Browsing by Author "Marahatta, SB"
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Publication Community based medical education: Prospects and challenges(Kathmandu University, 2009) Marahatta, SBNAPublication Comparative study of community medicine practice in MBBS curriculum of health institutions of Nepal(Kathmandu University, 2009) Marahatta, SB; Sinha, NP; Dixit, HAbstract Background: A revolution in health care is occurring as a result of changes in the practice of medicine and in society. Medical education needs to adapt to society's changing attitudes. Presently medical education has been criticised for its orientation and insensitivity to people’s need. MBBS curriculum of medical institutions of Nepal has been focusing on community-based approaches and still it’s guided by same notion. The question put forward is has it been appropriate to nurture the present health need and aspiration of people. Objective: The objective of the present study is to review the existing Community Based Medical Education in Health Institutions of Nepal to strengthen the components of community care. Materials and methods: Qualitative study was done by reviewing the curriculum and existing community medicine courses in MBBS curriculum of Kathmandu University Medical School, Institute of Medicine/Tribhuvan University and BP Koirala Institute of Health Sciences. Result: The curriculum of all the health institutions have addressed significantly on community medicine practice. As per Institute of Medicine, the community medicine practice is achieved through community based learning experiences like community diagnosis, concurrent field with families of sick members and district health systems management field. In BP Koirala Institute of Health Sciences community medicine practice is undertaken through exposure to community diagnosis program, health care delivery system, family health exercise, applied epidemiology and educational research methodology, management skills for health services and Community Oriented Compulsory Residential Rotatory Internship Program (COCRRIP). In KUSMS, community medicine module is carried out as- community diagnosis program, community health intervention project, school health project, occupational health project, health delivery system functioning, family health care activities and Compulsory Residential Rotatory Internship Program in outreach clinics. In the practice the practical aspects are largely unstructured that waste too much time in non-educational activities and rely on learning and doing. Meanwhile, expectation of the community is increasing and the challenge of nurturing their demands has come in forefront. Community has perceived that the medical schools are concentrating on fulfilling the demand of their curriculum rather directing on their health care need. Conclusion: Health institutions need to be accountable to take the responsibility of strengthening the health status of the community of their catchments areas. The practice of community medicine need to be done in an innovative way and these schools should execute continual intervention activities and complement other institutions working in their areas. Key words: Community Medicine, curriculum, BPKIHS, IOM, KUPublication Comparative study of community medicine practice in MBBS curriculum of health institutions of Nepal(Kathmandu University, 2009) Marahatta, SB; Sinha, NP; Dixit, H; Shrestha, IB; Pokharel, PKAbstract Background: A revolution in health care is occurring as a result of changes in the practice of medicine and in society. Medical education, if it is to keep up with the times, needs to adapt to society's changing attitudes. Presently medical education has been criticised for its orientation and insensitivity to people’s need. The MBBS curriculum of medical institutions of Nepal has been focusing on community-based approaches and is still guided by the same notion. The question put forward is whether it has been appropriate to nurture the present health needs and aspiration of people. Objective: The objective of the present study is to review the existing community based medical education in health institutions of Nepal to strengthen the components of community care. Materials and methods: Qualitative study was done by reviewing the curricula and existing community medicine courses/activities in MBBS curriculum of Institute of Medicine (IoM)/Tribhuvan University, BP Koirala Institute of Health Sciences (BPKHIS) and Kathmandu University School of Medical Sciences (KUSMS). Findings and Discussion: The curriculum of all the health institutions have addressed significantly on community medicine practice. As per Institute of Medicine, the community medicine practice is achieved through community based learning experiences like community diagnosis, concurrent field with families of sick members and district health system management practice. In BP Koirala Institute of Health Sciences, community medicine practice is undertaken through exposure to community diagnosis program, health care delivery system, family health exercise, applied epidemiology and educational research methodology, management skills for health services and Community Oriented Compulsory Residential Rotatory Internship Program (COCRRIP). In KUSMS, community medicine module is carried out as- community diagnosis program, community health intervention project, school health project, occupational health project, health delivery system functioning, family health care activities and Compulsory Residential Rotatory Internship Program in outreach clinics. In the practice the practical aspects are largely unstructured that waste too much time in non-educational activities and rely on learning and doing. Meanwhile, expectation of the community is increasing and the challenge of nurturing their demands has come in forefront. Community has perceived that the medical schools are concentrating on fulfilling the demand of their curriculum rather directing on their health care need. Conclusion: Health institutions need to be accountable to take the responsibility of strengthening the health status of the community of their catchments areas. The practice of community medicine need to be done in an innovative way and these schools should execute continual intervention activities and complement other institutions working in their areas. Key words: Community medicine, curriculum, field practicePublication Effect of preloading on haemodynamic of the patient undergoing surgery under spinal anaesthesia(Kathmandu University, 2010) Singh, J; Ranjit, S; Shrestha, S; Sharma, R; Marahatta, SBAbstract Background: Hypotension and bradycardia after conduction of spinal anaesthesia are common side effects because of sympathetic blockade. Efforts to prevent these complications have been attempted like preloading with crystalloids, colloids or use of vasopressors. The role of volume preloading to prevent haemodynamic changes associated with spinal anaesthesia has been recently questioned. Objective: The objective of the study was to investigate the effects of volume preload on changes of patient’s hemodynamic. Materials and methods: A Quasi- experimental design was used to conduct the study. Taking written informed consent, 40 patients of age group 18-45 years and ASA grade I and II undergoing surgery under spinal anaesthesia in operation theatre of Dhulikhel Hospital were selected as the sample of the study and allocated randomly to 2 groups. Group I did not receive volume preload and Group II received preload of 1000 ml of Ringer’s lactate solution within 30 minutes immediately before giving the spinal anaesthesia. An observational checklist was used to collect demographic, intra- operative and post-operative records of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR). Results: The findings revealed that the haemodynamic changes occurred in all patients. The decrease in SBP, MBP and DBP from baseline was statistically significant at all points of time (p=0.000). The decrease in HR from baseline was not statistically significant at all points of time (p>0.05). The overall incidence of hypotension was 50%, among which 9 (45%) were from without preload group and 11 (55%) were from with preload group. The incidence of hypotension was similar in groups, sexes and surgical conditions (General Surgery, Gynae/Obs and Orthopaedics). There were no signifi cant differences in haemodynamic changes among groups. Conclusion: On the basis of findings, it is concluded that volume preloading had no effect on the incidence of hypotension and bradycardia after spinal anaesthesia. Key words: Preload, Haemodynamics, Spinal Anaesthesia, CrystalloidPublication katG (SER 315 THR) Gene Mutation in Isoniazid Resistant Mycobacterium tuberculosis(Kathmandu University, 2011) Marahatta, SB; Gautam, S; Dhital, S; Pote, N; Jha, AK; Mahato, R; Mishra, S; Poudel, BH; Ramasoota, P; Kaewkungwal, J; Singhasivanon, PABSTRACT Background Isoniazid (INH) together with Rifampicin (RFP) forms the cornerstone of a short chemotherapy course for tuberculosis (TB) treatment. Mutation at codon 315 of katG gene is most prevalent in isoniazid resistant Mycobacterium tuberculosis (MTB) and is high in area with high TB incidence. Polymerase Chain Reaction Restriction Fragment Length Polymorphism (PCR-RFLP) has been found to be a reliable and effective tool for the identification of the specific gene alteration. Objective The objective of this study was to screen Ser315Thr mutation of KatG gene of INH resistant MTB strain by PCR-RFLP technique. Methods Altogether 37 INHr MTB isolates obtained from German Nepal Tuberculosis Project (GENETUP) Kathmandu Nepal was included in the study. Deoxyribonucleic Acid (DNA) extraction was performed according to protocol of SORPOCLEAN™ from the culture isolates. Amplification of the fragment with katG codon 315 was performed in a Biometra Thermocycler using primers. The amplified fragment was cleaved with MspI. The restriction fragments obtained were electrophoresed in a 2% agarose gel and were visualized using transilluminator. Results The katG Ser315Thr mutation was observed in 23 (62.2%) out of 37 INH resistant isolates. The drug susceptibility profile of INHr MTB isolates showed all isolates to be resistant to INH and RFP whereas 26 and 27 MTB isolates were resistant to Ethambutol (EMB) and Streptomycin (S) respectively. Seventeen (17) patients were harbouring katG gene mutated strain among Ethambutol and Streptomycin resistant cases. Conclusion The study identified high prevalence of Ser315Thr mutation in katG. The isolates harbouring this mutation were also simultaneously resistant to RFP. Ser315Th could be a potential genetic marker for predicting MDR-TB. KEY WORDS Isoniazid resistant MTB, katG gene, Mycobacterium tuberculosis, PCR-RFLP, mutation.Publication Medical education and training in Nepal: SWOT analysis(Kathmandu University, 2008) Dixit, H; Marahatta, SBAbstract Objective: To analyse the impact of the medical colleges that have been set up within the last two decades by production of the doctors and the effect on the health of the people Materials and methods: SWOT (strength, weakness, opportunities and threats) analysis of medical education in Nepal has been done by reviewing medical manpower produced by the different institutions in the undergraduate and postgraduate (PG) categories, their registration with the Nepal Medical Council in terms of the existing health scenario of the country Results: Shows severe shortage of basic sciences teachers. In the clinical areas ophthalmic manpower and services provided are exemplary. There are shortages and shortcomings in all areas if standard health care is to be provided to the Nepalese. There is a long way to go to provide the expected educational and medical services to foreigners prepared to pay more to avail of this in Nepal. Key words: HRH, undergraduate, PG, basic sciences, clinical, medical tourismPublication Multi-drug resistant tuberculosis burden and risk factors: An update(Kathmandu University, 2010) Marahatta, SBAbstract Multi-drug resistant (MDR) tuberculosis is defined as disease caused by Mycobacterium tuberculosis with resistance to at least two anti-tubercular drugs Isoniazid and Rifampicin. Recent surveillance data have revealed that prevalence of the drug resistant tuberculosis has risen to the highest rate ever recorded in the history. Drug resistant tuberculosis generally arises through the selection of mutated strains by inadequate therapy. The most powerful predictor of the presence of MDR-TB is a history of treatment of TB. Shortage of drugs has been one of the most common reasons for the inadequacy of the initial anti-TB regimen, especially in resource poor settings. Other major issues significantly contributing to the higher complexity of the treatment of MDR-TB is the increased cost of treatment. Other factors also play important role in the development of MDR-TB such as poor administrative control on purchase and distribution of the drugs with no proper mechanism on quality control and bioavailability tests. Tuberculosis control program implemented in past has also partially contributed to the development of drug resistance due to poor follow up and infrastructure. The association known for centuries between TB and poverty also applies to MDR-TB, a rather significant inverse association with MDR-TB. Various treatment strategies have been employed, including the use of standardised treatment regimens based upon representative local susceptibility patterns, empirical treatment based upon previous treatment history and local Drug Susceptibility Test (DST) patterns, and individualised treatment designed on the basis of individual DST results. Treatment outcomes among MDR-TB cases have varied widely; a recent survey of five Green Line Committee (GLC) approved sites in resource-limited countries found treatment success rates of 70%. Treatment continues to be limited in the resource poor countries where the demand is high. The ultimate strategy to control multidrug resistant tuberculosis is one that implements comprehensive approach incorporating treatment of multidrug-resistant tuberculosis based upon principles closely related to those of its general DOTS strategy for TB control: sustained political commitment; a rational case-finding strategy including accurate, timely diagnosis through quality assured culture and DST; appropriate treatment strategies that use second-line drugs under proper case management conditions; uninterrupted supply of quality-assured antituberculosis drugs; standardised recording and reporting system. Key words: DOTS Plus, Multi drug resistant (MDR) tuberculosis burden, risk factorsPublication Pattern of Organophosphorous Poisoning: A Retrospective Community Based Study(Kathmandu University, 2011) Chataut, J; Adhikari, RK; Sinha, NP; Marahatta, SBABSTRACT Background Pesticide poisoning is very common in Nepal. Hospital based studies from various parts of Nepal have shown that poisoning with organophosphorus compounds is the most common type of poisoning. Current study is undertaken to see the pattern of organophosphorus poisoning and to identify the common risk factors among the cases. If the risk factors are modifiable, attempts in addressing the risk factors and decreasing the likelihood of poisoning will certainly be fruitful in reducing the morbidity and mortality associated with organophosphorus poisoning. Objectives To assess the risk factors of organophosphorus poisoning which is major public health problem in Nepal. Methods A community based retrospective study of 75 cases of organophosphate poisoning who were brought to the emergency department of Dhulikhel hospital over the period of 3 years. Basic information was collected from hospital records and home visits were made to study the risk factors. Data were collected through interviews of the study population and their family members using a pre-designed questionnaire. Results In this study 75 cases and their families were interviewed of which there were 59% males and 42% females (M/F ratio of 1:1.4). The majority (40%) of the poisoning cases were in the age group 25-34 years. Lower literacy level showed positive association with the incidence of poisoning. Occupation wise vast majority (80%) of the cases were engaged in agricultural work. Suicidal attempts by ingesting organophosphate compounds were high in farmers and females. Conclusion In this study, majority of the poisoning were attempts of intentional self harm. Agriculture workers and females are high risk groups and may be associated with the fact that they have easy access to the poison. Interventions directed towards health education, counseling, and enforcement of laws restricting the availability and use of harmful pesticides may help in reducing such events in future. KEY WORDS Organophosphorus, Pesticides.Publication Poisoning cases attending emergency department in Dhulikhel Hospital- Kathmandu University Teaching Hospital(Kathmandu University, 2009) Marahatta, SB; Singh, J; Shrestha, R; Koju, RAbstract Objective: The objective of the present study is to evaluate the characteristics of acute poisoning cases admitted to emergency department over a one year period. The demographic, clinical and psycho-social aspects of the patients were analysed. Materials and methods: A hospital based study was carried out in the emergency department, Kathmandu University Teaching Hospital/ Dhulikhel Hospital, Dhulikhel analysing the data of the poisoning cases attended for one year. The study was carried out amongst inpatients attending emergency with acute poisoning. Results: A total of 54 patients were admitted to the emergency department with acute poisoning. The female-to-male ratio was 1.34:1. Most poisoning occurred in the age group of above 40 years. The mean ages of female and male were 29.87 ±14.85 years and 35.54±15.02 years respectively. By occupation 40.38% of the cases were farmers. Only 35.29% of the patients were illiterate. 79.24% of the cases intentionally consume the poison. Organ phosphorus poisoning (OP) was the most common poisoning. Oral route was the commonest route of poisoning accounting 98.1%. Sixty-six percentage (66.66%) of the cases had the poison stored in their home with 27.7% bought from the market once needed. Among the cases of acute poisoning 5.55% were fatal. Conclusion: The following conclusions were reached: (1) females were at greater risk for poisoning than males, (2) self-poisoning cases constituted the majority of all poisonings, and (3) the main agents of self-poisoning were OP poisoning. Key words: poisoning, insecticides, organophosphorusPublication Revitalizing primary health care - another utopian goal?(Kathmandu University, 2010) Marahatta, SBABSTRACT The quest for greater efficiency, fairness and responsiveness to the expectation of the people that system serve have brought about three generations of health system reforms in the twentieth century. The first generation saw the founding of national health care systems and extension to middle income nations of social insurance systems in the 1940s and 1950s. By the late 1960s the rising costs of hospital based care, its usage by better off, inaccessibility by the poor and rural population of even the most basic services heralded second generation reforms promoting primary health care as a means of achieving the affordable universal coverage. It included the best public health strategy that is prevention and the highest ethical principle of public health that is equity. It was expected the best system for reaching households with essential and affordable care, and the best route towards universal coverage. The primary health care approach though adopted universally did not materialize its notion of translating ethos of Health for All by 2000. Overall, primary health care movement by the end of 20th century became lifeless. Since the Declaration of Alma-Ata, fundamental changes have occurred affecting health service delivery, such as economic development and financing approaches, globalization of trade and knowledge, and the shift to privatization. This is the time to develop a new vision, taking into consideration the many changes affecting global health and the strategic developments in health of recent years. With this recognition, the third generation of reforms now underway in many countries is driven by the idea of responding more to demand, assuring access for the poor and emphasizing financing rather than just provision within the public sector. The key concern is: how to translate ethos of revitalizing in the reality. Otherwise the revitalizing concept will turn into utopian goal so like HFA by 2000 strategy. Key words health system, primary health care, reformPublication Risk factors of Multidrug Resistant Tuberculosis in central Nepal: A pilot study(Kathmandu University, 2010) Marahatta, SB; Kaewkungwal, J; Ramasoota, P; Singhasivanon, PABSTRACT Introduction Tuberculosis is the most widespread infectious disease in Nepal and poses a serious threat to the health and development of the country. Incidences of drug resistant tuberculosis in Nepal are increasing and this tuberculosisis a major threat to successfully controlling tuberculosis . Objective The general objective of the study was to assess the risk factors of multi-drug resistant tuberculosis among the patients attending the National Tuberculosis Centre, Bhaktpur Nepal. Methods An observational study/ case-control study with a Atotal number of 55 multi-drug resistant tuberculosis cases and 55 controls. The study was conducted among the patient attending in the National Tuberculosis Centre , Bhaktpur Nepal for six months, between May–October 2010. sImulti-drug resistant tuberculosis wasThe collected data was analysed in SPSS 11.5 version. The association between categorical variables were analysed by chi-square tests, OR and their 95% CI were measured. Results The total number of patients used for the study was 110, of which among them 55 were cases and 55 were controls . Our study revealed that there were significant associations between history of prior TB MDR-TB OR =2.799 (95 % CI 1.159 to 6.667) (p=0.020); smoking habit OR =2.350 and (95%CI 1.071 to 5.159) (p=0.032); social stigma social stigma OR 2.655 (95%CI r 1.071 to 5.159) (p=0.013); knowledge on MDR-TB OR =9.643 (95% CI 3.339 to 27.846) (p < 0.001)and knowledge on DOTS Plus OR=16.714 (95% CI is ranging from 4.656 to 60.008) (p< 0.001). However, there was no association found between alcohol drinking habits and ventilation in the room. Conclusion Our study revealed that there were significant associations between history of prior tuberculosis, smoking habit social stigma social stigma, knowledge on multi- drug resistant tuberculosis and knowledge on DOTS Plus with multi-drug resistant tuberculosis However there was no association between alcohol drinking habit and ventilation in room with multi-drug resistant tuberculosis. Key Words directly observed treatment short course-plus, multidrug-resistant tuberculosis, risk factorsPublication Students’ perception regarding medical education in Nepal(Kathmandu University, 2008) Marahatta, SB; Dixit, HAbstract Background: Medical schools and medical education look different as we advance into the 21st century. Nepal has seen a dramatic increase in the number of medical schools/colleges in the last decade. Most schools practice traditional teaching method while others are implementing problem based learning (PBL). It is important to explore the current advances and practices in medical education to meet the needs of the health services of the country. Objective: The objective of the present study is to explore the students’ perception regarding present status of medical education in Nepal and provide recommendations to address future needs. Materials and methods: The study design of the present research was descriptive and exploratory type. Structured Questionnaire was used to assess the students’ perception relating to different aspects of medical education. A total of 24 students studying in the final year of MBBS from six medical colleges were selected randomly. Results: The traditional teaching/learning methodologies have been prevailing in the medical schools of the country. PBL suits many objectives of self directed learning (SDL) because students learn to reason and deduce facts and figures rather than rote learning. For the success of PBL and SDL students require learning resources and as per our findings although 71% of the students were satisfied with library facilities 54% were dissatisfied with computer resources. Community based approaches have been focused in the curriculum of all the medical schools of Nepal. About public health and community medicine teaching 86% of the students reported to be appropriate, of which 18% actually thought it was excessive. About the teaching of evidence based medicine (EBM), 50% students felt it was adequate and other half thought it was inadequate. Majority of the students i.e. 62% of the students also felt that the care of ambulatory patients was as well covered as the care of hospitalized patients. The areas of clinical practice which the students felt were inadequate included: nutrition (71%), geriatrics (70%), end of life care (71%), palliative care (67%), long term health care (70%), continuity of care (70%), ethical decision making (56%) and patient follow up (50%). In spite of completing their training, 25% felt they were not confident that they had acquired the clinical skills required to begin the residency program. As much as 60% felt they did not receive information about specialities and alternative medical careers. About 75% of the students had the feeling that medical profession will not be financially rewarding; 80% felt it would not be as respectable; 99% felt it would be more scientifically challenging. Conclusion: The medical education of Nepal is still guided by the notion of the traditional approaches. The teaching methods should come up as per the advancement in contemporary medical education. The training needs to be more structured and focused in practical reality than only feeding students with theoretical knowledge. Key words: PBL, SDL, EBM