Journal of Nepal Medical Association <p><strong>About JNMA<br></strong>Journal of Nepal Medical Association (JNMA) is an internationally peer-reviewed, MedLine/PubMed indexed,&nbsp;a general medical journal of Nepal Medical Association. JNMA is the first and oldest medical journal from Nepal since 1963 AD. JNMA is available at <a href="">PubMed</a>, <a href=";query&quot;%3A%7B&quot;filtered&quot;%3A%7B&quot;filter&quot;%3A%7B&quot;bool&quot;%3A%7B&quot;must&quot;%3A%5B%7B&quot;term&quot;%3A%7B&quot;index.issn.exact&quot;%3A&quot;1815-672X&quot;%7D%7D%2C%7B&quot;term&quot;%3A%7B&quot;_type&quot;%3A&quot;article&quot;%7D%7D%5D%7D%7D%2C&quot;query&quot;%3A%7B&quot;match_all&quot;%3A%7B%7D%7D%7D%7D%2C&quot;from&quot;%3A0%2C&quot;size&quot;%3A100%7D">DOAJ</a>, <a href=";btnG=&amp;hl=en&amp;as_sdt=0%2C5">Google Scholar,</a>&nbsp;Index Copernicus, EBSCO, EMBASE and other repositories.&nbsp;<br>JNMA abide by:<br>1. 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The author(s) are allowed to retain publishing rights without restrictions. The JNMA work is licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License</a>. More about <a href="">Copyright Policy</a>.</p> Systematic Reviews and Meta-analysis: Principles and Practice <p>N/A</p> Badri Man Shrestha ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3986 Assessment of Palatal Plane and Occlusal Plane for Determining Anteroposterior Jaw Relation <p><strong>Introduction</strong>: Sagittal jaw relationship is an important parameter for orthodontic treatment planning. Angular and linear measurements both have been proposed and used in orthodontic cephalometrics to assess the sagittal jaw relationships. However, angular measurement has been questioned over the years for its reliability as a result of changes in facial height, jaw inclination and the variable positions of Nasion. So, the objective of our study was to assess the linear anteroposterior jaw relation in a sample of Nepali population using occlusal (Wits appraisal) and palatal planes as reference lines.<br><strong>Methods</strong>: A descriptive cross-sectional study was conducted using the lateral cephalogram of 101 individuals visiting the Department of Orthodontics, Kantipur Dental College, Kathmandu, Nepal. Individuals with Class I skeletal relation were selected using convenience sampling method. Radiographs were standardised and traced. Occlusal and palatal planes were drawn that were bisected by the perpendicular lines from Point A and Point B. The linear distances between the intersections were measured to determine sagittal jaw relations.<br><strong>Results</strong>: In Nepali individuals with normal ANB angle (3.05°±2.511°), the sagittal jaw relation with reference to occlusal (Wits appraisal) and palatal planes were found to be 0.203±3.343mm and 3.574±4.074mm respectively.<br><strong>Conclusions</strong>: Various methods has been proposed and used to assess the sagittal jaw relation and each method has its own strength and limitations. So, it is well advised to use additional cephalometric analysis whenever possible before arriving at any diagnosis and treatment plans.&nbsp;</p> <p><strong>Keywords:</strong> <em>ANB angle; Nepal; palatal plane; Wits appraisal.</em></p> Ujjwal Pyakurel Kamal Babu Thapaliya Khushboo Singh Alka Gupta Sujaya Gupta Manish Bajracharya Rabindra Man Shrestha Praveen Mishra ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4052 Practice of Breastfeeding and its Barriers among Women Working in Tertiary Level Hospitals <p><strong>Introduction</strong>: Breastfeeding provides ideal food for newborns and prevents recurrent infection and malnutrition in infants. In Nepal, breastfeeding is a universal practice but exclusive breastfeeding is low. As there is increased involvement of women in workforce, practice of breastfeeding may have been compromised. The main objective of the study was to examine the practice and barriers of breastfeeding among women working in tertiary level hospitals of Nepal. <br><strong>Methods</strong>: This was a hospital based descriptive cross-sectional study. Study participants were wom- en working in Dhulikhel Hospital and Kathmandu Medical College and Teaching Hospital and was conducted from December 2017 to June 2018. Ethical approval was taken from institutional review committee of both institutions. Total of 208 women were included in the study and face to face interview was conducted. Data entry and analysis was done using statistical package of social sciences (SPSS).<br><strong>Results</strong>: Breastfeeding practice was universal and colostrum was fed by 195 (94%) women. Pre- lacteal feeding was given by 14 (7%) women and 119 (57%) initiated breastfeeding within one hour of birth. Total of 93 (45%) children were exclusively breastfed for any duration while 10 (11%) were exclusively breastfed for six months. The mean duration of breastfeeding was 14.57 months and 90 (43%) started complementary feeding before six months. Total of 97 (51%) women and 42 (47%) women stated work as barrier for not exclusively breastfeeding and early complementary feeding respectively. <br><strong>Conclusions</strong>: Exclusive breastfeeding was very low and children were breastfed for less than two years. Complementary feeding was also started earlier and work was stated as the main barrier for poor breastfeeding practice.</p> <p><strong>Keywords</strong>: <em>breastfeeding; complementary feeding; working women.</em></p> Mukta Singh Bhandari Pratibha Manandhar Dipesh Tamrakar ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4035 Respiratory Disorders Among Dust Exposed Workers <p><strong>Introduction: </strong>Exposure to dusts and hard physical work is common in developing industrialized countries. Acute and chronic respiratory illnesses are highly been reported from jute and textile industry. This study was undertaken to explore status of respiratory health among the workers of jute and textile industries.<strong><br>Methods: </strong>This descriptive cross-sectional study enrolled 315 workers from each of textile and jute industry of Eastern Nepal. Almost all the workers were selected from the textile industry whereas those from dust prone areas of jute industry. Workers were interviewed using pre-tested questionnaires. Measurement of height, weight and peak expiratory flow rate was done.<strong> <br>Results: </strong>Majority were non-smokers in both the industries 230 (73%) in Jute vs. 223 (70.8%) in Textile. Most of the workers had the working experience of less than five years; jute 134 (42.5%) vs. textile 180 (57.1%). Upper respiratory disorder was found in more than 1/5 of workers (68) in jute vs. 1/20 of workers (18) in textile industry. One and two workers suffered from chronic bronchitis in the jute and the textile industry respectively. Chest tightness was reported among 4 (1.3%) in jute vs. 17 (5.4%) in textile workers, cough symptoms among 86 (27.3%) in jute vs. 26 (8.3%) in textile industry. Low practice of personal protective measure was seen in both industries. The mean score of PEFR of workers in jute mill was lower than the workers in textile industry.<strong><br>Conclusions:</strong> Workers with acute respiratory disorders were more in the jute industry while chest tightness was more in the textile industry. Chronic respiratory problems did not appear to be alarming in both the industries. Use of personal protective measures should be promoted among the dust exposed workers.&nbsp;</p> <p><strong>Key Words: </strong><em>dust exposure; </em><em>peak expiratory flow rate; </em><em>respiratory disorder.</em></p> <p><strong>&nbsp;</strong></p> Suman Bahadur Singh Swotantra Gautam Narendra Bhatta Gambhir Shrestha Rabin Gautam Sagar Poudel ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3987 A Study of Surgical Cases During Earthquake Disaster in A Medical College <p><strong>Introduction</strong>: An earthquake is an intense shaking of earth’s surface which is caused by movements in earth’s outermost layer. The earthquake of 25th April 2015, with a magnitude of 7.8 richter scale with its major aftershock on 12th May 2015 of 7.3 richter scale claimed around 8,962 lives across several districts of Nepal with 22,302 injuries. In this study we tried to figure out various surgical cases and the surgical procedures performed in a tertiary care hospital during an earthquake disaster.<br><strong>Methods</strong>: This study was a descriptive cross-sectional study of hospital data on all admitted surgical cases during an earthquake disaster. A total of 238 earthquake victims brought to emergency department of Kathmandu Medical College Teaching Hospital , a tertiary care center, from 26th April 2015 to 7th Jun 2015, for the period of 42 days were included. Those brought dead and discharged after primary treatments were excluded. Data obtained were entered and analysed in Microsoft Excel 2010.<br><strong>Results</strong>: Among 238 patients enrolled, 122 (51%) were male and 116 (49%) female with male to female ratio of 1.05:1. Age group (31-60 years) with an average age of 45 years were encountered most frequently 110 (46%) with the maximum number of patient burden from Sindhupalchowk district 80 (33.6%). Orthopedic surgery 185 (76%) appeared to be the most frequent followed by neurosurgery, plastic surgery, general surgery and dental surgery.<br><strong>Conclusions</strong>: In natural disaster like earthquakes, traumatic injuries are very common and thereby various surgical procedures especially ortho-plastic are the domain of treatment modalities. Disaster preparedness and combined surgical team effort needs to be focused to reduce both mortality and morbidity.</p> <p><strong>Keywords</strong>: <em>disaster; earthquake; Nepal; surgery. </em></p> <p>&nbsp;</p> Kanchan K.C Raj Kumar Thapa Sanubhai Khadka Damodar Paudel ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4063 Clinical Experience of Fluroscopy Guided Percutaneous Transpedicular Biopsy of Spinal Lesion <p><strong>Introduction</strong>: The diagnosis of the spinal lesions often puts the clinician in dilemma. The definite diagnosis is obviously needed for the proper management of the disease. The wrong diagnosis not only imposes the adverse effects, but sometimes may lead to the disabling conditions and even prove to be life threatening. This study is aimed at evaluating the need of fluoroscopy guided percutaneous transpedicular biopsy for establishing the proper diagnosis and find the diagnostic yield.<br><strong>Methods</strong>: This is the descriptive cross-sectional study conducted over the period of 10 years in the Upendra Devkota Memorial National Institute of Neurological and Allied Sciences among the patients who underwent transpedicular biopsy for various spinal lesions.<br><strong>Results</strong>: Among the 77 cases, 38 (49%) of the lesions on MRI were single level whereas 39 (51%) of the lesions were multiple. Most of the lesions were diagnosed as the non-tubercular infection 30 (42%), followed by the osteoporotic fractures and malignancy in 18 (25%) and 15 (21%) respectively. The sensitivity and specificity of the radiology with the background of clinical scenario was 79.5% and 90.9% respectively. The diagnostic yield of the biopsy was 93.5%.<br><strong>Conclusions</strong>: The transpedicular biopsy of the spinal lesion is the must for the proper diagnosis and treatment plan of such cases. The change in the diagnosis after biopsy is often possible which will drastically alter the treatment plan.</p> <p><strong>Keywords</strong>: <em>fluoroscopy guided; metastasis; spinal lesions; transpedicular biopsy; tuberculosis.</em></p> Suman Rijal Pankaj Raj Nepal Manita Raut Dinesh Nath Gongal ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3950 Morphometric Measurement of Cranial Vault Thickness: A Tertiary Hospital Based Study <p><strong>Introduction</strong>: The skull’s main function is to protect the brain. Total skull bone thickness is the total thickness of diploe and the external and internal tables. The measurement of the human skull based on CT images results are of great practical value in the fields of anatomy, clinical medicine, biomechanics study and head injury analysis. There are few literatures about imaging assisted measurement of the cranial vault thickness while sparse literature among Nepalese population. In this study, we aim to measure the thickness of Nepalese calvarian bones and find the difference between gender and ethnic groups.<br><strong>Methods</strong>: This was a descriptive cross-sectional study conducted in our center during a period of 6 months. Patient of age 15 to 50 years with normal CT finding were included in the study. Using the axial view of brain CT, the thickness of cranial vault was measured and recorded in millimeter. <br><strong>Results</strong>: Among 100 patients, 51 were male and 49 were female. Mean thickness of frontal bone, parietal, temporal and occipital bone were 8.02±1.97 mm, 7.04±1.43 mm, 4.71±1.34 mm and 7.98±2.47 mm respectively. <br><strong>Conclusions</strong>: There was no significant difference in cranial vault thickness among sex or ethnical groups in patients of a hospital.</p> <p><strong>Keywords</strong>:<em> cranial vault; ethnicity; Nepalese; thickness.</em></p> Suraj Thulung Kajan Ranabhat Suresh Bishokarma Dinesh Nath Gongal ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3949 An Echocardiographic Evaluation of Dilated Cardiomyopathy in a Tertiary Care Hospital <p><strong>Introduction</strong>: Cardiomyopathies are diseases of heart muscle that may originate from genetic defects, cardiac myocyte injury or infiltration of myocardial tissues. Dilated cardiomyopathy is the most common phenotype and is often a final common pathway of numerous cardiac insults. Mostly it remains unknown in the absence of echocardiography, histopathology and genetic evaluation. Though common it is underdiagnosed with not much of data available in our setup.<br><strong>Methods</strong>: This study was analytical cross-sectional study of hospital data on Echocardiographic findings in 65 patients of DCM visiting cardiology unit for Echocardiographic evaluation from 1st of February to 31st July 2018 for the period of six months in Shree Birendra Hospital, a tertiary care military hospital at Chhauni, Kathmandu. Pediatric age group patients and those who refused to give consent were excluded. Data obtained were entered in Microsoft Excel 2010 and analyzed by IBM SPSS 21.<br><strong>Results</strong>: Among 65 patients enrolled 40 (61%) were male and 25 (39%) female with male to female ratio of 1.6:1. Elderly people (61-75 years) with an average age of 65 were commonly involved and they presented mostly with congestive heart failure, 32 (49%). Echocardiographic evaluation showed 36 (55%) with mildly dilated Left Ventricle (5.6-6.0cm). Majority had reduced Left ventricular systolic function with an average Ejection fraction (EF) of 39.6%. No significant difference between male and female with the average EF% (P=0.990) and there was no significant relation between age and average EF% (P=0.091).<br><strong>Conclusions</strong>: Dilated Cardiomyopathy is the commonest cardiomyopathy phenotype mostly presenting with congestive heart failure. It is often underdiagnosed in our part of the world, however echocardiography will easily detect the condition.&nbsp;</p> <p>Keywords: <em>dilated cardiomyopathy; echocardiography; ejection fraction; left ventricle. </em></p> Raj Kumar Thapa Kanchan K.C Rishi Khatri Devendra Khatri Rajeeb Kumar Deo Drishti Shah ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3992 Role of MR Morphology and Diffusion-Weighted Imaging in the Evaluation of Meningiomas: Radio-Pathologic Correlation <p><strong>Introduction</strong>: Preoperative differentiation of benign, atypical and malignant meningiomas would significantly help in surgical planning and treatment. The aim of this study is to look at radio- morphologic behavior of various histopathological types and grades of meningiomas and their diffusion characteristics.<br><strong>Methods</strong>: We performed an analytical cross-sectional study including all patients operated on for meningiomas at our hospital during January 2016 to July 2018. We studied 38 meningiomas in 38 patients aged 14 to 73 years old. All patients underwent MRI prior to surgery, including diffusion- weighted sequences, in a 1.5T scanner. Signal intensity in T2-weighted images, diffusion-weighted images (b=0, 90 and 1,000), and Apparent Diffusion Coefficient maps within the tumors and in the normal parietal white matter as a reference were evaluated.&nbsp;<br><strong>Results</strong>: There was female predilection with male:female ratio of 1:2.4. Most meningiomas were supratentorial with most common origin being parafalcine and convexity. Of the 38 meningiomas, 31 were WHO grade I, 6 were WHO grade II (apalstic) and one was WHO grade III (anaplastic). Similarly, tumors showing pial invasion, breached tumor-brain interface, no capsular enhancement and parenchyma invasion showed significantly low NADC. Mean ADC value was 0.722±7.7x10-3 mm2/s (normalized ADC 0.9±0.1) in the atypical group and 0.876±24.56x10-3 mm2/s (normalized ADC 1.11±0.31) in the typical group. No statistically significant differences of ADC/NADC were found between histologic subtypes. Two subtypes of typical meningiomas, metaplastic and angiomatous meningioma had the highest values in the ADC maps.<br><strong>Conclusions</strong>: MR morphology like pial invasion, breached tumors brain interface, parenchymal invasion can predict aggressiveness and atypical nature of meningiomas. Meningioma shows moderately restricted diffusion. The signal on the ADC map is associated with tumors cellularity and aggressiveness suggesting its usefulness for predicting the histological grade.</p> <p><strong>Keywords</strong>: <em>apparent diffusion coefficient; atypical; histopathology; meningioma; MR morphology.</em></p> Kajan Ranabhat Suresh Bishokarma Prity Agrawal Pratyush Shrestha Ram Kumar Ghimire Rajesh Panth ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3968 A Comparative Analysis of Medical Education Models and Curriculums of A Medical University and A Medical Education Center <p><br><strong>Introduction</strong>: In order to solve the shortage of competent healthcare manpower at the village level of Yunnan Province, We compared the training mode of Kunming Medical University and The Medical Educational Center, Hat Yai of PSU. The aim of this study is to compare the difference of the two institutions and learn from each other’s advantages. <br><strong>Methods</strong>: The review covered relevant policy areas and stipulations governing general practitioner training for both countries. Quantitative research was done by using a questionnaire developed in house by the project team, students from the inaugural cohort at KMU and students from the MECH. In Qualitative research, in-depth interviews were carried out with the teaching administration and students from both schools.<br><strong>Results</strong>: In Kunming Medical University, besides the conventional lectures, teaching methods such as case based learning and problem based learning have been worked into the basic science, laboratory, and clerkship/internship sessions. The desired end product is a general practitioner.&nbsp; In Prince of Songkla University, the first and second phases consist of basic science and preclinical integrated topics taught at PSU. For the third and final phase, the students have core clinical modules and selective at MECH where the methods are learner centered, problem based, integrated and set in the context of community primary healthcare practice. <br><strong>Conclusions</strong>: We should start with the integration of the medical disciplines and the humanities, so as to restore the lost “art of doctoring”. We need to integrate the various foundational and clinical disciplines into an organ system based curriculum, not just in form, but also in function and purpose.</p> <p><strong>Keywords</strong>: <em>curriculums; Hat Yai; Kunming Medical University; medical education models; Medical Education Center. </em></p> QU Fanwei HE Jin MA Hua JIANG Yanling ZHAO Wenlan Virasakdi Chongsuvivatwong JIANG Runsheng ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4107 Giant Brunner’s Gland Adenoma Presenting as Upper Gastrointestinal Bleeding in 76 Years Old Male: A Case Report <p>Brunner’s gland adenoma is a rare benign tumor of small bowel, often incidentally discovered during endoscopy or radiological imaging. Mostly they are asymptomatic or often present with nonspecific symptoms such as nausea, vomiting, gastrointestinal hemorrhage, iron deficiency anemia. We reported a 76 years old male case presented with chief complaints of vomiting and black tarry stool. General physical examination was normal except mild tenderness over epigastrium. Esophagogastroduodenoscopy revealed a pedunculated polypoid tubular structure with blind end distally of length approximately 10-12* 3.5*1.5 cm in the second section of the duodenum with multiple skipped ulcers on the exposed surface of it. Additionally, there were few erosions in the duodenum proximally and multiple superficial ulcerations in the antrum, associated with helicobacter pylori confirmed by rapid urease test kit.&nbsp;</p> <p><strong>Keywords</strong>: <em>Brunner’s gland adenoma; Brunner’s gland hamartoma; Brunner’s gland hyperplasia; case report.</em></p> Ramesh Rana Rikesh Sapkota Bishal KC Anish Hirachan Bimas Limbu ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4013 Pleomorphic Adenoma of the Submandibular Gland: A Case Report <p>Salivary gland tumours are relatively rare and constitute about 3-4 % of head and neck tumours. Most of the tumours arise from parotid glands. Submandibular gland tumours are very rare. Pleomorphic adenoma of the submandibular gland is exceedingly rare tumour. Very few studies have been reported in the literature that is exclusively conducted on pleomorphic adenoma affecting submandibular gland. Patients usually present with a slow growing, painless and mobile mass without any other associated symptoms. Radiologic studies are usually unable to differentiate benign from malignant tumours in most cases. Recurrence is rare with complete en bloc excision of the tumour along with submandibular gland. Prognosis is excellent except for the rare cases of malignant transformation. This paper describes a case of pleomorphic adenoma affecting submandibular gland with brief review of current literature on submandibular gland tumours.</p> <p><strong>Keywords</strong>: <em>pleomorphic adenoma; salivary gland; submandibular gland tumours. </em></p> Prakash Khanal ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4001 Ingestion of Bell Clappers by a Shaman in Jumla, Nepal: A Case Report <p>Accidental foreign body ingestion is a common problem encountered in Emergency. Deliberate foreign body ingestion may result due to an act of insanity or an act of daring. A shaman locally known as Dhami was brought to Emergency with the history of ingestion of bell clappers. He denied the history of psychiatric illness or substance abuse. On physical examination, there were signs of peritonitis. Laparotomy was done to remove the foreign bodies. Post-operative period was uneventful. Apart from the surgical intervention, psychological counselling was given to him. This is a rare interesting case due to the fact that the 15 cm long foreign bodies passing all the way through without significant injury and finally causing obstruction in ileocecal junction and perforation in the distal ileum.</p> Niresh Thapa Subi Basnyat Muna Maharjan ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4055 Optometry in Nepalese Context: The Profession Beyond Providing Refraction Services <p>Optometry is an independent profession which is specialised for providing comprehensive eye care including refraction and dispensing services, diagnosis and management of eye diseases and visual rehabilitation. In clinical settings of Nepal, optometrists are primarily recognised as refractionists and are provided with working opportunities in the same area. This report highlights other optomet- ric services such as binocular vision, multifocal lenses, contact lenses and occupational lens design which can be provided by optometrists besides performing refraction and prescribing spectacles. Considering large proportion of optometrists with further education and being working outside the country, new specialised services can be introduced through training and workshop to the fellow optometrists so that specialised services can reach up to the public level.</p> <p><strong>Keywords</strong>: <em>Nepal; optometry; refraction services.</em></p> Dinesh Kaphle Himal Kandel Prakash Paudel ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3523 Regulation of Surgical Procedures and Health Care Facilities Rankings in Nepal <p>Globally, millions of surgeries are performed each year to compliment and manage a diverse set of medical conditions. Adverse surgical outcomes constitute a major proportion of avoidable death and disabilities in the hospital, especially in low-income countries like Nepal. A comprehensive study on the standards of surgical procedures and its institutional regulations is missing. We discuss here the importance of surgical regulation based on it’s financial as well as healthcare implications in the Nepalese healthcare system.</p> <p><strong>Keywords</strong>: <em>surgical procedures; health care facilities; safety; surgery; WHO. </em></p> <p>&nbsp;</p> Yogesh Acharya Ranjan Dahal Navindra Raj Bista Milan Chandra Khanal Sangita Bista ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.4088 Postprandial Blood Glucose can be less than Fasting Blood Glucose and this is not a Laboratory Error <p style="text-align: justify; line-height: 150%; background: white;">Higher fasting blood glucose level than post prandial level can be seen in variety of conditions in both normal population and diabetics. Various modifiable factors along with underlying condition of patient behind such laboratory picture are discussed in this article.</p> <p style="text-align: justify; line-height: 150%; background: white;">Keywords: <em>clinical laboratory; diabetes; fasting blood glucose; postprandial blood glucose.</em></p> Vivek Pant Keyoor Gautam Santosh Pradhan ##submission.copyrightStatement## 2019-02-28 2019-02-28 57 215 10.31729/jnma.3985