that Bhutanese maize landraces are a unique source of genetic agrobiodiversity for local adaptation. We found that the integration of genomics, climate science, and participatory methods can speed up the identification of genetic factors contributing to the sustainable intensification of maize cultivation in the Himalayas and beyond. [ABSTRACT FROM AUTHOR]

Bhutan sits across a geopolitical fault line in South Asia. To its south lies its traditional partner—India. To its north lies China: a country whose economic power could significantly benefit Bhutan but whose regional orientation is strategically opposed to that of India. This article explores how Bhutan manages its growing relationship with China and seeks to chart where the relationship might go in the future. It shows how increasing economic and commercial ties with China are exerting growing pressure on Bhutan, a country with few developmental opportunities. These ties—in parallel to increasing political engagements—are moving Bhutan closer to diplomatic recognition of China; a decision that will impact on the regional balance of power well beyond the country's borders. How and when this policy shift will occur is unclear, as Bhutan has been able to successfully prioritize its own interests over Chinese agendas. In doing so, Bhutan has managed to exert a higher degree of agency than other small states in the region. This outcome challenges traditional notions of small state agency in international relations. This study finds that this has been possible due to both material power considerations and the perceptional value accorded to the relationship. [ABSTRACT FROM AUTHOR]

Climate change is intensifying the risks faced by children's lives, as well as impacting their learning and education. How school communities in Bhutan are dealing with issues related to climate change is largely uncharted. This study examined how Bhutanese schools have been affected by the changing climate and how they were responding to it. The data sources included interviews with school principals, teachers, and district education officers, as well as observations, and document analysis. The global comprehensive school safety framework, along with a whole school approach to climate action framed the results of this study. Findings included that schools experienced multiple climate impacts and shocks affecting their children's health, education, and the school system itself. Adaptation and mitigation measures including climate change education have yet to gain traction at the sector and school's level. Schools, however, have attempted some actions such as through disaster management, and participatory environmental conservation and green school initiatives. Social capital was critical in filling the resource gap for initiating environmental and climate change actions, carried out through collective school, community, and student-based activities. Human capacities, policy and institutional structures, technical capacities, and capital (cultural and economic) constraints as well as slow mainstreaming into local development processes impeded efforts to build climate-resilient schools, including practices to contribute to greenhouse gases reduction. This study not only shed light on how climate change was affecting schools and children but also provided strong evidence for policymakers and relevant agencies to scale up interventions to enhance adaptation and mitigation practices. [ABSTRACT FROM AUTHOR]