Introduction  In-service training is an incentive to work and improve the quality of services of health human resources. In-service training for health human resources requires multi-sectoral efforts across relevant institutions, including the Ministry of Health (MOH), which is responsible for policy, and higher education institutions, teaching hospitals, etc.  The only national medical university of Bhutan, KGUMSB has developed a nationwide distance in-service training system using ICT, which had been prepared during the COVID-19 pandemic. Prior studies have reported that there are benefits to the use of ICT for in-service training in low- and middle-income countries to compensate for resource shortages.  In January 2023, a Memorandum of Understanding (MOU) was signed between the MOH and KGUMSB, etc. to cooperate and collaborate in the in-service training of health human resources across Bhutan.  This paper provides an overview of Bhutanese health systems and introduces how to establish a nationwide in-service training system by connecting central and regional health institutions through distance education using ICT, in the case of Bhutan.Methods  Participant observation, online interviews with stakeholders from KGUMSB, MOH, JICA, and documentary researches were conducted till July 2023.Results  ICT environment and simulation training center at KGUMSB and two regional referral hospitals (teaching hospitals) developed. KGUMSB developed facilities and systems for distance education (digital education equipment, learning management system, etc.), training of trainers, and distance education content. In addition, the MOU for in-service training was signed between the MOH, KGUMSB, etc.Conclusion  Through the efforts of KGUMSB, a specialized institution for health human resource development in Bhutan, to develop a distance education system, the MOU was concluded with MOH, and a nationwide in-service training system for health human resources was formed. For this system to work, in low- and middle-income countries with limited resources, a collaboration between the MOH, medical university, and teaching hospitals is essential.

Introduction: The effectiveness of first-aid measures (binding, incision and aspiration) for patients with habu bites and the indications of dry habu equine antitoxin for patients with habu bites are unclear. We investigated the relationships between first-aid measures and prognosis, and between symptoms (pain, swelling and bleeding) and antitoxin administration. Methods: We evaluated responses to a questionnaire submitted by 65 patients with habu bites. Patients who fully recovered were defined as "good", and those who had functional disorders, with or without rehabilitation, were defined as "bad." Fisher's exact test was used for analysis. Results: Pain was significantly related to antitoxin administration; however, swelling and bleeding were not related to antitoxin administration. First-aid measures and local symptoms were not related to prognosis. Conclusion: Our results revealed that many doctors determine the need for antitoxin administration according to pain. Moreover, our results suggested that the need for first-aid measures for patients is minimal. However, to clarify the indications for antitoxin administration and the effectiveness of first-aid measures for patients, further studies are warranted.

A 12-year-old girl had relative graft stenosis following the reconstruction of type A interrupted aortic arch. At 25 days after birth she underwent ascending aorta-descending aorta bypass with a 7mm knitted Dacron graft, ligation of the patent ductus arteriosus and pulmonary artery banding. She had patch closure of a ventricular septal defect (VSD) as well at 20 months of age. At age 12 catheterization was carried out, because she had headache and dizziness on exertion. The pressure of the ascending aorta was 163/79mmHg and the pressure gradient between the ascending and the descending aorta was 65mmHg. Aortography revealed severe stenosis of the graft, which might have occurred according to her growth. An extra-anatomic bypass was placed between the right axillary and the right common iliac artery through the intrapleural and preperitoneal route with a 10mm Dacron graft. Six months later, the blood pressure was 108/63mmHg in the upper extremities, the pressure gradient between the upper and lower extremities was reduced to 18mmHg, and headache and dizziness had disappeared.

BACKGROUND: Waldenström Macroglobulinemia (WM) is a rare subtype of indolent B-cell lymphoma, and prospective randomized studies on WM are scarce. The R-CHOP therapy [rituximab (R), cyclophosphamide, hydroxy-doxorubicin, vincristine, and prednisone] is a popular and recommended regimen for primary therapy, prescribed by several treatment guidelines for WM. However, treatment with R-CHOP is accompanied by severe myelosuppression and high rates of peripheral neuropathy. Therefore, we retrospectively evaluated the efficacy and toxicity of half-dose CHOP combined with R as a primary therapy for WM. METHODS: Patients with untreated symptomatic WM, treated at the Disaster Medical Center between April 2011 and September 2016, were retrospectively analyzed after administration of 6 cycles of half-dose R-CHOP for every 3 weeks. The response, median time to response, best response, progression-free survival, overall survival, and toxicities were evaluated. RESULTS: Of the 20 WM patients analyzed, 16 (80%) received half-dose R-CHOP without vincristine, and 13 (65%) responded to the treatment. With a median follow-up duration of 26.3 months, the 2-year progression-free survival and 2-year overall survival rates were 70 and 93.3%, respectively. The median time to response and best response were 6 and 9.9 weeks, respectively. Grade 3/4 leukocytopenia, neutropenia, febrile neutropenia, and Grade 1 peripheral neuropathy developed in 32, 37, 0, and 21% of patients, respectively. CONCLUSION: The half-dose R-CHOP is an effective and well-tolerated primary therapy for WM. To the best of our knowledge, this is the first study reporting the use of a reduced-dose R-CHOP regimen for the primary treatment of WM.
Cyclophosphamide ; Disasters ; Disease-Free Survival ; Febrile Neutropenia ; Follow-Up Studies ; Humans ; Leukopenia ; Lymphoma, B-Cell ; Neutropenia ; Peripheral Nervous System Diseases ; Prospective Studies ; Retrospective Studies ; Rituximab* ; Survival Rate ; Vincristine ; Waldenstrom Macroglobulinemia*

Purpose: We have previously reported the physiological and biochemical effects of bath salts. In this study, we used bath additive containing artificial carbon dioxide and sodium chloride (S bath additive), and the acute effects of bathing once with S bath additive and chronic effects of daily bathing with S bath additive for 15 consecutive days were compared with the effects of bathing once in plain water. Improvement in 10 symptoms was investigated using a 5-point verbal rating scale (VRS). Methods: Nine patients aged 51-82 years (mean, 66.6 years) with cold intolerance and lower leg pain were treated with balneotherapy. Whole-body bathing at 40°C was performed for 10 min daily (day 1, bathing in plain water; days 2-16, bathing with S bath additive). On days 1, 2, and 16, changes in patient’s subjective symptoms were evaluated using a VRS ranging from -1 to +3. Results: Compared with bathing once in plain water, bathing once with S bath additive was improvement of coldness, body warmth, blood circulation promotion, limb warmth, lightness of foot, and coldness in limbs. Daily bathing with S bath additive for 15 days significantly improved all symptoms compared with bathing in plain water. A comparison between single and daily bathing with S bath additive showed that relieving fatigue and lumbago were significantly improved after consecutive bathing, demonstrating the benefits of long-term usage. Discussion: Bathing once with S bath additive had acute effects on symptoms associated with peripheral circulation, such as coldness in limbs, body warmth, and limb warmth. Daily bathing with S bath additive improved bone- and joint-related symptoms, such as lumbago and shoulder stiffness, demonstrating that the chronic effects of S bath additive differ from the acute ones. These results are consistent with previous studies on natural hot springs which found that the efficacy of short-term treatment was distinct from that obtained after >2 weeks of treatment.