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  1. Shrestha S, Sapkota B, Thapa S, K C B, Khanal S
    PLoS One, 2020;15(10):e0240488.
    PMID: 33035243 DOI: 10.1371/journal.pone.0240488
    BACKGROUND: Understanding patient satisfaction with pharmacy services can help to enhance the quality and monitoring of pharmacy services. Patient Satisfaction with Pharmacist Services Questionnaire 2.0 (PSPSQ 2.0) is a valid and reliable instrument for measuring patient satisfaction with services from the pharmacist. The availability of the PSPSQ 2.0 in Nepalese version would facilitate patient satisfaction and enhance pharmacy services in Nepal. This study aims to translate the PSPSQ 2.0 into the Nepalese version, culturally adapt it and verify its reliability and validity in the Nepalese population.

    METHODS: The methodological and cross-sectional study design was used to translate, culturally adapt it, and validate PSPSQ 2.0 in Nepalese. The Nepalese version of PSPSQ 2.0 went through the full linguistic validation process and was evaluated in 300 patients visiting different community pharmacies in Kathmandu district, Nepal. Exploratory factor analysis was carried out using principal component analysis with varimax rotation, and Cronbach's alpha was used to evaluate the reliability.

    RESULTS: Three-hundred patients were recruited in this study. Participants ranged in age from 21 to 83 years; mean age was 53.93 years (SD: 15.21). 62% were females, and 34% educational level was above 12 and university level. Only 7% of the participants were illiterate. Kaiser-Meyer-Olkinwas found to be 0.696, and Bartlett's test of sphericity was significant with a chi-square test value of 3695.415. A principal axis factor analysis conducted on the 20 items with orthogonal rotation (varimax). PSPSQ 2.0 Nepalese version (20 items) had a good internal consistency (Cronbach's alpha = 0.758). Item-total correlations were reviewed for the items in each of the three domains of PSPSQ 2.0.

    CONCLUSION: The PSPSQ 2.0 Nepalese version demonstrated acceptable validity and reliability, which can be used in the Nepalese population for evaluating the satisfaction of patients with pharmacist services in both community pharmacy and research.

  2. Eltrafi A, Shrestha S, Ahmed A, Mistry H, Paudyal V, Khanal S
    Health Econ Rev, 2023 Oct 25;13(1):49.
    PMID: 37878082 DOI: 10.1186/s13561-023-00461-8
  3. Eltrafi A, Shrestha S, Ahmed A, Mistry H, Paudyal V, Khanal S
    Health Econ Rev, 2023 Sep 01;13(1):43.
    PMID: 37656228 DOI: 10.1186/s13561-023-00459-2
    BACKGROUND: Chronic migraine (CM) is a significant neurological condition affecting a substantial portion of the global population. The economic burden of CM includes both direct healthcare costs and indirect costs resulting from productivity losses and intangible impacts on patients' quality of life. However, there is limited research that comprehensively evaluates all cost components associated with CM, highlighting the need for a systematic review.

    METHODS: We conducted a systematic literature search in databases including MEDLINE, Embase, and CINAHL to identify studies estimating the cost of illness of chronic migraines. The search was restricted to English language articles published from inception to October 2021, and only findings from Organisation for Economic Co-operation and Development (OECD) countries were included. Methodology features and key findings were extracted from the studies, and reported costs were converted to GBP for cross-country comparisons.

    RESULTS: Thirteen cost-of-illness studies on CM from various OECD countries were included in this review. The studies demonstrated substantial variations in monetary estimates, but consistently highlighted the considerable economic burden of CM. Direct costs, particularly hospitalisation and medication expenses, were identified as the highest contributors. However, indirect costs, such as productivity losses due to absenteeism and presenteeism, were often underexplored in the reviewed studies. Additionally, intangible costs related to emotional and social impacts on patients were largely overlooked.

    CONCLUSION: Chronic migraine imposes a significant economic burden on individuals, healthcare systems, and society. Policymakers and healthcare stakeholders should consider both direct and indirect cost components, as well as intangible costs, in developing targeted strategies for effective CM management and resource allocation. Further research focusing on comprehensive cost assessments and sensitivity analyses is needed to enhance the understanding of CM's economic implications and inform evidence-based healthcare policy decisions. Addressing these research gaps can alleviate the economic burden of CM and improve patient outcomes.

  4. Imran M, Khanal S, Zhou XS, Antony-Babu S, Atiq M
    Plant Dis, 2022 Feb 14.
    PMID: 35156847 DOI: 10.1094/PDIS-10-21-2253-PDN
    Multiple diseases, including brown spot (Cochliobolus miyabeanus), leaf spot (Epicoccum sorghimum), and blast (Magnaporthe oryzae), can cause spot-like symptoms on the leaves of rice. In July 2021, a disease showing symptoms like brown spot was observed in an 8-hectare field of rice, with disease incidence of >30%, in Beaumont, Texas. Lesions started as small pinhead-size blackish spots on leaf tips or from the edges of leaf blades. The spots enlarged to become irregular (most) or oval brown spots with a slight chlorotic halo. Diseased leaves were collected, washed in running tap water and cut into small pieces. Pieces of the tissue were surface sterilized with 1%NaOCl for 2 min followed by 75% ethanol for 30 s and then washed in sterile distilled water three times with each time lasting for 1 min. The disinfected tissue pieces were air dried, placed on potato dextrose agar (PDA) medium and incubated at 25℃. Initially fungal colonies were hairy in texture with light dark brown center and whitish edge and dark brown pigmentation at the reverse side. Mature colonies turned to black in the center and dark brown toward the edge, with black at the reverse side after 2 or more weeks of incubation. Conidia were oval to narrowly oblong, rounded at the ends, with 2 to 6 distoseptate, and 15 to 35 × 6 to 10 µm in size. These morphological characteristics were similar to those described for Curvularia hawaiiensis (Aslam et al. 2019; Ellis 1971; Kusai et al. 2015). For molecular identification, DNA was extracted and the two different rRNA regions internal transcribed spacer (ITS) and large subunit (LSU), and the two genes RNA Polymerase II (RPB1) and translation elongation factor 1 alpha (EF1) of the fungus were amplified using the primers of ITS1/ITS4 (Wang et al. 2014), D1/D2 domain region of LSU (Fell et al. 200), and RPB1 and EF1 (Wang et al. 2014), respectively, and sequenced. The ITS sequence (OK397200) was 98.27% identical to C. hawaiiensis (KP131943); the EF1 sequence (OK492159) was 99.78% identical to C. hawaiiensis (KC503942); the LSU sequence (OK397295) was 98.96% identical to multiple C. hawaiiensis (MN055715, MH160813, MH875853, etc.); the RPB1 sequence (OK492160) was 97.41% identical to C. hawaiiensis (JN992363). To evaluate pathogenicity, three rice plants (cv. Presidio) at the 3-leaf stage were spray inoculated with a conidial suspension of 1 x 106 conidia/ml. Another set of three plants that were sprayed with sterilized distilled water served as the controls. Treated plants were maintained in a greenhouse with temperature ranging from 25 to 30℃. After 2 weeks, typical symptoms, like those observed in the field, developed on the inoculated plants while no symptoms developed on the control plants. The same fungus was consistently re-isolated from the diseased plants. The pathogenicity test was conducted three times with similar results. To our knowledge, this is the first report of brown leaf spot caused by C. hawaiiensis in rice in the United States. Curvularia species are frequently associated with rice grain and cause blackish discoloration symptoms on grain kernels. Recently, however, C. hawaiiensis has also been reported to cause brown leaf spot in Malaysia (Kusai et al. 2015) and Pakistan (Aslam et al. 2019). This research will help identify this disease from other leaf spot-like diseases and develop effective management strategies.
  5. Shrestha R, Sapkota B, Khatiwada AP, Shrestha S, Khanal S, Kc B, et al.
    Patient Prefer Adherence, 2021;15:1873-1885.
    PMID: 34475753 DOI: 10.2147/PPA.S320866
    Background: The General Medication Adherence Scale (GMAS) evaluates intentional and unintentional behaviour of patients, disease and medication burden and cost-related burden associated with non-adherence. GMAS was developed and validated among Urdu-speaking patients with chronic diseases. However, validated tool in Nepalese language to measure medication adherence among chronic illness patients currently does not exist.

    Aim: To translate, culturally adapt, and validate the English version of GMAS into the Nepalese language to measure medication adherence among chronic illness patients.

    Methods: The study was conducted among patients with chronic diseases in both hospital and community pharmacies of Nepal. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Good Practice Guideline for linguistic translation and cultural adaptation was used to translate and culturally adapt the English version of GMAS into the Nepalese version. The translated version was validated amongst patients with chronic diseases in Nepal. Exploratory factor analysis was carried out using principal component analysis with varimax rotation. Test-retest reliability and internal consistency were analysed.

    Results: A total of 220 (53.6% females, and 51.4% of 51 to 70 aged patients) patients with chronic diseases participated in the study. The majority of patients took two medications (27.3%) from six months to five and half years (68.2%). Kaiser Meyer Olkin was found to be 0.83. A principal axis factor analysis was conducted on the 3 items of GMAS without and with orthogonal rotation (varimax). The scree plot showed an inflexion on the third item that meant three components were present. The overall Cronbach's alpha value of the full-phase study was 0.82.

    Conclusion: The General Medication Adherence Scale was successfully translated into the Nepalese language, culturally adapted, and validated amongst chronic diseases patients of Nepal. Therefore, the GMAS-Nepalese version can be used to evaluate medication adherence among Nepalese-speaking patients with chronic disease.

  6. Khatiwada AP, Maskey S, Shrestha N, Shrestha S, Khanal S, Kc B, et al.
    J Pharm Policy Pract, 2021 Sep 29;14(1):79.
    PMID: 34587997 DOI: 10.1186/s40545-021-00366-z
    BACKGROUND: The COVID-19 pandemic has disproportionately affected all essential healthcare services delivery in low-resource settings. This study aimed to explore the challenges and experiences of providers and users of childhood immunisation services in Nepal during the COVID-19 pandemic.

    METHODS: Semi-structured qualitative interviews were conducted with childhood immunisation service providers and users (i.e., parents of children) from Kathmandu valley, Nepal. All interviews were conducted through phone or internet-based tools, such as Zoom, WhatsApp, and messenger. All interviews were audio-recorded, transcribed verbatim, and analysed using theme-based content analysis in an Excel spreadsheet.

    RESULTS: A total of 15 participants (n = 7 service providers and n = 8 service users) participated. Six themes were identified, namely: (1) impact of COVID-19 and lockdown on childhood immunisation services; (2) motivation and resilience for childhood immunisation; (3) Biosafety practices and Personal Protective Equipment (PPE) availability during the COVID-19 pandemic; (4) service adjustments and guidelines during pandemic; (5) availability of vaccines; and (6) immunisation program resilience in view of COVID-19. Service providers mentioned facing disruptions in services and some parents had decided to delay scheduled immunisation. However, most service providers showed determinations to deliver the services with high morale, while most service users reported taking their children for immunisation. Families migrating from urban to rural areas during the pandemic led to service providers having no means to confirm complete immunisation of migrating children. Service providers also experienced lack of adequate guidance to deal with the pandemic and personal protective equipment to protect themselves and service users.

    CONCLUSION: Despite experiencing disruptions in childhood immunisation service due to the COVID-19 pandemic, service users and providers were determined to vaccinate the children. There is an urgent need for effective preparedness plans to be in place to address the observed barriers and to ensure resilient immunisation services during ongoing and future pandemics.

  7. Shrestha S, Shrestha S, Kc B, Sapkota B, Khadka A, Khanal S, et al.
    J Patient Rep Outcomes, 2020 Jun 17;4(1):46.
    PMID: 32556701 DOI: 10.1186/s41687-020-00205-w
    BACKGROUND: The quality of life (QoL) of patients with lung cancer (LC) may be affected by disease-related limitations such as patients' functioning, the severity of symptoms, financial problems resulting along with the side effects of the treatment. The objective of this study was to translate LC-specific QoL questionnaire EORTC QLQ-LC29 into Nepalese language for Nepalese LC patients.

    METHODS: In the process of translation, the European Organization for Research and Treatment of Cancer (EORTC) translations guidelines were followed. The translated questionnaire was pilot-tested in a sample of 15 patients with LC. Descriptive statistics were calculated with SPSS version 21.0.

    RESULTS: All steps of the EORTC translation guideline were followed successfully. Fifteen lung cancer patients were included in the pilot study. Sixty percent were male and the mean age was 49.87 (range 21-76 years). For all items not related to thoracic surgery, patients used the entire range of the response options from 1 to 4 and no missing responses were observed. The highest mean (indicating a high symptom burden) was observed for the item number. 35 (shortness of breath; Mean = 3.33, SD = 1.11) and the lowest mean for an item number. 45 (dizzy; Mean = 1.73, SD = 0.96).

    CONCLUSION: The Nepalese version of EORTC QLQ-LC29 is a result of a successfully conducted rigorous translation procedure, and is highly comprehensible as well as acceptable to Nepalese LC patients. Thus, the Nepalese version of EORTC QLQ-LC29 is ready to be used in international clinical studies as well as in Nepalese clinical practice.

  8. Ahmed A, Dujaili JA, Chuah LH, Hashmi FK, Le LK, Khanal S, et al.
    Appl Health Econ Health Policy, 2023 Sep;21(5):731-750.
    PMID: 37389788 DOI: 10.1007/s40258-023-00818-4
    BACKGROUND: Although safe and effective anti-retrovirals (ARVs) are readily available, non-adherence to ARVs is highly prevalent among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. This systematic review aimed to review and appraise the decision analytical economic models developed to assess ARV adherence-improvement interventions.

    METHODS: The review protocol was registered on PROSPERO (CRD42022270039), and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant studies were identified through searches in six generic and specialized bibliographic databases, i.e. PubMed, Embase, NHS Economic Evaluation Database, PsycINFO, Health Economic Evaluations Database, tufts CEA registry and EconLit, from their inception to 23 October 2022. The cost-effectiveness of adherence interventions is represented by the incremental cost-effectiveness ratio (ICER). The quality of studies was assessed using the quality of the health economics studies (QHES) instrument. Data were narratively synthesized in the form of tables and texts. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis.

    RESULTS: Fifteen studies, mostly conducted in North America (8/15 studies), were included in the review. The time horizon ranged from a year to a lifetime. Ten out of 15 studies used a micro-simulation, 4/15 studies employed Markov and 1/15 employed a dynamic model. The most commonly used interventions reported include technology based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15) and others that involved multi-component interventions (5/15). In 1/15 studies, interventions gained higher quality-adjusted life years (QALYs) with cost savings. The interventions in 14/15 studies were more effective but at a higher cost, and the overall ICER was well below the acceptable threshold mentioned in each study, indicating the interventions could potentially be implemented after careful interpretation. The studies were graded as high quality (13/15) or fair quality (2/15), with some methodological inconsistencies reported.

    CONCLUSION: Counselling and smartphone-based interventions are cost-effective, and they have the potential to reduce the chronic adherence problem significantly. The quality of decision models can be improved by addressing inconsistencies in model selection, data inputs incorporated into models and uncertainty assessment methods.

  9. Shrestha S, Iqbal A, Teoh SL, Khanal S, Gan SH, Lee SWH, et al.
    Res Social Adm Pharm, 2024 Mar 13.
    PMID: 38514293 DOI: 10.1016/j.sapharm.2024.03.005
    INTRODUCTION: Pain is a significant healthcare challenge, impacting millions worldwide. Pharmacists have increasingly taken on expanded roles in managing pain, particularly in primary and ambulatory care contexts. This umbrella review aims to systematically evaluate evidence from published systematic reviews that explore the impact of pharmacist-delivered interventions on clinical, humanistic, and economic outcomes related to pain.

    METHODS: A systematic search was conducted across six electronic databases, including Ovid Embase, MEDLINE, CINAHL, Scopus, CENTRAL, APA PsycINFO, and DARE, from inception until June 2023. Prior to inclusion, two independent reviewers assessed study titles and abstracts. Following inclusion, an assessment of the methodological quality of the included studies was conducted. AMSTAR 2 was used to evaluate the methodological quality of the included SRs.

    RESULTS: From 2055 retrieved titles, 11 systematic reviews were included, with 5 out of 11 being meta-analyses. These SRs encompassed diverse pharmacist-led interventions such as education, medication reviews, and multi-component strategies targeting various facets of pain management. These findings showed favorable clinical outcomes, including reduced pain intensity, improved medication management, enhanced overall physical and mental well-being, and reduced hospitalization durations. Significant pain intensity reductions were found due to pharmacists' interventions, with standardized mean differences (SMDs) ranging from -0.76 to -0.22 across different studies and subgroups. Physical functioning improvements were observed, with SMDs ranging from -0.38 to 1.03. Positive humanistic outcomes were also reported, such as increased healthcare provider confidence, patient satisfaction, and quality of life (QoL). QoL improvements were reported, with SMDs ranging from 0.29 to 1.03. Three systematic reviews examined pharmacist interventions' impact on pain-related economic outcomes, highlighting varying cost implications and the need for robust research methodologies to capture costs and benefits.

    CONCLUSION: This umbrella review highlights the effectiveness of pharmacist-delivered interventions in improving clinical, humanistic, and economic outcomes related to pain management. Existing evidence emphasises on the need to integrate pharamacists into multi-disciplinary pain management teams. Further research is needed to investigate innovative care models, such as pharmacist-independent prescribing initiatives within collaborative pain management clinics.

  10. Adhikari B, Ranabhat K, Khanal P, Poudel M, Marahatta SB, Khanal S, et al.
    PLOS Glob Public Health, 2024;4(5):e0003128.
    PMID: 38696399 DOI: 10.1371/journal.pgph.0003128
    Ensuring access to essential medicines remains a formidable challenge in Nepal. The specific reasons for the shortage of essential medicines within Nepal have not been extensively investigated. This study addresses challenges associated with access to essential medicines, procurement process difficulties, and functionality of inventory management systems at different levels of public health facilities. Fifty-nine semi-structured in-depth interviews were conducted with health managers and service providers at provincial and local levels in six randomly selected districts of Bagmati province, Nepal. Interviews were audiotaped and transcribed verbatim, and the results were analyzed using the inductive approach and were later mapped within the four domains of "Procurement of essential medicines". The major barriers for the effective management of essential medicines included delays in the procurement process, primarily locally, leading to frequent stock-out of essential drugs, particularly at the health post level. Additionally, challenges arise from storage problems, mainly due to insufficient storage space and the need to manage additional comorbidities related to COVID-19. Other identified challenges encompass the absence of training on logistics management information systems, a lack of information technology resources in primary health facilities, inadequate qualified human resources to operate the IT system, and insufficient power backup. Moreover, unrealistic demand estimation from the service points, inadequate transportation costs, and manual inventory management systems further contributed to the complex landscape of challenges. This study identified procurement delays as the primary cause of essential medicine shortages in Bagmati Province, Nepal. We recommend implementing comprehensive procurement guidelines, collaborative training, and dedicated budgets to address this issue. Improving the procurement and inventory management process in low-resource settings requires a well-trained workforce, suitable storage spaces, and enhanced coordinated administrative tiers within health facilities at different levels to ensure the year-round availability of essential medicines in these settings.
  11. Ahmed A, Tanveer M, Shrestha S, Khatiwada AP, Khanal S, Dujaili JA, et al.
    Healthcare (Basel), 2022 Aug 26;10(9).
    PMID: 36141242 DOI: 10.3390/healthcare10091630
    Pharmacists are essential members of the healthcare team. The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has led pharmacists to undertake additional clinical roles. We aim to conduct a systematic review on the interventions and impact of pharmacist-delivered services in managing COVID-19 patients. We searched PubMed, Embase, Scopus, CINAHL plus, International Pharmaceutical Abstracts, and Web of Science from 1 December 2019 (the first case of COVID-19 emerged) to 13 January 2022 to retrieve the articles. Cochrane handbook and PRISMA guidelines were followed respectively to perform and report the review. The pharmacist-led interventions were reported following the Descriptive Elements of Pharmacist Intervention Characterization Tool (DEPICT) version 2. The protocol of systematic review was registered on PROSPERO (CRD42021277128). Studies quality was assessed with the modified NOS scale. In total, 7 observational studies were identified from 10,838 studies. Identification of dosage errors (n = 6 studies), regimen modifications (n = 5), removal of obsolete/duplicate medications (n = 5), identification and management of adverse drug reactions (n = 4), drug interactions prevention (n = 2), and physicians acceptance rate (n = 3) of therapy-related services delivered in-person or via tele-pharmacy were among the pharmacist-delivered services. Common interventions delivered by pharmacists also included optimizing the use of antibacterial, antivirals, and anticoagulants in COVID-19 infected patients. The acceptance of pharmacist-delivered services by physicians was high (88.5-95.5%). Included studies have described pharmacists' beneficial role in managing patients with COVID-19 including detection, resolution, and prevention of medication-related problems, with physicians demonstrating high trust in pharmacists' advice. Future research should assess the feasibility and scalability of such roles in real-world settings.
  12. Shrestha S, Khatri J, Shakya S, Danekhu K, Khatiwada AP, Sah R, et al.
    Drugs Ther Perspect, 2021;37(8):376-382.
    PMID: 34366660 DOI: 10.1007/s40267-021-00852-z
    Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a new species of β-coronavirus genus named severe acute respiratory syndrome coronavirus 2. The COVID-19 pandemic, which started in late 2019 and continues as at mid-2021, has caused enormous damage to health and lives globally. The urgent public health need has led to the development of vaccines against COVID-19 in record-breaking time. The COVID-19 vaccines have been widely rolled out for the masses by many countries following approval for emergency use by the World Health Organization and regulatory agencies in many countries. In addition, several COVID-19 vaccine candidates are undergoing clinical trials. However, myths, fears, rumors, and misconceptions persist, particularly in regard to adverse events. In this commentary, we describe the adverse events associated with COVID-19 vaccines and discuss why it is essential to have a functional adverse event monitoring system in this context.
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