Bhutan Health Journal
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Pre-delivery hypotension after spinal anesthesia during cesarean section and its associated factors at Jigme Dorji Wangchuck National Referral Hospital, Bhutan
Get PDFIntroduction: The current choice of anesthesia for the cesarean section is spinal anesthesia. However, hypotension is the major complication. If promptly not recognized and treated, it increases the morbidity and mortality of the mother and fetus. This study was conducted to evaluate the rate of pre-delivery hypotension and risk factors following spinal anesthesia for cesarean section at the National Referral Hospital in Bhutan.
Methods: A cohort study was conducted from 1st October 2018 to 30th June 2019 on 350 women undergoing cesarean section under spinal anesthesia. Pre-delivery hypotension was defined as systolic blood pressure < 100 mm Hg. The association of factors for hypotension was tested using multivariable binary logistic regression using a forward stepwise model. A p-value < 0.05 was considered significant.
Results: The rate of pre-delivery hypotension was 74.6 % (n=261). History of hypertension during pregnancy (Adjusted OR 0.25, [0.11-0.60], p=0.013), prophylaxis use of ephedrine (Adjusted OR 0.45, [0.22-0.92], p= 0.024) and ondansetron (Adjusted OR 0.43, [0.22-0.82], p= 0.010),longer preoperative fasting duration (Adjusted OR 1.12, [1.01-1.21], p=0.024,), sensory block level <= T4 (Adjusted OR 3.4, [1.8-6.4], p=<0.001) and baseline systolic blood pressure less than or equal to 120 mmHg (Adjusted OR 2.8, [1.5-5.1], p=0.001) were significant risk factors.
Conclusions: This study conduces that the rate of pre-delivery hypotension following spinal anesthesia in a cesarean section was high among women undergoing cesarean section. It is alarming as around two-third of women and fetus undergoing cesarean section under spinal anesthesia are at risk of consequences of hypotension. Most of the risk factors in the study are modifiable. The study suggests that if the anesthesia provider intervenes in managing the modifiable risk factors and treat hypotension promptly, it can help reduce the risk of women and fetus to spinal hypotension consequences
A rare case of intraosseous lipoma of distal tibia – A case report and review of literature
Get PDFIntroduction: Intraosseous lipoma is a very rare neoplasm accounting for < 0.1 % of primary bone tumors. Pain is the leading symptom in majority of the reported cases but it can be asymptomatic. There is slight male predominance in occurrence of this lesion. The plain radiological findings are not specific and requires differential diagnosis. The lesion is mostly diagnosed by histopathological examination.
Case report: A 31-year-old male presented with localized pain around the medial aspect of right ankle joint for one week. Examination revealed mild tenderness over the distal part of the right tibia over the medial aspect. Plain radiograph of the right leg showed well-defined expansile osteolytic lesion with sclerotic rim and calcified matrix at metaphysis of distal tibia. MRI showed enhancing T1-weighted hypo intense and T2-weighted hyperintense lesion. For this case, radiological impression was giant cell tumor with differential diagnosis of aneurysmal bone cyst and fibrous dysplasia. However, the histopathological examination showed intraosseous lipoma, consistent with stage II of Milgram’s classification.
Conclusions: Although the diagnosis of intraosseous lipoma can be very challenging due to its rarity and indistinct plain radiograph findings, combination of computed tomography or magnetic resonance imaging may be useful by being able to show the presence of fat within the lesion. However, the clinicians, surgeons and radiologist should be familiar and be aware of these findings to be able to come to a correct diagnosis since not all cases need surgery and can be managed conservatively
Burden and outcome of community-acquired pneumonia in adult patients admitted to National Referral Hospital, Bhutan
Get PDFIntroduction: Community acquired pneumonia is one of the leading causes of morbidity and mortality globally with the highest burden being reported from Asia. In Bhutan, community acquired pneumonia was reported to be one of the top five causes of mortality and one of the top ten causes of morbidity.
Methods: This was an observational study done in a cohort of adult patients with community acquired pneumonia who were admitted to National Referral Hospital of Bhutan from February 2020 – February 2021 using purposive sampling. The Research Ethics Board of Health, Bhutan, gave ethical approval. We evaluated the burden and outcome of the community acquired pneumonia, and assessed the predictive capability of CURB-65 score to predict mortality as an outcome in these patients.
Results: The inpatient burden of community acquired pneumonia was found to be 4.7% among patients admitted to medical wards. The mortality was 7.8%. 15.7 % of patients were managed in the intensive care unit out of which 5.9% patients needed mechanical ventilation. The mean hospital length of stay of these patients was 13 days. The sensitivity, specificity, PPV and NPV of CURB-65 score to predict death as an outcome in these patients were 87.5%, 43.6%, 11.7% and 97.6% respectively.
Conclusion: The inpatient burden of Community Acquired Pneumonia in the National Referral Hospital is of concern. The CURB-65 score can be used a supplement to clinical judgement to assess the severity of the disease and make appropriate management decisions
How reliable are the current Blood Pressure Measuring devices in Health Facilities of Bhutan?
Get PDFBackground: Accurate blood pressure measurement is vital before any inferences are made on the reading. Since device error is one of the potential causes of inaccurate results, blood pressure measuring (BPM) devices should be periodically assessed for its accuracy. This paper describes the types of BPM devices used in health facilities of Bhutan and the results of their performance verifications.
Method: This study assessed the pressure accuracy and leak rates of BPM devices in use at two regional referral hospitals, district hospitals and BHU I using calibrated Vital Signs Simulator (ProSimTM 8) from Fluke Biomedical as reference device. For pressure accuracy assessment, static pressures were simulated against which simultaneous readings of each of the devices were recorded (n=3). For the leak rate assessment, the simulator was set to a target pressure and leak rate (n=3) were recorded over 1 minute.
Result: A total of 395 devices of three types, viz., 135 aneroid, 125 electronic and 135 mercury were assessed. Deviations in readings of 64.72% of devices were found to be within acceptable range of ± 3 mmHg. The device-type specific pass percentages for pressure accuracy were 6.40 % for electronic, 88.81 % for aneroid and 94.81 % for mercury. A total of 71.85% of devices (aneroid and mercury) had acceptable leak rates of 15 mmHg per minute.
Conclusion: The study shows that not all the blood pressure measuring devices currently being used in the health facilities of Bhutan are accurate. Besides ensuring that only validated BPM devices enter the country, these devices should be verified for its performance periodically once they are in use
A rare case of plasma cell granuloma arising from facial nerve
Get PDFWe present a 38 year old male with a rare case of plasma cell granuloma arising from facial nerve which posed a diagnostic and therapeutic challenge. He has no other comorbidities except for a history of left ear modified radical mastoidectomy performed in 2002 for cholesteatoma after which he recovered uneventfully. This time he presented with mass in the ear canal with ear block and otorrhea for 1 month duration. Initial biopsy revealed granulation tissue. CT scan revealed bony destruction with soft tissue mass. Diagnosis of recurrence of cholesteatoma was made for which he underwent MRM under general anesthesia. Intraoperatively, there was soft tissue mass filling the mastoid and the middle ear and destruction of all ossicles. The mass was arising from facial nerve and there was bony dehiscence of facial nerve. The mass sent for histopathology revealed plasma cell granuloma. He recovered uneventfully with intact facial nerve and hearing level of 40 dB .Ear canal polyp should not be avulsed as it may arise from facial nerve and any mass should be subjected to histopathological examination and should not be left as granulation tissue. This case posed both diagnostic and therapeutic challenge and supported the hypothesis of that plasma cell granuloma are psudotumour and with proper excision and post-operative steroids, there will be complete remission
Is Leishmaniasis donovani elimination feasible in Bhutan? A review of current prevention and control mechanisms in Bhutan
Get PDFLeishmaniasis is a neglected tropical disease with an annual estimated 700,000 to 1 million new cases globally. The diseases affect the rural community and people living in poverty. It is transmitted by female phlebotomine sand-fly; a tiny 2–3 mm long insect vector. Along with the regional countries, Bhutan has embarked on the elimination goal. However, several challenges lies ahead on its path to elimination. There is no elimination strategy and actions. The reporting, surveillance system, control and prevention mechanisms are inadequate. Further, there is lack of knowledge among the health care providers that impedes elimination goals. Therefore, if Bhutan is serious about its elimination goal, all the gaps and current challenges needs to be addressed appropriately.
Keywords: Bhutan; Elimination; Leishmaniasis
Characteristics of attempted suicide patients admitted in Jigme Dorji Wangchuck National Referral Hospital from January 2014 to September 2018
Get PDFIntroduction: Attempted suicide is a major public health problem with a prevalence rate of approximately 2.7% worldwide. There is an increasing trend of attempted suicide in Bhutan. It is a strong clinical predictor of eventual suicide deaths and results in significant use of health care resources. This study aimed to describe the characteristics of attempted suicide patients admitted in Jigme Dorji Wangchuck National Referral Hospital from January 2014 to September 2018.
Methods: This descriptive record review analyzed 72 clinical records of attempted suicide patients. The characteristics of attempted suicides are described using detailed illness history of patients who were admitted in the psychiatric and medical wards.
Results: The result showed a higher rate of attempted suicide in females (56.9 %) and highest in the age range between 21 and 30 years. The percentage of patients from the western region of the country was higher (48.6%). The median duration of hospital stay was 5 days (range 1-74). There was a slightly higher number of attempted suicide admissions in the cold season. Pre-existing mental health disorders, mostly depressive disorder, was the major underlying cause of attempted suicide (55.5%). The predominant method used for attempted suicide was self-poisoning on medication (76.3%) with the common medicine being Paracetamol.
Conclusions: To prevent attempted suicide and eventual suicide, there is a need to strengthen early detection of depressive illnesses and regulate the accessibility of over-the-counter drugs like Paracetamol
Clinical profile of pathological Jaundice among neonates admitted in the National Referral Hospital, Bhutan
Get PDFIntroduction: Neonatal jaundice is a common condition especially in the first week of life. There are various maternal and neonatal clinical characteristics that have been associated with pathological jaundice.
Objectives: To describe clinical profile of pathological jaundice and to estimate its prevalence among newborns admitted at the National Referral Hospital.
Methods: A cross-sectional descriptive study design was used to study pathological jaundice cases admitted at the Gyaltsuen Jetsun Pema Neonatal Intensive Care Unit (NICU) of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) from 7th November 2018 till 6th November 2019. Data was collected using a predesigned case proforma, entered and analyzed in Epidata after obtaining ethical clearance from the Research Ethics Board of Health (REBH), Bhutan.
Results: Facility based prevalence rate of pathological neonatal jaundice was found to be 63.66% in our setting. The median age on presentation was 4 days. Blood group ABO incompatibility and neonates less than one week of age were found to be most common neonatal profile in this study. Significant association was found between primiparous mothers and excessive weight loss.
Conclusion: The prevalence of pathological jaundice was high in our setting. ABO incompatibility, neonates less than one week of age, primigravida mothers with feeding issues should be closely followed or screened for pathological jaundice especially during the first one week of life.
Keywords: Pathological jaundice, Prevalence, ABO incompatibility, feeding issues, excessive weight los
Situation of PMTCT in Bhutan, 14 Years’ Experience
Get PDFIntroduction: Prevention of mother-to-child transmission activities form important part of HIV/AIDS prevention program of any community or country.
Methods: Information from the PMTCT Programme from the Ministry of Health and other published literature on HIV in Bhutan were reviewed.
Results: The first case of mother to child transmission was reported in Bhutan in 2001. However, the retrospective study shows that one of the earliest mothers-to- child transmissions could have taken place back in 1997. Strategies for the prevention of mother-to-child transmission (PMTCT) of HIV in Bhutan have endured substantial advancement based on global scientific evidence. It is a concern as there is a slow rise in the number of HIV cases. The main modeof transmission is unsafe heterosexual practice in Bhutan. Before the planned PMTCT program, 3 children were infected. After launch of proper PMTCT program, we had all the components of effective strategies in PMCT program which have evolved with better ones with time. Due to this, MTCT was 3.2%. With undetected HIV infections, 32 children were born outside of the program and actual national MTCT rate is 5.5%.
Conclusion: There is increasing number of people every year with new HIV infections. In addition, our detection gap is 45% with about 602 undiagnosed in the community. Every effort should be put forward to upscale the PMTCT program for Bhutan to eliminate Mother-to-Child transmission (MTCT) of HIV by 2020 and beyond
Ocular sarcoidosis: a case report
Get PDFIntroduction: Sarcoidosis is a chronic granulomatous disorder which affects almost all parts of the body. It is usually idiopathic. Ocular involvement is noted in 25%–60% of patients with systemic sarcoidosis. It is very essential to rule out ocular tuberculosis as both can have similar presentations.
Case report: A 26 year old patient presented with blurring of vision in left eye for nine months at Mongar regional referral hospital. Previously he was treated with topical steroids and cycloplegics for anterior uveitis. There were no systemic symptoms like dry cough, fever, chest pain and loss of weight. He had anterior chamber inflammation with iris nodule, vitritis and disc edema in left eye.The right eye had minimal anterior chamber reaction with only subtle iris nodule. Posterior segment examination was normal in right eye. He underwent blood investigations, chest X ray and contrast enhanced computed tomography of chest(CECT). The blood reports were normal. The chest X ray showed radiopaque lesions at both hilar region and multiple tiny radiopaque lesions in both lung fields.CECT chest showed significant paratracheal lymph nodes.Lymph node biopsy was not attempted due to extreme location. Based on clinical presentations and investigation findings a diagnosis of Presumed ocular sarcoidosis was made by using the criteria based on Revised International Workshop on Ocular Sarcoidosis.The patient was treated effectively with oral steroids for six months. Currently he is on low maintenance dose of oral steroids.
Conclusions: Ocular sarcoidosis is a potentially blinding condition if not treated on time. There should be high suspicion of ocular sarcoidosis if patient presents with bilateral granulomatous anterior uveitis with hilar lymphadenopathy.However it is crucial to exclude ocular tuberculosis as both are mimickers of chronic granulomatous uveitis