Search

In 2008, Bangladesh initiated Preventive Chemotherapy (PCT) for school-age children (SAC) through bi-annual school-based mass drug administration (MDA) to control Soil-Transmitted Helminth (STH) infections. In 2016, the Ministry of Health and Family Welfare’s Program on Lymphatic Filariasis Elimination and STH (ELFSTH) initiated district-level community impact assessments with Children Without Worms (CWW) using standardized, population-based sampling to measure the post-intervention STH burden across all ages (≥ 1 yr) for the three STH species. The Integrated Community-based Survey for Program Monitoring (ICSPM) was developed by CWW and was used to survey 12 districts in Bangladesh from 2017–2020. We excluded the first two district data as piloting caused some sampling errors and combined the individual demographic and parasite-specific characteristics from the subsequent 10 districts, linking them with the laboratory data for collective analysis. Our analysis identified district-specific epidemiologic findings, important for program decisions. Of the 17,874 enrolled individuals, our results are based on 10,824 (61.0%) stool samples. Overall, the prevalence of any STH species was substantially reduced to 14% from 79.8% in 2005. The impact was similar across all ages. STH prevalence was 14% in 10 districts collectively, but remained high in four districts, despite their high reported PCT coverage in previous years. Among all, Bhola district was unique because it was the only district with high T.trichuris prevalence. Bangladesh successfully lowered STH prevalence across all ages despite targeting SAC only. Data from the survey indicate a significant number of adults and pre-school age children (PSAC) were self-deworming with purchased pills. This may account for the flat impact curve across all ages. Overall prevalence varied across surveyed districts, with persistent high transmission in the northeastern districts and a district in the central flood zone, indicating possible service and ecological factors. Discrepancies in the impact between districts highlight the need for district-level data to evaluate program implementation after consistent high PCT coverage., Author summary Bangladesh government conducted school-based mass drug administration (MDA) for over 10 years to control soil-transmitted helminth (STH) infections. School-based evaluations of MDA indicate a reduction in STH burden among school-aged children (SAC). To further assess the impact on the community, Children Without Worms and the Ministry of Health and Family Welfare’s Program on Lymphatic Filariasis Elimination and STH (ELFSTH) initiated district-level community impact surveys in 12 districts. We share the results from the latter 10 districts here (the first two pilots were excluded because of possible sampling errors). Our analysis of 10,824 interviews and stool samples from 10 districts showed an estimated 14% of community members infected with at least one species of STH. This finding is substantially lower than the baseline STH prevalence (79.8%) estimated in 2005. Bangladesh’s successful impact was achieved across all ages despite only treating SAC. Deworming source data showed significant numbers of adults and pre-school age children (PSAC) self-dewormed with locally purchased pills. Prevalence varied across the surveyed districts, with persistent high transmission in the northeastern districts and a district in the central flood zone, indicating possible ecological and service factors contributing to persistent infections. Variable impact across districts highlights the need for sub-national level data to evaluate program performance following the consistent high intervention and could be attributable to many additional factors.

Introduction: Bedside teaching is an important and established learning tool in medical education. However there is a decline in bedside teachings over the years throughout the world including Nepal, due to advancement in medical technology, clinical skills labs and simulation techniques. This study aimed to find out the perception of Nepalese medical students towards different domains of bedside teaching. Methods: This was a descriptive cross-sectional study. A questionnaire consisting of Likert scale, open ended and closed ended questions was developed on different aspect of bedside teaching and the filled questionnaires were included for analysis. Results: Three hundred and six questionnaires were included. Almost all of medical students responded that bedside teaching is a useful learning modality in clinical teaching 304 (99.3%) and provides active learning in real context 291 (95%). The majority of medical students 233 (76%) were satisfied with the steps of history taking, examination followed by management discussion employed at bedside teaching. The students 223 (73%) were satisfied, how to elicit signs following demonstration of clinical exam by teachers at bedside. However majority 196 (64%) felt lack of individual opportunity at bedside. According to students, focussing more on practically oriented clinical skills with proper supervision would improve learning while hindering factors were large number of students and patient’s uncooperativeness. Good communication was considered the best method of alleviating patient discomfort at bedside teaching in this study. Conclusions: The study concluded that medical students have positive response and learning attitudes towards different aspects of bedside teaching.

Background Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. Purpose To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. Data sources 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. Study selection Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. Data extraction One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. Data synthesis Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants). Limitations All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. Conclusion Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. Primary funding source Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Medicine of present world demands high level of competency in both clinical examination and performing a procedure in patients. The traditional methods of bedside skill learning and teaching should be supplemented by instruction in clinical skills lab of basic important clinical skills. Every medical school should work towards establishment and incorporation of clinical skills lab in basics science subjects and clinical posting along with other subjects to make it Practice oriented and Student centred learning.Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):49-51

Humanities have an essential role in medical education. The current gap between the humanities and medicine has to be bridged and there should be continuous and vigorous debate about the theory and practice of medical humanities. Medical humanities is a relatively new concept even in developed countries, and is at infancy stage in developing countries. In Nepal, modules on medical humanities have been initiated in certain medical schools by enthusiastic faculties and it requires further debates for inclusion in curriculum.

Background Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear. Purpose To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. Data sources 6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. Study selection 36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. Data extraction One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). Data synthesis Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. Limitations All studies had medium or high risk of bias. There was scarce evidence for many outcomes. Conclusion Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515). Primary funding source Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Objective Electronic laboratory reporting has been promoted as a public health priority. The Office of the U.S. National Coordinator for Health Information Technology has endorsed two coding systems: Logical Observation Identifiers Names and Codes (LOINC) for laboratory test orders and Systemized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for test results. Materials and Methods We examined LOINC and SNOMED CT code use in electronic laboratory data reported in 2011 by 63 non-federal hospitals to BioSense electronic syndromic surveillance system. We analyzed the frequencies, characteristics, and code concepts of test orders and results. Results A total of 14,028,774 laboratory test orders or results were reported. No test orders used SNOMED CT codes. To describe test orders, 77% used a LOINC code, 17% had no value, and 6% had a non-informative value, “OTH”. Thirty-three percent (33%) of test results had missing or non-informative codes. For test results with at least one informative value, 91.8% had only LOINC codes, 0.7% had only SNOMED codes, and 7.4% had both. Of 108 SNOMED CT codes reported without LOINC codes, 45% could be matched to at least one LOINC code. Conclusion Missing or non-informative codes comprised almost a quarter of laboratory test orders and a third of test results reported to BioSense by non-federal hospitals. Use of LOINC codes for laboratory test results was more common than use of SNOMED CT. Complete and standardized coding could improve the usefulness of laboratory data for public health surveillance and response.

Theoretically, it is possible to eliminate Salmonella, pathogenic bacteria that can cause a potentially fatal enteric fever. However, given the high prevalence of the disease in low-income countries that lack adequate facilities for sewage disposal and water treatment, and the fact that people can be long-term asymptomatic carriers, this goal is currently unrealistic. This levies constant need of a preventive measure to reduce morbidity and mortality in children associated with Typhoid Fever in endemic countries like Nepal. Currently, the best possible approach is to integrate the Typhoid vaccination into the Expanded Program of Immunization (EPI) until an improved sanitation and sewage disposal system is attained. We must acknowledge that this approach is not definitive until sufficient political and economic attention is received from all stakeholders. DOI: http://dx.doi.org/10.3126/jnps.v33i2.8715 J Nepal Paediatr Soc. 2013; 33(2):152-154

Objective To assess the utility of inpatient and ambulatory clinical data compiled by public and commercial sources to enhance the Centers for Disease Control and Prevention’s surveillance activities. Introduction Medical claims and EHR data sources offer the potential to ascertain disease and health risk behavior prevalence and incidence, evaluate the use of clinical services, and monitor changes related to public health interventions. Passage of the HITECH Act of 2009 supports the availability of standardized EHR data for use by public health officials to obtain actionable information. While full adoption of EHRs is still years away, there are presently publicly- and commercially-available EHR and medical claims data sets that could enhance public health surveillance at a national, regional and state level. The purposes of this evaluation were to i.) demonstrate the feasibility of gaining access to such data, ii.) evaluate their ability to augment current surveillance activities by developing measures for twenty separate healthcare indicators (e.g., HIV screening), iii.) evaluate each data source across a set of criteria needed for an effective surveillance system, and iv.) assess the ability of the data sources to evaluate changes in healthcare utilization and preventive services that may be a result of the 2009 Health Reform legislation. Methods Ten separate data sources were selected for inclusion in the study based on a number of criteria, including availability, representativeness, population, data structure and content, cost, and longitudinality. In collaboration with staff from seven Divisions across the CDC, detailed specifications were developed for twenty separate indicators of healthcare utilization or preventive services using best practices in healthcare quality measurement. Specifications were developed separately for EHR and medical claims data due to their differing structure, content and use of medical code sets and terminologies. Specifications for EHR data sources relied on the National Quality Forum (NQF) Meaningful Use (MUse) clinical quality measure specifications. The use of NQF MUse specification guidelines allowed us to gauge the current ability of each data source to measure healthcare utilization and preventive services as recommended by NQF, the national leader in healthcare measurement. Each of the data sources was also evaluated across established public health surveillance criteria, including data quality, representativeness, and flexibility, among others. Data analysis was performed using SAS 9.3 (SAS Institute, Cary, NC). Results All twenty of the healthcare indicators were developed for at least one data source; however, many of the indicator specifications had to be modified due to the low frequency of certain code sets (e.g., CPT-4 II, LOINC). The observed strengths of medical claims data were the relatively low cost, ability to track patients longitudinally, and the standardized representation of procedures and diagnoses through use of medical codes, such as ICD-9-CM, CPT-4 and HCPCS. The observed strengths of EHR data sources were the availability of information related to health behavior (e.g., current smoker), health assessment (e.g., BMI), prognostic indicators (e.g., vital signs, laboratory result), diagnostic testing, and functional status. While EHR data also capture diagnoses using ICD-9-CM, procedures such as medical and laboratory procedures remain documented through use of free text or semi-structured text fields, making it difficult to process. Conclusions Currently available healthcare data can improve the timeliness of health outcome monitoring and add complementary information on healthcare utilization to improve our interpretation of traditional public health surveillance data. Medical claims data support measurement of health outcomes and healthcare services provided to patient populations; however, without clinical encounter information, they cannot develop measures estimating the impact of services received on quality of care. EHR data have richer clinical information; however, the continued use of non-standards-based medical codes and free and semi-structured text fields make it difficult to analyze data at scale. Meaningful Use and other HITECH initiatives are changing this by incentivizing the standardization and aggregation of electronic healthcare data. In time, these data may yield timely, accurate and actionable information for public health surveillance.

Electronic Laboratory Reporting (ELR) has the potential to be more accurate, timely, and cost-effective. However, the continuing use of non-standard, local codes to represent laboratory test results complicates the use of ELR data in public health practice. Use of structured and standardized coding system(s) to support the concepts represented by local codes improves the computational characteristics of ELR data. We examined the use of LOINC and SNOMED CT codes for coding laboratory tests in hospital laboratory reports. We found that the hospitals more frequently used LOINC codes than SNOMED CT in reporting test results.

Assess whether Medicare data are useful for monitoring tissue allograft safety and utilization. We used health care claims (billing) data from 2007 for 35 million fee-for-service Medicare beneficiaries, a predominantly elderly population. Using search terms for transplant-related procedures, we generated lists of ICD-9-CM and CPT(®) codes and assessed the frequency of selected allograft procedures. Step 1 used inpatient data and ICD-9-CM procedure codes. Step 2 added non-institutional provider (e.g., physician) claims, outpatient institutional claims, and CPT codes. We assembled preliminary lists of diagnosis codes for infections after selected allograft procedures. Many ICD-9-CM codes were ambiguous as to whether the procedure involved an allograft. Among 1.3 million persons with a procedure ascertained using the list of ICD-9-CM codes, only 1,886 claims clearly involved an allograft. CPT codes enabled better ascertainment of some allograft procedures (over 17,000 persons had corneal transplants and over 2,700 had allograft skin transplants). For spinal fusion procedures, CPT codes improved specificity for allografts; of nearly 100,000 patients with ICD-9-CM codes for spinal fusions, more than 34,000 had CPT codes indicating allograft use. Monitoring infrequent events (infections) after infrequent exposures (tissue allografts) requires large study populations. A strength of the large Medicare databases is the substantial number of certain allograft procedures. Limitations include lack of clinical detail and donor information. Medicare data can potentially augment passive reporting systems and may be useful for monitoring tissue allograft safety and utilization where codes clearly identify allograft use and coding algorithms can effectively screen for infections.

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals’ natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.

The prevalence of smoking continues to be higher in some ethnic groups than in others, despite the overall decrease of smoking during the last 30 years. The goal of this project was to investigate the trends and predictors of cigarette smoking among a population of Caucasians, Japanese, Chinese, Filipino, and Native Hawaiians.We combined data from 19 earlier studies conducted in Hawaii between 1975 and 2001. After excluding 1,885 individuals without smoking data, 158,629 subjects (40.0% Japanese, 30.3% Caucasian, 14.3% Hawaiian, 8.1% Filipino, 3.0% Chinese) were included in the analysis. The prevalence of current smoking and past smoking was estimated for 5-year periods by sex and ethnicity and age-adjusted to the state's population. We calculated odds ratios and 95% confidence intervals by using polytomous logistic regression to explore determinants of smoking, while controlling for clustering by study.Men were more likely to smoke than women throughout the study period, but they experienced a greater decline in smoking until 1994. We observed a small increase in smoking prevalence thereafter. Native Hawaiians reported the highest smoking prevalence, Japanese the lowest, and Caucasians intermediate levels. Graduate level education had the strongest inverse association with current and past smoking. Older age at interview, being married, and a higher body weight were related to lower smoking prevalence.Our data suggest a modest reversal in the declining smoking prevalence during the late 1990s. The persistent ethnic differences require new approaches that reach those groups who remain at high risk for adverse health effects from smoking.

Background The purpose of this study was to use insurance claims and tumor registry data to examine determinants of breast conserving surgery (BCS) in women with early stage breast cancer. Methods Breast cancer cases registered in the Hawaii Tumor Registry (HTR) from 1995 to 1998 were linked with insurance claims from a local health plan. We identified 722 breast cancer cases with stage I and II disease. Surgical treatment patterns and comorbidities were identified using diagnostic and procedural codes in the claims data. The HTR database provided information on demographics and disease characteristics. We used logistic regression to assess determinants of BCS vs. mastectomy. Results The linked data set represented 32.8% of all early stage breast cancer cases recorded in the HTR during the study period. Due to the nature of the health plan, 79% of the cases were younger than 65 years. Women with early stage breast cancer living on Oahu were 70% more likely to receive BCS than women living on the outer islands. In the univariate analysis, older age at diagnosis, lower tumor stage, smaller tumor size, and well-differentiated tumor grade were related to receiving BCS. Ethnicity, comorbidity count, menopausal and marital status were not associated with treatment type. Conclusions In addition to developing solutions that facilitate access to radiation facilities for breast cancer patients residing in remote locations, future qualitative research may help to elucidate how women and oncologists choose between BCS and mastectomy.

When officials and activists were busy celebrating a sharp fall in maternal mortality in Nepal an impoverished woman from an under developed region in the far west of the country was making a heart-rending request to a social worker. Parvati wanted poison. Unable to bear the constant pain and discomfort due to severe uterine prolapse Parvati had expressed her wish to die at the first opportunity she had to express her misery. 36-year-old Parvati comes from a marginalised Dalit (so-called untouchables) community. She was married at age 10 years to a man 20 years older. She had ten children - six of whom survived. 2 years ago she gave birth to her last child but that delivery proved too much for her frail weary and undernourished body. Uterine prolapse is often the result of difficult labour frequent pregnancies lack of antenatal care and a rigorous working schedule. In less severe cases the womb can be stabilised by inserting a rubber ring or pessary but surgery is required in severe cases. 600 000 women all over Nepal need urgent medical care for uterine prolapse according to the UN Population Fund. (excerpt)