bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of multiple sexual partnerships among women and men in two urban townships in Bhutan
Authors: Dorji Gampo , Umeh Chukwuemeka , Ramesh B.M. , Isac Shajy , Lorway Robert , Blanchard James
Published: December 2020

Introduction: Multiple sexual partnering is a known predictor for risk of STI and HIV transmission. This study explored the multiple sexual partnering and its predictors among people who visited public social venues (bars, restaurants, hotels, lodges, cafes, karaokes and discos) in Bhutan’s two largest townships of Thimphu and Phuntsholing.
Methods: We interviewed 755 sexually active venue patrons from 102 randomly selected venues (56 in Thimphu, 46 in Phuntsholing) from a list of all venues identified as having sex workers or patrons seeking sexual partners. Both bivariate and multivariate analyses were carried out to characterize the predictors of multiple sexual partnering among 755 respondents who had previously had sex.
Results: Of the 755 patrons, 46.09% had one sexual partner while the remaining 54.91% had multiple sex partners (greater than or equal to 2 sexual partners) in the 12 months preceding the study. Overall, 6.23% of respondents had received payment from someone at least once for sex; 34.61% of male respondents had paid someone at least once for sex. Nearly all patrons (97.72%) had heard about HIV/ AIDS. About one quarter (24.20%) felt that they were at risk of being infected with HIV, while 37.28% had taken an HIV test in the 12 months preceding the study. In multivariate analysis, males had higher odds of multiple sexual partners compared to females (OR =3.19, 95% CI 1.90-5.20). The odds of having multiple sexual partners was 2.24 (95% CI 1.30-3.90) times higher in those never married compared to those who were married/divorced or separated; multiple partnering increased with increasing age (OR = 1.07 per year, 95% CI 1.02-1.13). Between the townships of Phuentsholing and Thimphu, the odds of multiple sexual partnering did not vary.
Conclusions: Venue patrons had a high prevalence of multiple sexual partnering and have the potential for creating sexual networks that could propagate wider transmission of infection, including to their monogamous partner. Targeting HIV prevention program to these groups of people in urban locations presents an opportunity to make a great impact in maintaining Bhutan’s current low HIV epidemic level.
Liver parenchymal transection techniques
Authors: Mangla Vivek , Lalwani Shailendra , Mehrotra Siddharth , Mehta Naimish , Nundy Samiran
Published: December 2020

While liver surgery has become safer with improvements in peri-operative management, parenchymal resection is the part of the procedure which is associated with major loss of blood and damage to important structures if not performed carefully. The ideal technique for hepatic parenchymal transection should be quick, easy to perform, reduce intra-operative blood loss and transfusion requirement, reduce post-operative bile leakage, and cause minimal damage to the surrounding hepatic parenchyma-- preferably at the lowest cost possible. This paper is a review of commonly used techniques for liver parenchymal transection during liver resections. According to the literature, there is little benefit of using the complicated and expensive devices over the simpler clamp crushing technique. We in our institution, who perform a large number of liver resections and living donor transplants, prefer to use the clamp crushing technique with a bipolar cautery for most resections and cavitron ultrasonic aspirator(CUSA) with a bipolar cautery for removal of part of the liver from a living donor.
Unusual presentation of a burst appendix
Authors: Dargay Sonam
Published: December 2020

A 56 year old woman referred from a district hospital for a liver mass on initial evaluation was found to have perforation of gas-containing hollow viscus. Emergency exploratory laparotomy revealed a burst appendix. She did well post op and was discharged in a healthy state. This case report was done to highlight the importance of proper history taking and clinical examination in order to prevent delay in implementing appropriate treatment.
Retained intraocular metallic foreign body causing retinal detachment
Authors: Rai Bhim Bahadur , Dorji Samten , Zangmo Pema , Tshering Thukten
Published: December 2020

A 60 year old farmer presented on 4th Sept, 2015with progressive diminution of vision in the right eye following trauma while hammering about a month previously. His vision was Hand Movement only in the right eye and 6/6 in left eye. The anterior segment showed normal findings, except mild anterior chamber reaction and an early cataract in the right eye. The left eye was normal except for an early age-related cataract. Fundoscopy revealed retained intra-ocular foreign body (ROOFB, subtotal RD with macula off in right eye. Interestingly, no entry wound was found. A B-scan and CT scan of the brain and orbit confirmed RIOFB and RD. On 9th September 23G PPV was done and RIOFB was removed. Fluid-air exchange, endolaser and silicon oil injection were done to attach the RD. On 6th February 2016 a cataract extraction with intraocular lens implantation and silicon oil removal was performed which improved the patient’s vision to 6/18p.
Incidence and pattern of leukemia in Bhutanese population: a retrospective analysis of eight years (January 2008 to December 2015)
Authors: Dorji Kuenzang , Sharma Krishna Prasad , Jamtsho Rinzin , Samal Puja Devi , Wangchuk Dorji , Rai Pratap
Published: December 2020

Introduction: The burden of haematological malignancies in developing countries is on the rise. This burden may be further aggravated in Bhutan due to the aging population and rapid modernization of the nation. Despite this, there is a paucity of information about the incidence and pattern of leukemia in the Bhutanese population. In this retrospective study, we aim to investigate the incidence and pattern of leukemia in Bhutan using a database of leukemia diagnosed at Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan from January 2008 to December 2015.

Methods: The diagnoses and classification of leukemias were based on the morphology of blood cells on peripheral blood and bone marrow smears. The data was analyzed with descriptive statistics. The age-standardized incidence rate per 100,000 populations and its 95% confidence interval was calculated to assess the statistical significance.

Results: In total 118 patients were diagnosed with leukemia over the period of eight years. Leukemia was found to be more frequent in male (51.69%) compared to female (48.30%) with a male to female ratio of 1.1:1. Acute leukemia accounted for 66.95% of all leukemia case diagnosed, whereas chronic leukemia accounted for only 33.05% of the cases. The average, annual, age-standardized incidence rate of leukemia per 100,000 population was 2.30 (95% CI: 1.87-2.73).

Conclusions: The incidence and pattern of leukemia in the Bhutanese population is similar to other published literature. Leukemia is not uncommon in the Bhutanese population, thus additional studies on risk factors for leukemia in the Bhutanese population is necessary.
HBeAg negative chronic hepatitis B in South Asia
Authors: Shrestha Ananta , Lama Thupten Kelsang , KC Sudhamshu , Sharma Dilip , Khadka Sandip , Dhakal Guru Prasad , Gupta Birendra Prasad
Published: December 2020

Chronic Hepatitis B (CHB) infection has an intermediate prevalence rate in South Asian countries, except for Nepal and Sri Lanka where it has a low rate. HBeAg negative CHB infection has been found to be more pronounced in this part of the world. As described previously, CHB infection has two phases with HBeAg positive and HBeAg negative based on ALT, DNA & biopsy. The latter was previously described to have a benign course. The later guidelines have distinguished HBeAg negative status into two categories with an inactive phase and a reactivation one. In this review article we have highlighted HBeAg Negative status burden in South Asian countries and shown that HBeAg negative CHB infection may not be as benign as previously thought. Furthermore , mutations at precore and basal core promoter region may contribute to disease severity in HBeAg negative CHB infection.
Strangulation - a rare complication of inguinal hernia in a neonate
Authors: P Singh Aditya , Ramesh Tanger , Vinay Mathur , Arun Gupta
Published: December 2020

Strangulation is a rare complication of incarcerated inguinoscrotal hernia in the neonate and infants. We report a case of a 15-day old male neonate, who presented with strangulated inguinal hernia containing loop of ileum. Resection of the gangrenous part of the ileum was done and end-to-end anastomosis was performed. Strangulated inguinal hernia in neonates is a rare occurrence.
Catching congenital heart diseases early : the ten- point approach for Bhutan
Authors: Bhandari Purushotam
Published: December 2020

Congenital heart disease is the most common birth defect and is the main reason for out country referral of pediatric patients from Bhutan. Given the limited resources and expertise, detecting congenital heart defects is often delayed, resulting in delayed initiation of treatment and management of associated complications. Congenital heart diseases, if detected early, can be appropriately treated and complications minimized. A ten-point approach consisting of antenatal diagnosis, neonatal pulse oximetry, well child visits, sick child visits, immunization clinics, school health checkups, pediatric echocardiographers, pediatric cardiologists, basic echocardiography skills in pediatric residents and comprehensive birth defect surveillance is suggested, in order to catch congenital heart defects early in life.
Cessation of Betel Quid Chewing: Lessons from the ex-chewers
Authors: Dorji Nidup
Published: December 2020

Introduction: The practice of chewing of betel quid is deep-rooted age-old traditions of most Asian countries including Bhutan. Health is an integral part of happy living and healthcare providers are generally looked up to as role models for healthier living. This paper focuses on the prevalence of ex-betel quid chewers and correlates of successful cessation of betel quid chewing among healthcare professionals in Thimphu, Bhutan.
Methods: Data for this study was collected from six healthcare centres within Thimphu, during June – July 2016, using self-administered questionnaire. 478 questionnaires were handed over to the healthcare professionals, and 391 (82%) were returned. Statistical analysis was performed using statistical package for social science version 21.0.
Results: The prevalence of ex-betel quid chewers was 16.9%. More than half (51.5%) of the ex-chewers discontinuedchewing betel quid because of fear of the ill effects of chewing it. About 29% gave up chewing betel quid because of healthrelated problems. Betel quid chewing was first sourced either with a friend or a parent (59.1%, 24.2% respectively). Number of family members chewing betel quid, smoking and drinking status were significantly associated with quitting of betel quid chewing.
Conclusions: Findings suggest that family and health risk behaviours such as drinking and smoking were significant correlates of quitting betel quid chewing. Hence, effective public health awareness could be targeted to both individual and their family members to enable them to quit betel quid chewing.
Serotypes and antibiotic susceptibility of Streptococcus pneumoniae in the Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan: a preliminary finding
Authors: Tshokey Tshokey , Yangzom Deki , Sharma Ragunath , Tshering Nima
Published: December 2020

Introduction: Streptococcus pneumoniae cause life-threatening infections, mostly affecting children under five years in developing countries. Several countries in South Asia have incorporated a pneumococcal vaccine in their immunization schedule. Bhutan is currently considering the introduction of a vaccine, although no studies in the country to date have characterized the serotypes of S.pneumoniae to gauge the potential vaccine coverage. We, therefore, characterized pneumococcal serotypes isolated from patients in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu.
Methods: Four hospitals attempted to study S.pneumoniae from various clinical specimens from January 2014 to December 2015, although only the JDWNRH was able to isolate pneumococci. Isolates were tested for antibiotic susceptibility and serotyped at a reference laboratory in India.
Results: Thirtyseven isolates were preliminarily identified as S. pneumoniae at the JDWNRH. At the reference laboratory, two isolates could not be revived and 14 were identified as non-pneumococcal streptococci. From the remaining 21 isolates, 15 different serotypes were identified. The Bhutanese serotypes were more comparable to those of India than Bangladesh or Nepal. Current vaccines would  cover 26.7% (Prevnar, 7-valent), 40.0% (Synflorix, 10-valent), and 53.3% (Prevnar, 13-valent and Pneumovax23, 23-valent) of these serotypes. All isolates were sensitive to penicillin, chloramphenicol, and ceftriaxone; 9.5% were resistant to erythromycin and  38.1% to cotrimoxazole.
Conclusions: For the first time, we characterized serotypes of S. pneumoniae in Bhutan. However, the findings need to be interpreted cautiously due to small numbers of isolates from one referral hospital. A larger study is needed to validate the findings and guide selection of an appropriate vaccine.
Sexual Diversity in Bhutan
Authors: Wangdi Sonam , Tshering Ugyen
Published: December 2020

This article attempts to describe sexual diversity among people in Bhutan. We investigate ways in which Bhutan addresses sexual diversity in sex education and the law. We also review existing data to assess health issues affecting sexually diverse populations in Bhutan. Although limited, the available evidence indicates a higher likelihood of committing suicide, abusing substances, and facing barriers to accessing health care services and programs. The review finds the need for more representative researches for understanding sexually diverse people in Bhutan. The paper highlights the need for research with these populations with equal focus in ensuring active participation by the lesbian, gay, bisexual, transgender, inter sex & questioning (LGBTI&Q) community. The judiciary, education, and health system are crucial agencies that can facilitate and create accepting environments for the sexually diverse population in Bhutan.
An unusual pseudoneoplasm: mass-forming tuberculosis infection mimicking rectal carcinoma
Authors: Dhungel Bal M. , Wangdi Tashi D. , Cuba Magalys L. , Pelden Sonam , DePetris Giovanni
Published: December 2020

A rare case of primary rectal tuberculosis presented as a rectal mass, indistinguishable clinically and radiologically from advanced rectal carcinoma . Histology failed at first to identify granulomas, acid fast bacilli, or malignancy, but subsequent biopsies showed multiple epithelioid granulomas with caseating necrosis and Langhans giant cells. Given these findings and the high regional incidence of tuberculosis, presumptive diagnosis was given and anti-tubercular drugs were initiated followed by resolution of the mass and symptoms.
Anemia and risk factors among children 6 months to 59 months old: a hospital-based prospective study
Authors: Chhetri Kalpana , Mynak Mimi L. , Pedon Kuenley
Published: December 2020

Background: Anemia is a major public health problem and the most common nutritional issue in many parts of the world, especially in developing countries. The objective of the study was to determine the prevalence of anemia and factors associated with anemia among children 6 to 59 months old admitted in Pediatric ward of National Referral Hospital, Thimphu.

Methods: A hospital-based descriptive cross-sectional study. All children 6 months to 59 months old admitted in Pediatric ward of National Referral Hospital, Thimphu were included in the study. A total of 353 children were included in the study. Data was analyzed using STATA 12.

Results: The prevalence of anemia was 58.4%. Mild, moderate and severe anemia was 65%, 22.8% and 12.2% respectively. Anemia was more common in children less than 2 years old. The majority of the children had microcytic hypochromic anemia with low serum iron. The risk factors associated with moderate to severe anemia were malnutrition [p-value 0.001, OR 32.1, 95% CI (9.10-118.8)], low education level of caregiver [p value 0.0019, OR 5.10, 95% CI (1.66-15.68), monthly family income less than 5000/month [p-value 0.0004, OR 4.6 , 95% CI (1.89-11.54)] and chronic illness [p value 0.030, OR 2.43, 95% CI (1.08-5.47)].

Conclusion: This study found a high prevalence of anemia in under-5 children, with iron deficiency accounting for the majority of the cases. Children under 2 years were affected more.
Maternal Hypovitaminosis D as a Cause of neonatal seizure
Authors: Nishizawa Yoriko , Sonam Sonam , Mize Carolyn , Vesel Tamara
Published: December 2020

Maternal hypovitaminosis D has many implications for both mother and newborn. The prevalence of vitamin D deficiency in Bhutan is not yet known. The case presented below represents a severe symptomatic presentation of vitamin D deficiency in a neonate due to maternal vitamin D deficiency. It highlights the need for raised suspicion of vitamin D deficiency as a cause of late-onset neonatal seizures, epidemiologic studies, and potential vitamin supplementation for pregnant women, as well as the need for vitamin D-only liquid supplements in pharmacies in Bhutan.
South-East Asian Children’s Environmental Health: networking to improve health outcomes
Authors: Sly Peter D. , Arphacharus Neeranuch , Aung Wai Phyo , Coleman Gwen W. , Gamble Mary V , Graziano Joseph , Hai Doan Ngoc , Henshaw Dennis L. , Navasumrit Panida , Ravichandran Beerappa , Ruchirawat Mathuros , Suk William A. , Tshering Ugyen
Published: December 2020

Major progress has been made in improving the health of vulnerable populations, especially children and pregnant women in low and middle income countries after the launch of the Millennium Development Goals in 2000. While fewer children die, many now face the prospect of years lived with disability (YLD) from chronic non-communicable diseases (NCDs). The estimate for the total YLD for children under-5 years of age for South-East Asia was 2,780,104 in 2015. To improve the health outcomes for children globally, the World Health Organization’s Department of Public Health, Environment and Social Determinants of Health has designated a number of collaborating centres, each with differing areas of expertise. The collaborating centres have formed a network to address children’s environmental health (CEH) issues at the local, national, regional and international levels. However, many gaps in knowledge exist. To further this aim, the 1st Regional Workshop of South-East Asian Children’s Environmental Health was held at the Chulabhorn Research Institute, Bangkok, on 18th November 2016. The workshop was attended by three of WHO Collaborating Centres with representatives of five regional countries of Bhutan, India, Myanmar, Thailand and Vietnam. Workshops such as this one are designed to bring together researchers and policy makers from regionals areas to identify and close gaps in knowledge.
Breastfeeding problems: an analysis of secondary data from Lactation Management Unit at the national referral hospital in Bhutan from 2014 to 2016
Authors: Zangmo Kencho , Wangmo Diki , Tobgay Tashi , Gurung Mongal S.
Published: December 2020

Introduction: Breastfeeding is one of the most natural and best forms of preventive medicine for the newborns. Lack of optimal breastfeeding contributes to about over million preventable child deaths every year. Despite numerous benefits of breastfeeding and continuous efforts to improve breastfeeding practices, breastfeeding rates are far from optimal. Problems faced by lactating mothers while breastfeeding are main reason leading to non-exclusive breastfeeding or early termination of breastfeeding. This descriptive study is aimed at examining breastfeeding problems among women visiting Lactation Management Unit [LMU] at Bhutan’s national referral hospital in Thimphu.

Methods: Data of all 2751 women-infant pair visiting Lactation management unit of Jigme Dorji Wangchuck National Referral Hospital with breastfeeding problems were double entered into Epi Data (version 3.1). Using STATA, descriptive statistical analyses were carried to examine common breastfeeding problems among the lactating mothers. Exclusive breastfeeding rates were also examined among the group.

Results: The commonest types of breastfeeding problem were nipple sore (60.8%), incorrect breastfeeding techniques (12.9%), and nipple problems (8.2%). Teenage, first timers, caesarean delivery, preterm infants, underweight infants, and mothers with full time paid job were more likely to suffer from breastfeeding problems.

Conclusion: Breastfeeding interventions for timely correction of breastfeeding techniques early in postnatal units could warrant prevention of up to 73.7% breastfeeding problems and thus, promoting exclusive breastfeeding and preventing early termination of breastfeeding.
Positioning Nurses in Primary Health Care in Bhutan
Authors: Wangmo Diki , Windosr Carol , Clark Michele
Published: December 2020

Introduction: Nursing in Bhutan had its beginning in the early 1960s, approximately 20 years prior to the Alma Ata Conference. From basic nursing care and housekeeping roles, Bhutanese nurses have now occupied central place in nursing service, administration and management and education. Nursing education has progressed from certificate level in the 1960s to bachelor, master and PhD levels in 2014. Although nurses have been closely associated with Primary Health Care development in Bhutan, apart from the role of the Auxiliary Nurse Midwives, nurses have rarely been explicitly associated with this area of practice. Therefore, the objective of this study was to find out the role of Bhutanese Nurses in PHC.

Methods: qualitative case study method was used to carry out focus group and in-depth interviews with 66 respondents that included policy makers, planners, educators, regulators and implementers. Data were analyzed through manifest and latent content analysis.

Results: The centrality of the nursing role in the area of PHC has not been realized. Discharge of the PHC role was identified more in terms of the place of work and by title or designation of the nurses. Primary Health Care momentum appeared to have slowed down and nurses differed in their understanding of PHC concept.

Conclusion: Although Nursing in Bhutan has made much progress, the uneven development of the nurses’ role in PHC in Bhutan and globally suggests a need to identify and implement strategies such as standardizing, role profiling, curricula review and leadership improvement to ensure progress in this area.
Relying on Widal test alone could lead to over diagnosis of typhoid fever: Findings from a records review of febrile patients at Damphu Hospital, Bhutan, 2011-2012
Authors: Nepal Tej Nath , Dorji Tshering , Tsheten Tsheten , Tenzin Karma , Pelzom Dorji , Gurung Mongal S. , Rinchen Namgay , Wangchuk Sonam
Published: December 2020

Introduction: The Widal test is widely used in hospitals in Bhutan for diagnosis of typhoid fever. The right test with high sensitivity and specificity supplements clinical judgement and contributes to correct diagnosis of disease. This study focuses on the contribution of the Widal test in the diagnosis of typhoid fever.

Methods: Data was collected from records of patients who presented to Damphu hospital from March 2011 to June 2012 with clinical suspicion of typhoid fever. Blood samples were collected from patients and tested at Damphu Hospital, Tsirang and the Royal Centre for Disease Control, Thimphu. Seventy records were used for the study.

Results: There was no growth of Salmonella typhi on blood cultures from patients who had tested positive in the Widal test. There were 20 (28.57%) samples which tested positive for scrub typhus; among these Widal test was positive in 10 (50%) samples. Thirty four out of 36 (94.44%) patients had duration of illness less than seven days and among them 26 (74.47%) had positive Widal test results.

Conclusion: None of the samples that tested positive by Widal test gave a definite diagnosis of typhoid fever with blood culture. Clinical judgement may be more challenging because patients with other febrile illnesses like Scrub typhus also have positive Widal test result. We conclude that it is best not to rely on the Widal test alone for the diagnosis of typhoid fever and this test should be replaced by more accurate ones.
To study the effect of Triamcinolone injection for low back pain due to lumbar disc herniation
Authors: Wangchuk Tashi , Wangmo Kunzang P. , Norbu Thinley
Published: December 2020

Introduction: Low back pain is one of the most common complaints in the general population which represents a significant public health problem. Epidural Steroid Injection is being considered as a simple, effective and minimally invasive treatment modality for lumbar disc herniation. However, most studies only find a short-term benefit. In Bhutan, till date, no study has been done in Bhutan on this subject. The objective of our study was to find the effect of epidural steroid injection for low back pain due to lumbar disc herniation.

Methods: An observational one-year-period study completed in Jigme Dorji Wangchuck National Referral Hospital. Symptomatic and positive Magnetic Resonance Imaging patients with lumbar disc herniation were included in our study. Pain scores were collected using Numeric Rating Scale at three different points of study. We also included patients’ age, weight and trauma history as some of the independent variables to study their associations with pain scores. The data obtained were analyzed using the Stata software program. One way repeated measures ANOVA was used to assess the significant difference in pain score.

Results: Out of 100 participants recruited for the study, 91 of them completed demographic data and only 81 patients completed follow-up till 4 weeks post-treatment for demographic analysis and analytical analysis, respectively. There was a significant difference in pain scores in all three different points of study (p <0.01). No significant difference was observed in the pain scores amongst different age groups, gender, occupation and trauma history (p >0.05) at all three points of study.

Conclusion: Our study observed a significant short-term benefit from epidural Triamcinolone injection for symptomatic lumbar disc herniation.
The management of benign biliary strictures
Authors: Bhat Bharath Kumar , Lalwani Shailendra , Mehrotra Siddharth , Mangla Vivek , Yadav Amitabh , Mehta Naimish , Nundy Samiran
Published: December 2020

The most common cause of Benign Biliary Stricture is post cholecystectomy bile duct injury. Following introduction of the laparoscopic cholecystectomy procedure the incidence of bile duct injury and stricture has increased. The studies suggest that the incidence remained stable even after the improved learning curve. The early diagnosis and prompt management is the key in preventing devastating sequelae of this benign condition. The management of post cholecystectomy biliary strictures involves a multidisciplinary approach. Our review aims to describe the present strategy in management of post cholecystectomy biliary strictures.
Barriers to self-injection of insulin among patients attending the diabetes clinics at the three referral hospitals in Bhutan: a cross-sectional study
Authors: Dorji Thinley , Lhamo Pema , Tshering Tshering , Zangmo Lungten , Choden Kencho , Choden Deki , Namgyal Sang
Published: December 2020

Introduction: Insulin, despite its increasing cost, is prescribed to selected cases of diabetes patients with an aim to achieve good glycaemic control. However, many on insulin do not achieve glycaemic control. We, therefore, studied the possible factors that may act as barriers to effective self-injection of insulin among diabetes patients at the three referral hospitals in Bhutan.
Methods: This was a cross-sectional study, conducted from January-June 2017, involving all patients on insulin therapy for more than three months duration. Convenience sampling was used. Respondents’ basic details and self-reported barriers to insulin therapy under various domains were collected using an interviewer-administered questionnaire. Ethics approval was granted by the Research Ethics Board of Health, Bhutan.
Results: There were 207 respondents on insulin therapy. The mean age of the sample was 55 years (±13.8 years) and the mean duration of diabetes was 10.6 years (± 7.8 years). Injection dexterity was an issue in 77 respondents (37.2%) while 37 respondents (17.8%) reported that they would miss their insulin shots if their caregiver were unavailable. Insulin regimens were burdensome and interfered with their daily activities (80; 38.7%) and meal timings (64; 30.9%). Although the majority (179; 86.4%) knew why insulin was indicated for them, 149 (72.0%) found that the healthcare personnel’s demonstration on the use of insulin was inadequate and 50 respondents (24.2%) felt that they did not receive enough information on how to inject insulin.
Conclusions: Barriers to self-injection are common among insulin users and coordinated efforts are needed to overcome them.
Community action to reduce harmful use of alcohol: a pilot study in the remote villages of eastern Bhutan
Authors: Subba Dil K. , Gurung Mongal S. , Wangmo Diki , Dorji Mindu , Tobgay Tashi
Published: December 2020

Introduction: As per the Annual Health Bulletin, 2017, alcohol related liver disease is the leading cause of death in Bhutan. There were 190 deaths due to harmful use of alcohol in 2016 and alcohol liver disease (ALD) incidence was 46 per 10,000 people. Community action to reduce harmful use of alcohol in the communities is one of the strategies being implemented in Bhutan. However, the impact of such community action is not assessed in the country. Therefore, this pilot study was conducted in two gewogs (sub-district) of Trashiyangtse dzongkhag to assess the short-term effects of this community action to reduce alcohol use.

Methods: This pilot study involved one intervention and one control community. The interventions were developed and implemented in consultation with the community by empowering them for monitoring to ensure effectiveness of the intervention. The data were collected pre and post-intervention in both the gewogs through repeated cross-sectional surveys.

Results: The practice of offering tshogchang decreased from about 99% to about 50% after the intervention. Practice of children drinking alcohol decreased by 6.83%. The average monthly spending on alcohol reduced from about Nu. 418 to about Nu. 97, and the amount of grains used for brewing decreased from about 34 Kg to 18 Kg, after the intervention.

Conclusion: This study found that the community action is effective in bringing positive impacts in reducing harmful use of alcohol in community. Therefore, expansion of such community action in other communities in Bhutan with similiar context is strongly recommended..
Incidence and clinicopathological profile of gestational trophoblastic disease in tertiary care centre
Authors: Tamang Tshering , Tshomo Ugyen
Published: December 2020

Introduction: Gestational trophoblastic disease (GTD) arises from abnormal proliferation of placental trophoblastic tissue. The aim of this study was to determine the incidence and clinicopathological profiles with treatment outcome of gestational trophoblastic disease in Jigme Dorji Wangchuck National Referral Hospital, a tertiary hospital in Bhutan.

Method: A prospective and retrospective observational study was conducted over a period of 18 months.

Results: A total of 121 cases of gestational trophoblastic disease were diagnosed with an incidence rate of 19.7 per 1000 deliveries. Majority comprised hydatidiform moles(115);of which, 30 (26.1%) were complete and 85(73.9%) partial moles. The mean gestational age at diagnosis of hydatidiform mole was 9.8± 1.6 weeks and the most common symptom being vaginal bleeding (72.8%). Nine (7.8%) of these progressed to gestational trophoblastic neoplasia and was strongly associated with high pre-evacuation beta-hCG level (> 100,000 mIU/ml) and larger uterine size (> 14 weeks).

Conclusions: This study revealed a high incidence of gestational trophoblastic disease in national referral hospital. Further in-depth research and instituting a GTD registry can be useful to validate these findings and find the true incidence. A substantial number of molar pregnancies can progress to GTN, and thus requires strict follow-up.
Situation of maternal health in Bhutan 2018
Authors: Dorji Phurb , Lethro Pema , Tshering Lobzang , Tshomo Tashi
Published: December 2020

Bhutan has opened up to modernization in 1961s and since then good progress has been made in social sectors. Providing free health service and education has the top priority from the beginning to this day. With humble starting from almost bare grounds, the situation of maternal health has improved. Until the start of the Safe Motherhood program in 1994, health programs were not streamlined. The maternal mortality ratio (MMR) was 380 per 100000 livebirths in 1994. A lot of efforts with different programs have been implemented by the reproductive health program of Ministry of Health to improve maternal health. Main challenge has been with health human resource from the very beginning and it still stands to this day as number one challenge. With the inputs of various programs to improve maternal health and development in non-health sectors, the MMR has come down to 89 per 100000 livebirths in 2017.
Hypotension, bradycardia and reversible conduction defect induced by prescription of Bhutanese traditional medicines
Authors: Tshering Ugyen , Levine Shankar , Watts Melanie
Published: December 2020

Aconite is widely used in both Chinese and Ayurvedic medications and therefore often used within the Himalayan Kingdom of Bhutan. Despite its use in traditional medicine, because of its narrow therapeutic index, significant cardiotoxic and neurotoxic events are documented due to both intentional and unintentional ingestion. In this case series we present 2 cases of bradycardia, hypotension and reversible conduction defects caused by prescribed aconite-based Bhutanese traditional medicines, for different therapeutic goals, who suffered cardiac dysrhythmias.
Taking action on prevention and control of noncommunicable diseases in Bhutan by strengthening gross national happiness
Authors: Sithey Gyambo , Thow Anne Marie , Sharma Jayendra , Lhazin Karma , Li Mu
Published: December 2020

Noncommunicable diseases (NCDs) are major public health problem in Bhutan, accounting for 68% of total deaths. The growing epidemic of NCDs threatens the achievement of Gross National Happiness (GNH). NCDs are the results of complex interaction of social and economic risk factors and change in diet and lifestyle. Effective action to prevent and control these diseases requires a whole-of-government approach.In this paper we review new evidence to support political priority for NCDs in Bhutan. One third of the Bhutanese are overweight (33%) and hypertensive (35.7), and 6.4% are diabetic. The prevalence of modifiable risk factors is also very high. We also present the analysis of strategic policy opportunities for health sector to integrate the ‘Multisectoral national action plan for the prevention and control of NCDs, 2015-2020’ into policies across all relevant sectors. Our analysis has identified three specific opportunities for the health sector to engage strategically to strengthen action on NCDs and GNH, concurrently: 1) raising priority actions on NCDs within the existing GNH multisectoral committee, to achieve both health and happiness objectives; 2) identifying shared agenda between NCDs and GNH to achieve both health and happiness objectives; and 3) identifying shared GNH determinants between NCDs and GNH to enhance action on NCDs. Addressing NCDs aligns with the optimization of Gross National Happiness. It is imperative that the Government of Bhutan recognize that action on NCDs is an integral element for achieving GNH.
Effect of use of direct observation of procedural skills for assessment for learning in Obstetrics and Gynaecology postgraduate students at Medical University, Bhutan: a prospective study
Authors: Tenzin Karma , Gyamtsho Sonam , Wangdon Tshering , Buttia Pema C. , Chandan Lalitha , Rege Nirmala
Published: December 2020

Introduction: Direct Observation of Procedural Skills (DOPS) is a valuable method to evaluate procedural skills. The aim of this study was to explore the effect of DOPS as an assessment method and its effect on their learning in Obstetrics and Gynecology Postgraduate students.
Methods: Five residents and four faculty members from the department of Obstetrics and Gynecology, Khesar Gyalpo University of Medical Sciences of Bhutan participated in this study. A validated checklist was adopted, from which five core areas of DOPS were utilized for this study. The two skills selected for this study were Pap smear and Intra Uterine Contraceptive Device (IUCD) insertion. The acquired data were analyzed by descriptive statistics (frequency, percent and mean).
Results: The results showed that student’s initial mean score was 4/9, which increased to nearly 8/9 in third attempt. Practically, all faculty members and students believed that DOPS was effective in facilitating students’ learning. Some of the students thought that repeated exposure to DOPS reduced their level of stress.
Conclusions: It may be stated that DOPS is effective in facilitating students’ learning and clinical skills.
Keywords: Assessment; DOPS; learning; Obstetrics and Gynecology; WPBA.
Incidence and factors associated with surgical site infections at the Surgical Ward, National Referral Hospital, Bhutan
Authors: Jamtsho Sonam , Wangdi Tashi Dendup , Wangdi Phuntsho , Wangdi Phurba
Published: December 2020

Introduction: The burden related to surgical site infection (SSI) and antibiotic sensitivity of the organisms causing SSI is acause of concern. This is the first study to assess SSI at Bhutan’s largest surgical centre.
Methods: This was an observational descriptive study conducted involving patients undergoing incisional surgeries at the Department of Surgery, JDWNRH from July – December 2017 using convenient sampling. Data was collected using a pro forma. The health care workers conducted the first two wound examinations and the information on the third examination was done though phone call. Southampton Wound Score (SWS) was used to assess the postoperative wound. The Research Ethics Board of Health, Bhutan, gave ethical approval.
Results: The incidence of surgical site infection was 30.7% and the most common organism was Escherichia coli. SSI occurred in Southampton Wound Grade I and IV. Contaminated (46.2%) and dirty (33.3%) wounds had higher incidence of SSI. Patients age >60 years (p= 0.049) and those with contaminated wound (p= 0.005) were significant risk factors for SSI. Hypertension, diabetes, smoking, alcohol intake and obesity, elective or emergency case, and the seniority of surgeon were not risk factors for SSI.
Conclusions: The incidence of SSI is high and antibiotic sensitivity patterns a cause of concern. Strict infection control and patient safety measures need to be implemented.
Knowledge, attitude and practice on advanced cardiac life support (ACLS) among the general duty medical officers in Bhutan
Authors: Pradhan Sona , Tenzin Karma , Pelzom Dorji , Dorji Jigme L , Dorji Passang , Gurung Mongal Singh
Published: December 2020

Advanced cardiac life support (ACLS) is one of the important lifesaving procedures administered by emergency medical professionals. International guidelines and literature recommends periodic training of health personnel on ACLS. In Bhutan, the General Duty Medical Officers (GDMO) is often the first line doctors to attend to the critically sick including cardiac arrest patients.
Methodology and criteria for setting national health research priorities in Bhutan: a workshop report
Authors: Humphries Debbie L. , Ingber Hannah , Gurung Mongal Singh , Khoshnood Kaveh
Published: December 2020

The Bhutanese health system is committed to providing health services for all citizens and is interested in strengthening the country’s health research capacity. The objectives of this workshop were to understand the range of health research activities in Bhutan; to formulate a prioritized research agenda for the Ministry of Health (MoH); to share challenges, gaps and opportunities in health research; and to provide insights for future prioritization exercises. The MoH partnered with Khesar Gyalpo University of Medical University of Bhutan and USA-based facilitators to develop and pilot a methodology for health research priority setting.  The Bhutan priority setting process was adapted from the Combined Approach Matrix and the Essential National Health Research methods.  The methodology proved successful in the systematic creation of a list of health research priorities. Future priority setting processes will build on this workshop, continuing to refine and strengthen the priority setting process in Bhutan.
The eradication of polio in Bhutan in the context of global polio eradication
Authors: Dorji Thinley , Dorji Tandi , Melgaard Bjørn
Published: December 2020

Bhutan has made tremendous health gains in public health, particularly in vaccine-preventable diseases. Polio was eradicated two years ahead of the launch of the Global Polio Eradication Initiative and only 12 years after the introduction of oral polio vaccination nationwide. The last case of clinical poliomyelitis in Bhutan was reported in 1986. Bhutan maintains a very high coverage of polio immunisation coupled with a strong health system and surveillance network. The success story in the elimination of polio provides examples for other successful public health programmes now and in the future.
Age of menarche and menstrual hygiene of pubertal female students in Bhutan: a cross-sectional survey, 2017
Authors: Dorji Thinley , Wangmo Sangay , Pongpirul Krit
Published: December 2020

Introduction: In Bhutan, pubertal and adolescent female students (10-19 years) make up 8.5% of the population. The need for menstrual hygiene management (MHM) is more urgent in post-menarcheal female students and in resource-poor settings. However, until recent time, there were strong socio-cultural barriers to discourses on menarche and MHM. This study was conducted to determine the age of menarche among Bhutanese female students to identify when to offer MHM support, their knowledge on menstruation and practices related to menstrual hygiene.
Methods: This was a cross-sectional survey of female students studying in Grade 10 in Thimphu, Bhutan. A multistage clustered sampling was used. Data was collected using a self-administered questionnaire developed for the purpose of this study.
Results: A total of 439 post-menarcheal female students were interviewed. The mean age of menarche was 12.8±1.1 years, and fear (38.3%) and confusion (25.1%) were the commonest responses. The mean score on knowledge on menstruation and MHM was 5.9±1.5 out of 9. The proportion of students with good knowledge was 36.7%. The common sources of information were the mother, teacher, and sister. The majority used commercial pads (92.5%) while some used clean cloths (5.7%) and tampons (1.6%). The proportion who stayed absent from school during menstruation in the month prior to data collection was 9.8%. Visiting religious places (67.6%) and participating in sports (4.3%) were common restrictions during menstruation.
Conclusions: Female students experience difficulties in menstrual hygiene management in schools. Menstruation could lead to missing schools and other activities.
 Keywords: Developing country; Health behaviour; Menstrual hygiene product; Standard of living.
Blood Lead Levels in children 2 through 59 months old in Bhutan
Authors: Erbele Phillip , Pem Deki , Tobgay Phensum , Pelden Sonam , Gurung Mongal S. , Ugen Sonam , Erbele Krista
Published: December 2020

Introduction: Pediatric lead exposure has long-term health, public health, and economic consequences; however, it is an underrecognized problem in low and middle-income countries. Our objective was to determine the prevalence of elevated blood lead levels (EBLLs) (greater than or equal to 5mg/dL) and evaluate risk factors for EBLLs in infants and children in two cities in Bhutan.
Methods: A cross-sectional study of children 2 through 59 months old was conducted in Thimphu and Phuentsholing, Bhutan during 2018. Blood was obtained by finger-stick and tested using a LeadCare II analyzer (Meridian Bioscience). Data were double entered in EpiData 3.1 and validated. Excel, Prism8, and STATA/IC 15.1 were used for analysis.
Results: Among 531 participants, the prevalence of EBLLs was 43.88%. The prevalence of EBLLs in girls and boys was 37.40% (n=262) and 50.19% (n=269), respectively (p= 0.004). The prevalence in Thimphu was 52.35% (n=361), compared to 25.88% (n=170) in Phuentsholing (p less than 0.001). In Thimphu, 70.47% (n=149) of 1 - 4 year old children tested in spring had EBLLs, compared to 51.45% (n=138) in autumn (p=0.001). Of the risk factors assessed, only regularly eating with fingers or hands was significantly associated with EBLLs (p < 0.001).
Conclusions: Nearly half of participants in two cities in Bhutan had elevated blood lead levels. Seasonal exposure to lead appears to be present. The high prevalence in this study is alarming. Further studies are urgently needed to both characterize the sources of lead and validate these findings on a larger scale.
A clinical audit report on quality of nursing documentation at Jigme dorji Wangchuck national referral Hospital, 2018
Authors: Zangmo Kencho , Dema Tshering , Acharya Bhagawat , Sonam Sonam , Choden Tshering , Dechen Kelzang , Om Kinga
Published: December 2020

Introduction: Whether it is a written documentation or an oral communication, the practice and delivery of healthcare is debated to be critically dependent on effective and efficient communication. Nursing documentation is one of the principal sources of information about patient care and an important tool for communication. This descriptive study assessed both quantitative completeness and quality of nursing documentation by major in-patient units of Jigme Dorji Wangchuck National Referral Hospital.
Methods: This cross-sectional study used D-catch tool. Data of randomly selected 317 patient records from six major in-patient units were entered into EpiData file. Using STATA version IC/14, descriptive statistics and multi variable analysis were carried out.
Results: Overall quantitative completeness (M-3.4, SD-.59) of the nursing documentation was higher compared to the quality of the documents maintained (M-2.8, SD-.79). The basic and less time-consuming information such as admission data and vital signs charting are documented better compared to the more time consuming and complex documentation such as nursing care process.
Conclusion: Systems should not only be in place to enhance documentation quantitatively but also consider uplifting the quality of the documents maintained. Initiating centralized admission system in the hospital may reduce nurses’ burden of clerical documentation, which will allow them to focus on quality nursing documentation and overall nursing care of patients.