Publications by authors named "Sanjib Kumar Sharma"

45 Publications

The 20-minute whole blood clotting test (20WBCT) for snakebite coagulopathy-A systematic review and meta-analysis of diagnostic test accuracy.

PLoS Negl Trop Dis 2021 Aug 10;15(8):e0009657. Epub 2021 Aug 10.

Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science University of Edinburgh, Edinburgh, United Kingdom.

Background: The 20-minute whole blood clotting test (20WBCT) has been used to detect coagulopathy following snakebite for almost 50 years. A systematic review and meta-analysis of the 20WBCT was conducted to evaluate the accuracy of the 20WBCT to detect coagulopathy, indicative of systemic envenoming.

Methods And Findings: Databases were searched from inception up to 09/12/2020 to identify studies that compared the 20WBCT and INR/fibrinogen on five or more subjects. Data was extracted from full-text articles by two reviewers using a predetermined form. Authors of 29 studies that lacked sufficient details in the manuscript were contacted and included if data meeting the inclusion criteria were provided. Included studies were evaluated for bias using a tailored QUADAS-2 checklist. The study protocol was prospectively registered on PROSPERO database (CRD42020168953). The searches identified 3,599 studies, 15 met the inclusion criteria and 12 were included in the meta-analysis. Data was reported from 6 countries and included a total of 2,270 patients. The aggregate weighted sensitivity of the 20WBCT at detecting INR >1.4 was 0.84 (CI 0.61 to 0.94), the specificity was 0.91 (0.76 to 0.97) and the SROC AUC was 0.94 (CI 0.91 to 0.96). The aggregate weighted sensitivity of the 20WBCT at detecting fibrinogen <100 mg/dL was 0.72 (CI 0.58 to 0.83), the specificity was 0.94 (CI 0.88 to 0.98) and the SROC AUC was 0.93 (0.91 to 0.95). Both analyses that used INR and fibrinogen as the reference test displayed considerable heterogeneity.

Conclusions: In the absence of laboratory clotting assays, the 20WBCT remains a highly specific and fairly sensitive bedside test at detecting coagulopathy following snakebite. However, clinicians should be aware of the importance of operator training, standardized equipment and the lower sensitivity of the 20WBCT at detecting mild coagulopathy and resolution of coagulopathy following antivenom.
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http://dx.doi.org/10.1371/journal.pntd.0009657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8405032PMC
August 2021

Microbiological and Clinicoepidemiological Profile of a Series of Patients with Infective Endocarditis at a Center in Eastern Nepal.

Can J Infect Dis Med Microbiol 2021 22;2021:9980465. Epub 2021 Jul 22.

Department of Internal Medicine, B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan 56700, Sunsari, Nepal.

Background: The microbiological and clinicoepidemiological profile of infective endocarditis (IE) has undergone significant change over time. The pattern of IE studied at local level provides broader vision in understanding the current scenario of this disease. This study aimed to depict the overall picture of IE and its changing profile by evaluating the microbiological and clinicoepidemiological features in the context of a tertiary care center of eastern Nepal.

Methods: The descriptive study was conducted from September 2017 to August 2018 among IE patients presenting to B. P. Koirala Institute of Health Sciences, Nepal. Detailed history and clinical manifestations of patients were noted. Microorganisms isolated from the blood culture were processed for identification by standard microbiological methods, and susceptibility testings were done. Each patient was assessed daily during hospital stay.

Results: Ten definite and 7 possible endocarditis cases were studied. The mean age was 41.4 ± 15.85 (17-70) years with predominance of male (4.7 : 1). Rheumatic heart disease (41.1%) was the most common underlying heart disease observed followed by injection drug user endocarditis (23.5%). All the cases had native valve endocarditis. Aortic valve was the most common valve involved (35.3%) followed by mitral, tricuspid, and pulmonary valves. Blood culture positivity was 53%. was the major causative agent responsible for 23.5% of the cases followed by , , and . Mortality of 2 cases (11.8%) was associated with and . Majority of patients developed acute kidney injury (35.3%) and congestive cardiac failure (23.5%).

Conclusion: IE patients in our center exhibited differences from the west in terms of age at presentation and predisposing factors but held similarity in terms of commonly isolated microorganisms. The changing patterns of IE, etiological agents, and their antimicrobial susceptibility observed in this study may be helpful for clinicians in formulating a new empirical antibiotic treatment protocol.
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http://dx.doi.org/10.1155/2021/9980465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8324388PMC
July 2021

What is the impact of snakebite envenoming on domestic animals? A nation-wide community-based study in Nepal and Cameroon.

Toxicon X 2021 Jul 5;9-10:100068. Epub 2021 Jun 5.

Institute of Global Health, Department of Community Health and Medicine, Faculty of Medicine, University of Geneva, Chemin des mines 9, 1202, Geneva, Switzerland.

Snakebite envenoming is a life-threatening disease in humans and animals and a major public health issue in rural communities of South-East Asia and sub-Saharan Africa. Yet the impact of snakebite on domestic animals has been poorly studied. This study aimed to describe the context, clinical features, treatment, and outcomes of snakebite envenoming in domestic animals in Nepal and Cameroon. Primary data on snakebite in animals were recorded from a community-based nation-wide survey on human and animal snakebite in Nepal and Cameroon ( project). Mobile teams collected data on snakebite in humans and animals in 13,879 and 10,798 households in Nepal and Cameroon respectively from December 2018 to June 2019. This study included 405 snakebite cases (73 in Nepal and 332 in Cameroon) in multiple types of animals. An interview with a structured questionnaire collected specific information about the animal victims. Snake bites in animals took place predominantly inside and around the house or farm in Nepal (92%) and Cameroon (71%). Other frequent locations in Cameroon were field or pasture (12%). A large diversity of clinical features was reported in all types of envenomed animals. They showed either a few clinical signs (e.g., local swelling, bleeding) or a combination of multiple clinical signs. Only 9% of animal victims, mainly cattle and buffaloes and less frequently goats, sheep, and dogs, received treatment, predominantly with traditional medicine. The overall mortality of snakebite was 85% in Nepal and 87% in Cameroon. Results from this nationwide study show an important impact of snakebite on animal health in Nepal and Cameroon. There is a need for cost-effective prevention control strategies and affordable snakebite therapies in the veterinary field to save animal lives and farmer livelihood in the poorest countries of the world. The WHO global strategy to prevent and control snakebite envenoming supports a One Health approach, which may help develop integrated solutions to the snakebite problem taking into account human and animal health.
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http://dx.doi.org/10.1016/j.toxcx.2021.100068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214143PMC
July 2021

Novel transdisciplinary methodology for cross-sectional analysis of snakebite epidemiology at national scale.

PLoS Negl Trop Dis 2021 02 12;15(2):e0009023. Epub 2021 Feb 12.

Institute of Global Health (IGH), Department of Community Health and Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.

Background: Worldwide, it is estimated that snakes bite 4.5-5.4 million people annually, 2.7 million of which are envenomed, and 81,000-138,000 die. The World Health Organization reported these estimates and recognized the scarcity of large-scale, community-based, epidemiological data. In this context, we developed the "Snake-Byte" project that aims at (i) quantifying and mapping the impact of snakebite on human and animal health, and on livelihoods, (ii) developing predictive models for medical, ecological and economic indicators, and (iii) analyzing geographic accessibility to healthcare. This paper exclusively describes the methodology we developed to collect large-scale primary data on snakebite in humans and animals in two hyper-endemic countries, Cameroon and Nepal.

Methodology/principal Findings: We compared available methods on snakebite epidemiology and on multi-cluster survey development. Then, in line with those findings, we developed an original study methodology based on a multi-cluster random survey, enhanced by geospatial, One Health, and health economics components. Using a minimum hypothesized snakebite national incidence of 100/100,000/year and optimizing design effect, confidence level, and non-response margin, we calculated a sample of 61,000 people per country. This represented 11,700 households in Cameroon and 13,800 in Nepal. The random selection with probability proportional to size generated 250 clusters from all Cameroonian regions and all Nepalese Terai districts. Our household selection methodology combined spatial randomization and selection via high-resolution satellite images. After ethical approval in Switerland (CCER), Nepal (BPKIHS), and Cameroon (CNERSH), and informed written consent, our e-questionnaires included geolocated baseline demographic and socio-economic characteristics, snakebite clinical features and outcomes, healthcare expenditure, animal ownership, animal outcomes, snake identification, and service accessibility.

Conclusions/significance: This novel transdisciplinary survey methodology was subsequently used to collect countrywide snakebite envenoming data in Nepal and Cameroon. District-level incidence data should help health authorities to channel antivenom and healthcare allocation. This methodology, or parts thereof, could be easily adapted to other countries and to other Neglected Tropical Diseases.
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http://dx.doi.org/10.1371/journal.pntd.0009023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906452PMC
February 2021

Pharmacovigilance of Antiretroviral Drugs at B.P. Koirala Institute of Health sciences.

J Nepal Health Res Counc 2021 Jan 21;18(4):596-603. Epub 2021 Jan 21.

Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Background: Antiretroviral drugs are lifeline for patients living with HIV. Adverse drug reactions can compromise the compliance to antiretroviral therapy. The objectives of the study were to estimate the prevalence of adverse drug reactions and to assess its risk factors in patients living with HIV and receiving antiretroviral therapy.

Methods: A prospective cohort study was conducted among 496 patients living with HIV at B.P. Koirala Institute of Health Sciences for a period of one year. Adverse drug reactions were evaluated based upon clinical history, clinical examination and investigations.

Results: Majority of patients were of 31-45 year age group (58.1%) and on first-line antiretroviral therapy regimen (94.3%). Total of 240 adverse drug reactions were documented. Prevalence of adverse drug reaction was 34.7%. Skin rash, anemia and nausea and vomiting were the three most common adverse drug reactions. The adverse drug reactions were more common in patients having non-communicable diseases, chronic co-infections, taking more than 3 non-HIV drugs, second and third-line antiretroviral regimen and it was statistically significant (P-value < 0.05).

Conclusions: Prevalence of adverse drug reaction was high in the patients living with HIV. Age, gender, co-infections, non-communicable diseases, taking more than three non-HIV drugs and second and third-line antiretroviral regimen were identified as possible risk factor for occurrence of adverse drug reactions and their prior identification is important to optimize the best suited antiretroviral regimen.
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http://dx.doi.org/10.33314/jnhrc.v18i4.2634DOI Listing
January 2021

Recognition and management of community-acquired acute kidney injury in low-resource settings in the ISN 0by25 trial: A multi-country feasibility study.

PLoS Med 2021 01 14;18(1):e1003408. Epub 2021 Jan 14.

Division of Nephrology, Department of Medicine, University of California San Diego, San Diego, California, United States of America.

Background: Acute kidney injury (AKI) is increasingly encountered in community settings and contributes to morbidity, mortality, and increased resource utilization worldwide. In low-resource settings, lack of awareness of and limited access to diagnostic and therapeutic interventions likely influence patient management. We evaluated the feasibility of the use of point-of-care (POC) serum creatinine and urine dipstick testing with an education and training program to optimize the identification and management of AKI in the community in 3 low-resource countries.

Methods And Findings: Patients presenting to healthcare centers (HCCs) from 1 October 2016 to 29 September 2017 in the cities Cochabamba, Bolivia; Dharan, Nepal; and Blantyre, Malawi, were assessed utilizing a symptom-based risk score to identify patients at moderate to high AKI risk. POC testing for serum creatinine and urine dipstick at enrollment were utilized to classify these patients as having chronic kidney disease (CKD), acute kidney disease (AKD), or no kidney disease (NKD). Patients were followed for a maximum of 6 months with repeat POC testing. AKI development was assessed at 7 days, kidney recovery at 1 month, and progression to CKD and mortality at 3 and 6 months. Following an observation phase to establish baseline data, care providers and physicians in the HCCs were trained with a standardized protocol utilizing POC tests to evaluate and manage patients, guided by physicians in referral hospitals connected via mobile digital technology. We evaluated 3,577 patients, and 2,101 were enrolled: 978 in the observation phase and 1,123 in the intervention phase. Due to the high number of patients attending the centers daily, it was not feasible to screen all patients to assess the actual incidence of AKI. Of enrolled patients, 1,825/2,101 (87%) were adults, 1,117/2,101 (53%) were females, 399/2,101 (19%) were from Bolivia, 813/2,101 (39%) were from Malawi, and 889/2,101 (42%) were from Nepal. The age of enrolled patients ranged from 1 month to 96 years, with a mean of 43 years (SD 21) and a median of 43 years (IQR 27-62). Hypertension was the most common comorbidity (418/2,101; 20%). At enrollment, 197/2,101 (9.4%) had CKD, and 1,199/2,101 (57%) had AKD. AKI developed in 30% within 7 days. By 1 month, 268/978 (27%) patients in the observation phase and 203/1,123 (18%) in the intervention phase were lost to follow-up. In the intervention phase, more patients received fluids (observation 714/978 [73%] versus intervention 874/1,123 [78%]; 95% CI 0.63, 0.94; p = 0.012), hospitalization was reduced (observation 578/978 [59%] versus intervention 548/1,123 [49%]; 95% CI 0.55, 0.79; p < 0.001), and admitted patients with severe AKI did not show a significantly lower mortality during follow-up (observation 27/135 [20%] versus intervention 21/178 [11.8%]; 95% CI 0.98, 3.52; p = 0.057). Of 504 patients with kidney function assessed during the 6-month follow-up, de novo CKD arose in 79/484 (16.3%), with no difference between the observation and intervention phase (95% CI 0.91, 2.47; p = 0.101). Overall mortality was 273/2,101 (13%) and was highest in those who had CKD (24/106; 23%), followed by those with AKD (128/760; 17%), AKI (85/628; 14%), and NKD (36/607; 6%). The main limitation of our study was the inability to determine the actual incidence of kidney dysfunction in the health centers as it was not feasible to screen all the patients due to the high numbers seen daily.

Conclusions: This multicenter, non-randomized feasibility study in low-resource settings demonstrates that it is feasible to implement a comprehensive program utilizing POC testing and protocol-based management to improve the recognition and management of AKI and AKD in high-risk patients in primary care.
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http://dx.doi.org/10.1371/journal.pmed.1003408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808595PMC
January 2021

Study of Health-Related Quality of Life and Healthcare Utilization among Type 2 Diabetic Population in an Urban Area of Eastern Nepal.

Int J Endocrinol 2020 24;2020:8839905. Epub 2020 Dec 24.

School of Public Health and Community Medicine, B.P.Koirala Institute of Health Sciences, Dharan, Nepal.

Introduction: Diabetes mellitus is a major cause of morbidity and mortality and places huge burden on public health funding. Diabetes affects quality of life through associated complications, comorbidity, and disease burden. Consequently, people have frequent healthcare visits. This study assessed quality of life and healthcare utilization patterns among type 2 diabetic populations in an urban area of eastern Nepal.

Methods: A cross-sectional study was conducted among 270 participants of age ≥20 years with type 2 diabetes in Itahari using a semistructured questionnaire. A D-39 questionnaire was used to assess quality of life. Five wards were selected by systematic random sampling, and the population was proportionate according to the sample size. Multiple linear regressions were conducted to identify the factors associated with quality of life and its domains.

Results: The highest mean score ± SD was found in the domain anxiety and worry (57.34 ± 11.08). About 18.5% of the participants perceived extremely affected quality of life. Hypertension (55.55%) was the most common comorbidity. Age, marital status, literacy, alcohol, disease duration, comorbidity, and complications were significantly associated with overall quality of life. In last 6 months of duration, 93.7% had hospital visits. Among them, 8.1% had emergency visit and 5.9% were admitted in the hospital.

Conclusion: People with diabetes in this study were more affected in the domain anxiety and worry. The frequency of healthcare access and utilization in patients with type 2 diabetes was high. The quality of life among them could be improved by taking care on healthy behavior, comorbid conditions, and complications.
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http://dx.doi.org/10.1155/2020/8839905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775169PMC
December 2020

Worksite intervention study to prevent diabetes in Nepal: a randomised trial protocol.

Open Heart 2020 08;7(2)

Yale School of Public Health, New Haven, Connecticut, USA.

Introduction: In Nepal, approximately 31% of adult industrial employees have diabetes. While the prevention of type 2 diabetes through behavioural intervention has been disseminated, worksite could be an effective platform for the translation of this knowledge into action as employed adults spend most of their workday waking hours at workplaces.

Methods And Analysis: We will conduct a randomised controlled trial to assess the effectiveness of a behavioural and a canteen intervention on diabetes risk reduction among those who are prediabetic at two worksites in eastern Nepal. We will recruit 162 adult full-time factory workers with haemoglobin A1c (HbA1c) of 5.7%-6.4% at baseline or fasting blood sugar of 100-125 mg/dL. The 8-14 months' control period will be followed by the behavioural intervention where half of the participants will be randomised to receive the behavioural intervention and half will act as a control and will not receive any intervention. Then, all participants will receive the canteen intervention. The analysis will be intent-to-treat, comparing the difference in the change in HbA1c% between the behavioural intervention group and the control group using a two-sample t-test. The within-participant changes in HbA1c after 6 or more months on the canteen intervention among those not randomised to the behavioural intervention in the previous period will be assessed using the paired t-test.

Ethics And Dissemination: Ethical approval was obtained from the Institutional Review Board at Yale School of Public Health, New Havens, USA and the Nepal Health Research Council.

Trial Registration Number: NCT04161937.
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http://dx.doi.org/10.1136/openhrt-2019-001236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451278PMC
August 2020

The INVICTUS rheumatic heart disease research program: Rationale, design and baseline characteristics of a randomized trial of rivaroxaban compared to vitamin K antagonists in rheumatic valvular disease and atrial fibrillation.

Am Heart J 2020 07 25;225:69-77. Epub 2020 Mar 25.

University Teaching Hospital of Kigali, Rwanda.

Background: Rheumatic heart disease (RHD) is a neglected disease affecting 33 million people, mainly in low and middle income countries. Yet very few large trials or registries have been conducted in this population. The INVICTUS program of research in RHD consists of a randomized-controlled trial (RCT) of 4500 patients comparing rivaroxaban with vitamin K antagonists (VKA) in patients with RHD and atrial fibrillation (AF), a registry of 17,000 patients to document the contemporary clinical course of patients with RHD, including a focused sub-study on pregnant women with RHD within the registry. This paper describes the rationale, design, organization and baseline characteristics of the RCT and a summary of the design of the registry and its sub-study. Patients with RHD and AF are considered to be at high risk of embolic strokes, and oral anticoagulation with VKAs is recommended for stroke prevention. But the quality of anticoagulation with VKA is poor in developing countries. A drug which does not require monitoring, and which is safe and effective for preventing stroke in patients with valvular AF, would fulfill a major unmet need.

Methods: The INVestIgation of rheumatiC AF Treatment Using VKAs, rivaroxaban or aspirin Studies (INVICTUS-VKA) trial is an international, multicentre, randomized, open-label, parallel group trial, testing whether rivaroxaban 20 mg given once daily is non-inferior (or superior) to VKA in patients with RHD, AF, and an elevated risk of stroke (mitral stenosis with valve area ≤2 cm, left atrial spontaneous echo-contrast or thrombus, or a CHADSVASc score ≥2). The primary efficacy outcome is a composite of stroke or systemic embolism and the primary safety outcome is the occurrence of major bleeding. The trial has enrolled 4565 patients from 138 sites in 23 countries from Africa, Asia and South America. The Registry plans to enroll an additional 17,000 patients with RHD and document their treatments, and their clinical course for at least 2 years. The pregnancy sub-study will document the clinical course of pregnant women with RHD.

Conclusion: INVICTUS is the largest program of clinical research focused on a neglected cardiovascular disease and will provide new information on the clinical course of patients with RHD, and approaches to anticoagulation in those with concomitant AF.
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http://dx.doi.org/10.1016/j.ahj.2020.03.018DOI Listing
July 2020

Case Report: Management of Pit Viper Envenoming without Antivenom: A Case Series.

Am J Trop Med Hyg 2020 06;102(6):1440-1442

Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

Pit viper envenoming is common in the hilly and the Himalayan regions of Nepal. Antivenom present in Nepal is unlikely to neutralize the venom of these pit vipers, although it has been used often by the healthcare providers in the clinical practice. Here, we report 15 cases of snakebite with a deranged coagulation profile. All patients recovered from envenoming on conservative management and without the administration of antivenom.
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http://dx.doi.org/10.4269/ajtmh.20-0035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253110PMC
June 2020

Prevalence of Selected Chronic Non-Communicable Diseases in Nepal.

J Nepal Health Res Counc 2019 Nov 14;17(3):394-401. Epub 2019 Nov 14.

Nepal Health Research Council (NHRC), Ramshah Path, Kathmandu, Nepal.

Background: The burden of non-communicable diseases has increased in the last few decades in low-and middle-income countries including in Nepal. There is limited data on population based prevalence of non-communicable diseases. Hence, this study aims to determine the nationwide prevalence of selected chronic non-communicable diseases in Nepal.

Methods: A nationwide cross-sectional population-based study was conducted from 2016 to 2018. Data was collected electronically on android device inbuilt with research and monitoring software from 13200 eligible participants aged 20 years and above. Data was cleaned in SPSS version 20.0 and analyzed using Stata version 13.1.

Results: The overall prevalence of selected non-communicable diseases was found to be chronic obstructive pulmonary disease 11.7% (95% CI: 10.5-12.9), diabetes mellitus 8.5% (95% CI: 7.8-9.3), chronic kidney disease 6.0% (95% CI: 5.5-6.6) and coronary artery disease 2.9% (95% CI: 2.4-3.4) in Nepal. Prevalence of non-communicable diseases varied across provinces. Higher prevalence of chronic obstructive pulmonary disease (25.1%, 95% CI: 18.1-33.8) in Karnali Province, diabetes (11.5%, 95% CI: 9.8-13.4) in Province 3, chronic kidney disease (6.8%, 95% CI: 5.6-8.1) in Gandaki Province and coronary artery disease in Gandaki (3.6%, 95% CI: 2.2-5.7) and Sudurpaschim Province (3.6%, 95% CI: 2.1-6.1) was observed.

Conclusions: The study reported substantial proportion of adult population was found to have chronic non-communicable diseases in Nepal. The findings of this study may be useful for revising/updating multi-sectoral action plans on prevention and control of non-communicable diseases in Nepal.
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http://dx.doi.org/10.33314/jnhrc.v17i3.2327DOI Listing
November 2019

Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom.

J Trop Med 2019 2;2019:2689171. Epub 2019 May 2.

Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Diagnosing and treating acute severe and recurrent antivenom-related anaphylaxis (ARA) is challenging and reported experience is limited. Herein, we describe our experience of severe ARA in patients with neurotoxic snakebite envenoming in Nepal. Patients were enrolled in a randomised, double-blind trial of high vs. low dose antivenom, given by intravenous (IV) push, followed by infusion. Training in ARA management emphasised stopping antivenom and giving intramuscular (IM) adrenaline, IV hydrocortisone, and IV chlorphenamine at the first sign/s of ARA. Later, IV adrenaline infusion (IVAI) was introduced for patients with antecedent ARA requiring additional antivenom infusions. Preantivenom subcutaneous adrenaline (SCAd) was introduced in the second study year (2012). Of 155 envenomed patients who received ≥ 1 antivenom dose, 13 (8.4%), three children (aged 5-11 years) and 10 adults (18-52 years), developed clinical features consistent with severe ARA, including six with overlapping signs of severe envenoming. Four and nine patients received low and high dose antivenom, respectively, and six had received SCAd. Principal signs of severe ARA were dyspnoea alone (n=5 patients), dyspnoea with wheezing (n=3), hypotension (n=3), shock (n=3), restlessness (n=3), respiratory/cardiorespiratory arrest (n=7), and early (n=1) and late laryngeal oedema (n=1); rash was associated with severe ARA in 10 patients. Four patients were given IVAI. Of the 8 (5.1%) deaths, three occurred in transit to hospital. Severe ARA was common and recurrent and had overlapping signs with severe neurotoxic envenoming. Optimising the management of ARA at different healthy system levels needs more research. This trial is registered with NCT01284855.
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http://dx.doi.org/10.1155/2019/2689171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530221PMC
May 2019

Respiratory Problems among Workers of Udayapur Cement Factory in Eastern Nepal.

J Nepal Health Res Counc 2019 Apr 28;17(1):51-55. Epub 2019 Apr 28.

Department of Internal Medicine, B.P Koirala Institute of Health Sciences, Sunsari, Nepal.

Background: There have been very limited studies regarding health of the cement factory workers in Nepal. This study aimed to find out the prevalence of health problems and the factors associated with respiratory symptoms among the workers of Udayapur cement factory.

Methods: This is a cross-sectional study conducted from March to August 2015 in Udayapur cement factory in eastern Nepal. All the workers working in the factory more than a year were included in the study. Thedata was collected by using a semi-structured questionnaire consisting of socio-demographic characteristics,type of work, reported health problems, use of personal protective measures.Chi-square test was used to determine the association of respiratory symptoms with related variables.

Results: A total of 295 workers were included in this study with mean age of 45.9 years (SD=7.7). Majority 279 (94.6%) were males. The most common health problems were musculoskeletal pain (55.6%) followed by eye problems (33.2%). Among them, 17(21.1%) reported that they had at least one respiratory problem and chest tightness while running/climbing and wheeze were the most common. A total of 233 participants (79%) used at least one form of personal protective equipment. Low education, longer duration of work and smoking were found to be positively associated with respiratory symptoms.

Conclusions: Respiratory problems were high among the workers of the cement factory. Proper use of PPEs and dust control measures should be promoted among the workers.
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http://dx.doi.org/10.33314/jnhrc.1489DOI Listing
April 2019

Lupus nephritis: An experience of a tertiary care center in Nepal.

Saudi J Kidney Dis Transpl 2019 Mar-Apr;30(2):462-469

Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

Lupus nephritis (LN) is one of the common complications of systemic lupus erythematosus (SLE). Timely treatment will decrease progression to chronic kidney disease. Treatment varies with different stages for which biopsy is needed. Controversies still exist regarding its requirement in management. This is a retrospective study from September 2014 to August 2016 in B. P. Koirala Institute of Health Sciences, Dharan, Nepal among all patients with SLE and undergone renal biopsy. Of 92 patients, most were female 85 (92.4%) with a median age of 32 years. In this study, 80.4% had some clinical symptomatology. Of the clinical manifestations, 41.3% had polyarthritis, edema (20.7%), and malar rash (17.4%). Anti-nuclear antibody was positive in 80.4% and ds DNA in 70.7%. Renal biopsy showed more number of patients 27 (35%) had Stage IV LN, followed by Stage I, 19 (24%), and Stage II, 16 (20%) LN. Median urinary protein in Class I was 1.05 g, Class II (0.63 g), Class III (1.5 g), Class IV (2.44 g), Class V (3.99 g), and Class VI (4.7 g). Only Stage IV had Kappa of 0.269 {P = 0.003) showing agreement between proteinuria and histological staging which was statistically significant (P <0.005). However, overall Kappa analysis showed none to fair strength of agreement for different stages of LN (-0.014-0.269) with proteinuria. Kappa (k) analysis showed none to fair strength of agreement for different stages of LN and proteinuria. Hence, only proteinuria is not sufficient to replace the need of renal biopsy in LN.
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http://dx.doi.org/10.4103/1319-2442.256853DOI Listing
December 2019

The timing is right to end snakebite deaths in South Asia.

BMJ 2019 Jan 22;364:k5317. Epub 2019 Jan 22.

Department of Tropical Medicine and Public Health, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt, Germany.

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http://dx.doi.org/10.1136/bmj.k5317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340368PMC
January 2019

Price Variation and Availability of Free Medicine for Non-communicable Diseases.

J Nepal Health Res Counc 2018 Jul 3;16(2):118-123. Epub 2018 Jul 3.

Internal Medicine, BPKIHS, Dharan, Nepal.

Background: Nepal is witnessing rise in non-communicable chronic diseases. Costs of the medicine, availability of the medicine for free in public health sectors and variation of price of medicines may play an important role in the management of chronic disease. The study was undertaken to find out the variation in price of drugs used for treating non communicable diseases among private pharmacies and availability of free essential medicines in public facilities.

Methods: Randomly selected 33 public health centers and 13 pharmacies were included for the study. Availability of free essential medicines for treating selected chronic diseases was assessed in public health centers and percentage price variation in various branded drugs used for treating these diseases was assessed at the consumer level.

Results: Out of 89 different formulations, variations between maximum and minimum priced brands of more than 100% were observed in 37 formulations and that of > 200% in 22 formulations. Thirty-seven formulations had more than 100% inter-pharmacy variation. The most commonly available free essential medicines was 4 mg salbutamol (88.57%) while the least available free essential drug was levothyroxine 5 mg (9.0%).

Conclusions: Considerable variation in prices is seen among similar drugs and in prices of same drug in different pharmacies. These factors may have implications in the management of chronic disease in Nepal offsetting the government's effort to control chronic diseases.
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July 2018

Dose of antivenom for the treatment of snakebite with neurotoxic envenoming: Evidence from a randomised controlled trial in Nepal.

PLoS Negl Trop Dis 2017 May 16;11(5):e0005612. Epub 2017 May 16.

Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Background: Currently, there is inadequate evidence on which to base clinical management of neurotoxic snakebite envenoming, especially in the choice of initial antivenom dosage. This randomised controlled trial compared the effectiveness and safety of high versus low initial antivenom dosage in victims of neurotoxic envenoming.

Methodology/ Principal Findings: This was a balanced, randomised, double-blind trial that was conducted in three health care centers located in the Terai plains of Nepal. Participants received either low (two vials) or high (10 vials) initial dosage of Indian polyvalent antivenom. The primary composite outcome consisted of death, the need for assisted ventilation and worsening/recurrence of neurotoxicity. Hourly evaluations followed antivenom treatment. Between April 2011 and October 2012, 157 snakebite victims were enrolled, of which 154 were analysed (76 in the low and 78 in the high initial dose group). Sixty-seven (43·5%) participants met the primary outcome definition. The proportions were similar in the low (37 or 48.7%) vs. high (30 or 38.5%) initial dose group (difference = 10·2%, 95%CI [-6·7 to 27·1], p = 0·264). The mean number of vials used was similar between treatment groups. Overall, patients bitten by kraits did worse than those bitten by cobras. The occurrence of treatment-related adverse events did not differ among treatment groups. A total of 19 serious adverse events occurred, including seven attributed to antivenom.

Conclusions: This first robust trial investigating antivenom dosage for neurotoxic snakebite envenoming shows that the antivenom currently used in Nepal performs poorly. Although the high initial dose regimen is not more effective than the low initial dose, it offers the practical advantage of being a single dose, while not incurring higher consumption or enhanced risk of adverse reaction. The development of new and more effective antivenoms that better target the species responsible for bites in the region will help improve future patients' outcomes.

Trial Registration: The study was registered on clinicaltrials.gov (NCT01284855) (GJ 5/1).
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http://dx.doi.org/10.1371/journal.pntd.0005612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446183PMC
May 2017

Fatal neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal: a case report.

J Venom Anim Toxins Incl Trop Dis 2016 3;22:19. Epub 2016 Jun 3.

Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Germany.

Background: Neurotoxic envenomation following bites by kraits (Bungarus species) is a leading cause of snakebite mortality in South Asia. Over a long time, this had been attributed only to one species, the common krait (Bungarus caeruleus). However, recent research has provided increasing evidence of the involvement of several krait species. Here, we report a fatal case of neurotoxic envenomation following the bite of a greater black krait (Bungarus niger) in Nepal.

Case Presentation: A 33-year-old man was bitten in the outdoor corridor of his home in the eastern hills of Ilam district while handling a snake he thought to be non-venomous. He subsequently developed severe abdominal pain, frequent vomiting, and signs of neurotoxic envenomation leading to respiratory paralysis. The patient did not respond to Indian polyvalent antivenom given 4 h after the bite and died under treatment 8 h after the bite. This is the second time that a B. niger was observed in Nepal, the first documented case of envenomation by this species in the country and the sixth reported case worldwide.

Conclusions: Previous distribution records - from eastern India and western Nepal, from western hills in Nepal, and from lowland localities in India and Bangladesh - indicate risk of envenomation by B. niger throughout the low and intermediate elevations of Nepal up to at least 1,500 m above sea level. As very few people in Nepal bring killed snakes to healthcare centers and because there is a general belief among local people that there are no kraits in the hills, bites by B. niger are likely to be misdiagnosed and underreported.
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http://dx.doi.org/10.1186/s40409-016-0073-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891907PMC
June 2016

Use of Molecular Diagnostic Tools for the Identification of Species Responsible for Snakebite in Nepal: A Pilot Study.

PLoS Negl Trop Dis 2016 Apr 22;10(4):e0004620. Epub 2016 Apr 22.

Division of Tropical and Humanitarian Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Snakebite is an important medical emergency in rural Nepal. Correct identification of the biting species is crucial for clinicians to choose appropriate treatment and anticipate complications. This is particularly important for neurotoxic envenoming which, depending on the snake species involved, may not respond to available antivenoms. Adequate species identification tools are lacking. This study used a combination of morphological and molecular approaches (PCR-aided DNA sequencing from swabs of bite sites) to determine the contribution of venomous and non-venomous species to the snakebite burden in southern Nepal. Out of 749 patients admitted with a history of snakebite to one of three study centres, the biting species could be identified in 194 (25.9%). Out of these, 87 had been bitten by a venomous snake, most commonly the Indian spectacled cobra (Naja naja; n = 42) and the common krait (Bungarus caeruleus; n = 22). When both morphological identification and PCR/sequencing results were available, a 100% agreement was noted. The probability of a positive PCR result was significantly lower among patients who had used inadequate "first aid" measures (e.g. tourniquets or local application of remedies). This study is the first to report the use of forensic genetics methods for snake species identification in a prospective clinical study. If high diagnostic accuracy is confirmed in larger cohorts, this method will be a very useful reference diagnostic tool for epidemiological investigations and clinical studies.
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http://dx.doi.org/10.1371/journal.pntd.0004620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841570PMC
April 2016

Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study.

Lancet Glob Health 2016 May;4(5):e307-19

IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Italy; Department of Medicine, Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.

Background: Chronic kidney disease is an important cause of global mortality and morbidity. Data for epidemiological features of chronic kidney disease and its risk factors are limited for low-income and middle-income countries. The International Society of Nephrology's Kidney Disease Data Center (ISN-KDDC) aimed to assess the prevalence and awareness of chronic kidney disease and its risk factors, and to investigate the risk of cardiovascular disease, in countries of low and middle income.

Methods: We did a cross-sectional study in 12 countries from six world regions: Bangladesh, Bolivia, Bosnia and Herzegovina, China, Egypt, Georgia, India, Iran, Moldova, Mongolia, Nepal, and Nigeria. We analysed data from screening programmes in these countries, matching eight general and four high-risk population cohorts collected in the ISN-KDDC database. High-risk cohorts were individuals at risk of or with a diagnosis of either chronic kidney disease, hypertension, diabetes, or cardiovascular disease. Participants completed a self-report questionnaire, had their blood pressure measured, and blood and urine samples taken. We defined chronic kidney disease according to modified KDIGO (Kidney Disease: Improving Global Outcomes) criteria; risk of cardiovascular disease development was estimated with the Framingham risk score.

Findings: 75,058 individuals were included in the study. The prevalence of chronic kidney disease was 14·3% (95% CI 14·0-14·5) in general populations and 36·1% (34·7-37·6) in high-risk populations. Overall awareness of chronic kidney disease was low, with 409 (6%) of 6631 individuals in general populations and 150 (10%) of 1524 participants from high-risk populations aware they had chronic kidney disease. Moreover, in the general population, 5600 (44%) of 12,751 individuals with hypertension did not know they had the disorder, and 973 (31%) of 3130 people with diabetes were unaware they had that disease. The number of participants at high risk of cardiovascular disease, according to the Framingham risk score, was underestimated compared with KDIGO guidelines. For example, all individuals with chronic kidney disease should be considered at high risk of cardiovascular disease, but the Framingham risk score detects only 23% in the general population, and only 38% in high-risk cohorts.

Interpretation: Prevalence of chronic kidney disease was high in general and high-risk populations from countries of low and middle income. Moreover, awareness of chronic kidney disease and other non-communicable diseases was low, and a substantial number of individuals who knew they were ill did not receive treatment. Prospective programmes with repeat testing are needed to confirm the diagnosis of chronic kidney disease and its risk factors. Furthermore, in general, health-care workforces in countries of low and middle income need strengthening.

Funding: International Society of Nephrology.
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http://dx.doi.org/10.1016/S2214-109X(16)00071-1DOI Listing
May 2016

Snakebite and Acute Kidney Injury: We Must do Better!

Indian Pediatr 2015 Jul;52(7):570-1

Department of Internal Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

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July 2015

Management of chronic kidney disease and its risk factors in eastern Nepal.

Lancet Glob Health 2014 Sep 27;2(9):e506-e507. Epub 2014 Aug 27.

Clinical Research Center For Rare Diseases 'Aldo e Cele Dacco', IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy.

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http://dx.doi.org/10.1016/S2214-109X(14)70281-5DOI Listing
September 2014

Outcome of sepsis-associated acute kidney injury in an intensive care unit: an experience from a tertiary care center of central Nepal.

Saudi J Kidney Dis Transpl 2014 Jul;25(4):912-7

Department of Nephrology, College of Medical Sciences Teaching Hospital, Bharatpur, Nepal.

Acute kidney injury (AKI) is a common and major complication of sepsis. Sepsis-induced AKI is associated with higher morbidity and mortality. A prospective study was designed to include all the patients with a provisional diagnosis of sepsis with AKI admitted in our intensive care unit from August 2009 to September 2010. Detailed demographic data including various clinical parameters, co-morbidities, investigations, complications and outcome were entered in a designated proforman and were analyzed. A total of 53 subjects with the provisional diagnosis of sepsis with AKI were included in the study. The majority of patients (60.37%) were female. The mean age of the study population was 45.84 ± 20.5 years. Forty-nine percent of the subjects were <45 years old and 26.4% patients were >65 years. Among the co-morbid conditions, 9.4% subjects had diabetes mellitus type 2. Among the primary causes of AKI, 72% of the cases were due to medical causes, in which pneumonia was the major cause, and 28% were due to surgical causes, in which cholecystitis was the major cause. 47.1% cases expired, 11.3% subjects left against medical advice and 41.5% cases had favorable outcome. Among the expired cases, 20.7% subjects expired within 24 h; for others, the median hospital stay was four days. This prospective study showed that the major causes of AKI were medical illness and pneumonia. Mortality in sepsis-induced AKI is significantly high. This highlights the importance of prevention of AKI in sepsis by early and renal-friendly aggressive treatment of sepsis and the need for improvement in the management of such AKI cases.
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http://dx.doi.org/10.4103/1319-2442.135229DOI Listing
July 2014

Kidney Biopsy: An Experience from Tertiary Hospital.

JNMA J Nepal Med Assoc 2014 Jan-Mar;52(193):707-12

Department of Cardiology, College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal.

Introduction: Kidney Biopsy is an important diagnostic tool in Nephrology. It is useful in Nephrology in terms of diagnosis, prognosis and management. There is little information on renal biopsy data from central Nepal. We describe our center`s experience in kidney biopsy in term of histological patterns, complications and outcomes.

Methods: We prospectively analyzed the biopsies data of patients over a period of one and half year. All kinds of kidney disease patients were included for kidney biopsy, irrespective of their clinical syndromes and underlying diagnosis.

Results: A total of 75 biopsies were analyzed. Majority of them were females; 42 (56%). Most of the biopsies; 63 (84%) were from younger subjects ≤ 45 years and majority of them fell in the age group 11-20 years. Most common clinical renal syndrome to undergo biopsy was Sub Nephrotic range Proteinuria in 40 (53.3%). Among comorbid conditions, 40 (53.3%) had Hypertension. The most common histological pattern seen was Mesangial proliferative Glomerulonephritis seen in 18 (24%). Among complications associated with the procedure, macroscopic hematuria was seen in 5 (6.7%) cases and clinically significant perinephric hematoma causing pain was seen in 4 (5.3%). There was no mortality associated with biopsy procedure.

Conclusions: Sub Nephrotic range Proteinuria was the commonest clinical renal Syndrome observed. In terms of renal histology, Mesangial Proliferative Glomerulonephritis (MesPGN) was the commonest histological pattern observed. Kidney biopsy is a safe procedure without any significant adverse events.
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August 2016

Comparison of complications in diabetic outpatients with or without mental illness.

Indian J Endocrinol Metab 2013 Oct;17(Suppl 1):S313-5

Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

Diabetes Mellitus (DM) and psychiatric illness are related in many ways by prevalence, burden, course, and outcome. Co-morbid mental illness may play a role in determining the complication in diabetic patients. This study was conducted in 2010 among consecutive diabetic out-patients diagnosed as per American Diabetes Association (ADA) guidelines 2009, of age above 14 years, to compare the complications in diabetic patients with or without mental illness. Diabetic neuropathies, cardiovascular complications, and morbid obesity were among the complications significantly more among diabetic patients with mental illness (GHQ-12 ≥ 2) than without mental illness (GHQ-12 ≤ 2).
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http://dx.doi.org/10.4103/2230-8210.119643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3830344PMC
October 2013

Percutaneous coronary intervention without onsite cardiac surgery backup.

JNMA J Nepal Med Assoc 2013 Jan-Mar;52(189):267-71

Department of Cardiology, College of Medical Sciences and Teaching Hospital, Bharatpur-10, Chitwan, Nepal.

Introduction: Mechanical revascularization by percutaneous coronary interventions has now become an established and preferable method of revascularization in patients with acute coronary syndromes. The aim of the study was to identify the clinical indications for percutaneous coronary interventions and in-hospital outcomes of percutaneous coronary interventions in a tertiary-level hospital without onsite cardiac surgery backup.

Methods: This was a prospective descriptive study. All consecutive patients who were admitted for percutaneous coronary interventions, including both primary as well as elective percutaneous coronary interventions, between March 2011 and December 2012 were included in the study.

Results: Total 101 percutaneous coronary interventions were performed. The mean age was 58.9 ± 12.3 years. The most frequent indication was ST-elevation myocardial infarction 72 (71.3%). Proximal artery stenting were performed in 39 (38.5%) and the non proximal artery stenting in 62 (61.5%). The outcomes were mortality 5 (4.9%), periprocedural myocardial infarction 2 (1.9%), cardiogenic shock 6 (5.9%), contrast induced nephropathy requiring dialysis in 3 (2.9%), minor complications which were managed conservatively in 13 (12.9%).

Conclusions: Percutaneous coronary intervention was feasible with acceptable complications in a tertiary-level hospital without onsite cardiac surgery backup. ST-elevation myocardial infarction was the major indication and cardiogenic shock was the major complication observed, and non proximal artery stenting was more common than the proximal artery stenting.
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April 2014

Community-based screening for chronic kidney disease, hypertension and diabetes in Dharan.

JNMA J Nepal Med Assoc 2013 Jan-Mar;52(189):205-12

Department of Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

Introduction: Nepal cannot afford renal replacement therapy for End Stage Renal Disease due to lack of resources. Early diagnosis of Chronic Kidney Disease and its risk factors may reduce the need of renal replacement therapy.

Methods: A community-based screening on, 3218 people ≥20 years were assessed by door-to-door survey in Dharan, Nepal. Health status, lifestyle habit, physical examination and blood pressure were evaluated. Spot urine was examined for proteins and glucose by dipstick. Fasting blood glucose and serum creatinine were measured in a subset of 1000 people and the prevalence of Chronic Kidney Disease was evaluated.

Results: Overweight, obesity, hypertension, diabetes and proteinuria were found in 20%, 5.0%, 38.6%, 7.5%, and 5.1% respectively. In the subset group, Chronic Kidney Disease was detected in 10.6%. Multivariate analysis indicated age (P <0.0001) and diabetes (P = 0.027) as statistically significant predictors for Chronic Kidney Disease. Total of 848 patients entered the management program of lifestyle modification and pharmacologic intervention. Glycemic and blood pressure control was achieved in 60% and 72%, respectively. Regression or stabilization of proteinuria was reported in 52% of patients.

Conclusions: Burden of Chronic Kidney Disease and cardiovascular risk factors are high in Dharan. Reasonable control of blood sugar, hypertension and proteinuria was achieved in this program. Findings indicate that activation a large prevention and intervention program to tackle Chronic Kidney Disease and Cardiovascular Disease in Nepal is needed.
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April 2014

Preventing renal and cardiovascular risk by renal function assessment: insights from a cross-sectional study in low-income countries and the USA.

BMJ Open 2012 22;2(5). Epub 2012 Sep 22.

Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Villa Camozzi, Ranica, and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Mario Negri Institute for Pharmacological Research, Bergamo, Italy.

Objective: To assess the prevalence of microalbuminuria and kidney dysfunction in low-income countries and in the USA.

Design: Cross-sectional study of screening programmes in five countries.

Setting: Screening programmes in Nepal, Bolivia, the USA (National Health and Nutrition Examination Survey (NHANES) 2005-2008) Bangladesh and Georgia.

Participants: General population in Nepal (n=20 811), Bolivia (n=3436) and in the USA (n=4299) and high-risk subjects in Bangladesh (n=1518) and Georgia (n=1549).

Primary And Secondary Outcome Measures: Estimated glomerular filtration rate (eGFR)<60ml/min/1.73 m(2) and microalbuminuria (defined as urinary albumin creatinine ratio values of 30-300 mg/g) were the main outcome measures. The cardiovascular (CV) risk was also evaluated on the basis of demographic, clinical and blood data.

Results: The prevalence of eGFR<60ml/min/1.73 m(2) was 19%, 3.2% and 7% in Nepal, Bolivia and the USA, respectively. In Nepal, 7% of subjects were microalbuminuric compared to 8.6% in the USA. The prevalence of participants with predicted 10-year CV disease (CVD) risk ≥10% was 16.9%, 9.4% and 17% in Nepal, Bolivia and in the USA, respectively. In Bangladesh and Georgia, subjects with eGFR<60 ml/min/1.73 m(2) were 8.6% and 4.9%, whereas those with microalbuminuria were 45.4% and 56.5%, respectively. Predicted 10-year CVD risk ≥10% was 25.4% and 25% in Bangladesh and Georgia, respectively.

Conclusions: Renal abnormalities are common among low-income countries and in the USA. Prevention programmes, particularly focused on those with renal abnormalities, should be established worldwide to prevent CVD and progression to end-stage renal disease.
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http://dx.doi.org/10.1136/bmjopen-2012-001357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3467605PMC
October 2012

Cardiovascular autonomic function and vibration perception threshold in type 2 diabetes mellitus.

J Diabetes Complications 2012 Jul-Aug;26(4):339-42. Epub 2012 Apr 24.

Department of Physiology, Nepalgunj Medical College, Nepalgunj, Nepal.

Objective: The aim of this study was to compare cardiovascular autonomic function tests (AFT) and vibration perception threshold (VPT) of patients with type 2 diabetes mellitus (T2DM) with controls.

Research Design/methods: The study was conducted on 60 diabetic patients comparing with 30 controls. The cardiovascular AFT and VPT were assessed in both groups.

Results: Among cardiovascular AFT, E:I ratio [1.24 (1.2-1.32) vs 1.3 (1.24-1.4), p=0.001], and Valsalva ratio [1.28 (1.22-1.4) vs 1.6 (1.5-1.73), p=0.001], the indicators of parasympathetic reactivity were reduced in T2DM. Rise in DBP during handgrip, an indicator of sympathetic reactivity was lower in T2DM [12 (10-14) vs 16 (14-18) mmHg, p=0.001] whereas, fall in SBP during head up tilt [4 (4-8) vs 5 (4-8) mmHg] was comparable. VPT (somatic sensation) was comparable between T2DM and control.

Conclusion: Autonomic involvement is more marked than somatic, and parasympathetic involvement is more marked than the sympathetic, possibly reflecting severity and chronological pattern of their involvement.
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http://dx.doi.org/10.1016/j.jdiacomp.2012.03.026DOI Listing
January 2013
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