Letter from Nepal.

The Federal Democratic Republic of Nepal is a beautiful and stunning country which is part of the Himalayan mountain ranges. Nepal has a population of 30 million spread over 147,516 km. The capital of Nepal is Kathmandu. Nepal is home to people from more than 100 ethnic groups, most of whom share the official Nepali language. As a small, landlocked country, Nepal’s topography, climate, religion and population are diverse. Nepal has eight of the world’s 10 tallest mountains and contains more than 240 peaks over 6096 m above sea level. Nepal is a low-middle income country; its per capita income was US $729 in 2016. In Nepal, health care is delivered by a hybrid system of public and private sectors with predominantly modern health care and some traditional Ayurveda health care and other alternative medicines. The public healthcare system is composed of hospitals, primary healthcare centres and outreach healthcare providers (the latter provides basic level of health care by paramedical staff targeting the rural population). Nepal used to have a high prevalence of communicable diseases (CDs); currently, the country has higher agestandardized death rates and disability-adjusted life years from non-CDs (NCDs) than CDs. NCDs account for 80% of outpatient visits and are the leading cause of death, with two thirds of deaths due to NCDs and an additional 9% due to injuries. The remaining 25% of deaths are due to communicable, maternal, neonatal and nutritional diseases. As a percentage of total deaths, the leading five causes in 2017 were ischaemic heart disease (16.4%), chronic obstructive pulmonary disease (COPD; 9.8%), diarrhoeal diseases (5.6%), lower respiratory infections (5.1%) and intracerebral haemorrhage (3.8%). The rising incidence of NCDs is partly due to changing age structure and lifestyles, such as increasing sedentary behaviour, tobacco use, modified eating habits and harmful use of alcohol. The increase in life expectancy as well as the burden of NCDs signals a demographic shift to an ageing population, which could have significant effects on resource distribution in the Nepalese health system. Bronchiectasis and COPD are the most common chronic respiratory diseases diagnosed in developing countries. Despite differing aetiology, pathophysiology and prognosis, bronchiectasis clearly overlaps with features of COPD in a subset of patients. Bronchiectasis–COPD overlap syndrome (BCOS) is a discrete, chronic clinical entity meeting the structural and diagnostic criteria of bronchiectasis, that is, the presence of ‘bronchiectatic’ airway wall changes and physiological criteria for the diagnosis of COPD. There are no data on the prevalence of BCOS among patients presenting with respiratory symptoms complex (i.e., cardinal chronic symptoms of the respiratory system occurring together) in Nepal. Within this context, we conducted a hospital-based cross-sectional study at the Department of Pulmonary, Critical Care and Sleep Medicine of the B. P. Koirala Institute of Health Sciences (BPKIHS), a tertiary care university teaching hospital in Dharan, Nepal (Figure 1). The aim was to study the occurrence of BCOS among 236 patients presenting with complex respiratory symptoms in a year. Ethical clearance to conduct the study was obtained from the Institutional Ethical Review Board (IRC/1529/01). We took a three-step approach to the diagnosis of BCOS: