Journal of Kathmandu Medical College https://www.nepjol.info/index.php/JKMC <p>The official journal of Kathmandu Medical College, Sinamangal, Kathmandu. Full text articles available. Content also available on the journal's own&nbsp;<a href="http://www.jkmc.com.np/">website</a>.</p> <p>JKMC is a multidisciplinary, peer reviewed, open access, quarterly journal which publishes a wide range of scientific works including original research paper, case reports, reviews, editorials, book reviews and articles from medical students. It includes work from basic science, clinical science, dental, nursing and other related medical fields.</p> <p>Journal of Kathmandu Medical College does NOT charge authors for article submission and processing fees.</p> Kathmandu Medical College en-US Journal of Kathmandu Medical College 2091-1785 <p>Copyright © Journal of Kathmandu Medical College<br>The ideas and opinions expressed by authors or articles summarized, quoted, or published in full text in this journal represent only the opinions of the authors and do not necessarily reflect the official policy of Journal of Kathmandu Medical College or the institute with which the author(s) is/are affiliated, unless so specified.</p> <p>Authors convey all copyright ownership, including any and all rights incidental thereto, exclusively to JKMC, in the event that such work is published by JKMC. JKMC shall own the work, including 1) copyright; 2) the right to grant permission to republish the article in whole or in part, with or without fee; 3) the right to produce preprints or reprints and translate into languages other than English for sale or free distribution; and 4) the right to republish the work in a collection of articles in any other mechanical or electronic format.</p> Communication and Patient safety https://www.nepjol.info/index.php/JKMC/article/view/28161 <p>Not available.</p> Sanjaya Mani Dixit ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 49 50 10.3126/jkmc.v8i2.28161 Outcome of supplementation of vitamin D on intact parathyroid hormone level in chronic kidney disease patients https://www.nepjol.info/index.php/JKMC/article/view/28164 <p><strong>Background:</strong> Secondary hyperparathyroidism is present in majority of patients with estimated glomerular filtrate rate&nbsp;less than 60 mL/min/1.73 m2. Sustained elevated parathyroid hormone level can cause osteitis-fibrosa-cystica, fracture,&nbsp;hypercalcemia, hyperphosphatemia, and calciphylaxis. Kidney Disease Improving Global Outcome guidelines for Chronic&nbsp;Kidney Disease Mineral and Bone Disorder 2017 recommends treatment with calcitriol or vitamin D analogue if&nbsp;parathyroid hormone level is progressively increasing and remains persistently above the upper limit despite&nbsp;correction of modifiable factors.</p> <p><strong>Objectives:</strong> The objective of this study was to determine the mean change in intact parathyroid hormone after<br>calcitriol supplementation in patients with chronic kidney disease (stage 3 to 5).</p> <p><strong>Methodology:</strong> This prospective observational study enrolled 92 patients with chronic kidney disease stage 3 to 5, not&nbsp;under maintenance hemodialysis. Patients who had intact parathyroid hormone level more than 200 pg/ml, serum&nbsp;phosphate level less than 4.5 mg/dl and corrected serum calcium less than 9.5 mg/dl were selected for the study. They&nbsp;were supplemented with oral calcitriol 0.25μg thrice weekly for three months and intact parathyroid hormone level was&nbsp;measured after three months.</p> <p><strong>Results:</strong> Mean intact parathyroid hormone level before supplementation was 332.91 ± 96.046pg/ml and after three&nbsp;months of supplementation with calcitriol was 176.49 ±53.764pg/ml. This finding was statistically significant (Correlation:&nbsp;0.471, p-value less than 0.05). Thus, supplementation of calcitriol reduced the mean intact parathyroid hormone level in&nbsp;the chronic kidney disease patients in our study.</p> <p><strong>Conclusion:</strong> Calcitriol supplementation seems to be an effective measure to reduce intact parathyroid hormone level in&nbsp;chronic kidney disease patients when it remains persistently high despite correction of modifiable factors.</p> Laxman Prasad Adhikary Aarjan Khanal ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 51 54 10.3126/jkmc.v8i2.28164 Prevalence of overweight and obesity among school children of Bhaktapur and Kathmandu https://www.nepjol.info/index.php/JKMC/article/view/28163 <p><strong>Background:</strong> World Health Organization defines childhood obesity as “one of the most serious public health challenges”.&nbsp;Low income countries like Nepal experience a burden of infectious diseases as well as rising incidence of noncommunicable&nbsp;diseases frequently associated with obesity. There is paucity of information on childhood obesity in Nepal.</p> <p><strong>Objectives:</strong> This study aims to determine the prevalence of childhood obesity and overweight in school going children&nbsp;and find its association with blood pressure.<br><strong>Methodology:</strong> A school based cross-sectional analytical study was conducted on 509 children aged between 10-16&nbsp;years, studying in grade 5-10 of private schools in Kathmandu and Bhaktapur. Simple random sampling technique was&nbsp;used for data collection. Anthropometric measurements and blood pressure were taken using standard protocol. Obesity&nbsp;was assessed using Body Mass Index criteria.<br><strong>Results:</strong> The overall prevalence of obesity and overweight in children were found to be 1.6% and 6.1% respectively. This&nbsp;study also showed that prevalence of obesity in children from Kathmandu is comparatively more, which was statistically&nbsp;significant (p&lt;0.001). A highly significant relationship was observed for diastolic blood pressure and Body Mass Index&nbsp;(p&lt;0.001) between the two groups.<br><strong>Conclusion:</strong> This study concludes that obesity though small in percentage, was found in rising trend when compared&nbsp;with previous data. Also, there was strong association with blood pressure, so timely identification and control of obesity&nbsp;is required for prevention of development of other cardiovascular comorbidities.</p> Pawana Kayastha Binit Vaidya Dipesh Shakya ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 55 59 10.3126/jkmc.v8i2.28163 Awareness about expressed breast milk feeding among working mothers visiting a tertiary level hospital, Kathmandu https://www.nepjol.info/index.php/JKMC/article/view/28165 <p><strong>Background</strong>: Expressed breast milk can be a healthy feeding option as compared to formula for working mothers. A&nbsp;large number of mothers are working these days and despite their desire to breastfeed, mothers have to get back to their&nbsp;work because of various constraints.<br><strong>Objectives:</strong> The research objective was to assess the status of knowledge and attitude regarding expressed breastfeeding&nbsp;and to identify the barriers to expressed breastfeeding among working mothers visiting Kathmandu Medical College&nbsp;Teaching Hospital.<br><strong>Methodology:</strong> A cross-sectional study was conducted at Pediatric Outpatient Department of Kathmandu Medical&nbsp;College Teaching Hospital from June 2018 till December 2018. One hundred and eighty working mothers were chosen&nbsp;purposively and interviewed. Research instrument was a structured questionnaire containing questions about technique&nbsp;of pumping and storing breast milk, benefits of breastfeeding, attitude regarding expressed breastfeeding and reasons&nbsp;for not expressing breast milk. Mean standard deviation and Chi-square tests were used for statistical analysis.<br><strong>Results:</strong> Out of 180 mothers, half of the mothers had adequate knowledge regarding expressed breastfeeding while&nbsp;slightly more than half of them (52.2%) had negative attitude about it. Only 11.7% of the mothers shared that they had&nbsp;expressed breast milk ever. The most important reason for not expressing breast milk was stated to be inadequate breast&nbsp;milk production (30.7%) and lack of time (26.4%).<br><strong>Conclusion:</strong> The study concludes that about half of the working mothers have adequate knowledge and positive attitude&nbsp;regarding expressed breastfeeding. Moreover, very few mothers ever expressed breast milk and the main reason for not&nbsp;doing so was inadequate milk production.</p> Shrijana Pandey ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 60 65 10.3126/jkmc.v8i2.28165 Ischemic stroke: Observations and analysis of stroke patients admitted in a tertiary hospital of Kathmandu https://www.nepjol.info/index.php/JKMC/article/view/28166 <p><strong>Background:</strong> Stroke is a disabling condition that has physical and mental impact on a patient’s life. Stroke is an important&nbsp;morbidity for low and middle income countries like Nepal. Hypertension, diabetes, smoking, and dyslipidemia are&nbsp;common risk factors in this regard and are inadequately controlled; mainly because of poor public awareness, inadequate&nbsp;infrastructure, lack of service and qualified manpower.<br><strong>Objectives:</strong> This study aims to provide insight into the epidemiology and risk factors in ischemic stroke patients.<br><strong>Methodology:</strong> A descriptive cross sectional study was conducted in 92 ischemic stroke patients at a tertiary care hospital&nbsp;Kathmandu Medical College and Teaching Hospital (KMCTH), Sinamangal, Nepal from December 2017 to June 2018.&nbsp;Consecutive sampling technique was used and data was collected from ischemic stroke patients above 14 years of age&nbsp;who were admitted in the Department of Neurology. Information regarding pre-morbid and morbid conditions, imaging&nbsp;findings as well as results was obtained from biochemical analysis of blood after taking consent from the patient or&nbsp;patient’s relative. Statistical Package for the Social Sciences Version 20 was used as a tool for statistical analysis.<br><strong>Results:</strong> Their mean age was 63.25 years with standard deviation of 16.45. Dyslipidemia was the most commonly found risk&nbsp;factor which was present in 77.2% of the subjects, followed by smoking (59.8%), presence of carotid artery atherosclerosis&nbsp;(59.8%), hypertension (50%), atrial fibrillation (26.1%) and diabetes mellitus(15.2%). Smoking was significant in males and&nbsp;heart disease was mostly seen in females.<br><strong>Conclusion:</strong> Dyslipidemia and smoking were the most common risk factors followed by carotid artery atherosclerosis.&nbsp;Patients with hypertension and dyslipidemia had higher incidence of stroke in both young and elderly group.</p> Dipesh Shakya Rabindra Shrestha Krishna Dhungana Raisha Kafle Sabnam Bhatta ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 66 71 10.3126/jkmc.v8i2.28166 Estimation of sex using discriminant function analysis of percutaneous finger lengths in Nepalese adults https://www.nepjol.info/index.php/JKMC/article/view/28167 <p><strong>Background:</strong> Disasters are a common occurrence in Nepal. This necessitates the development of baseline forensic&nbsp;anthropological data specific to the Nepalese population. Recent advances in the field of forensic medicine and sciences&nbsp;have somewhat reduced the relevance of forensic anthropology in the western developed world. The financial burden of&nbsp;these newer techniques, however, puts emphasis back on methodological examination of remains to establish identity.<br><strong>Objectives:</strong> To establish the sex of the individual from the percutaneous length of the fingers.<br><strong>Methodology:</strong> One hundred and twenty medical students (58 males and 62 females) were randomly selected and their&nbsp;finger lengths measured. These measurements were analyzed to establish discriminant functions to estimate sex.<br><strong>Results:</strong> The equation derived was Y = (1.822 x Left index finger length) + (1.141 x Left little finger length) – 19.211.&nbsp;Group centroids were calculated to be -0.933 for females and 0.998 for males. The sensitivity was found to be 76.9% and&nbsp;a specificity of 78.2%. Overall, the function correctly classified 77.5% of the original cases.<br><strong>Conclusion:</strong> Based on these findings, finger length is as reliable in estimation of sex of an individual as other longs bones&nbsp;and can be an ideal tool for examination, especially in remains where the skull and pelvis are absent or missing.</p> Eugen Dolma Walung Mani Raj Maharjan Rijen Shrestha ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 72 75 10.3126/jkmc.v8i2.28167 Awareness and concern towards anesthesia among patients undergoing surgical procedure: A cross-sectional study at pre-anesthetic clinic of a Teaching Hospital https://www.nepjol.info/index.php/JKMC/article/view/28168 <p><strong>Background:</strong> With the advent of anesthesia, surgery is no longer a race against the clock and surgeons. Many studies in&nbsp;the past have demonstrated limited knowledge among patients about various aspects of anesthesia.<br><strong>Objectives:</strong> To assess the awareness and concern of elective surgical patients towards anesthesia.<br><strong>Methodology:</strong> A cross-sectional questionnaire survey was conducted over two months’ period in adult patients of age&nbsp;eighteen years and above. Two hundred surgical patients accessing services at the pre-anesthesia check-up clinic were&nbsp;interviewed using 12 questions assessing demographic characteristics, educational status and their knowledge about&nbsp;anesthesia.<br><strong>Results:</strong> Out of 200 patients, only 32% knew that anesthesiologists provide anesthesia. It was found that 63% didn’t have&nbsp;any knowledge about the types of anesthesia. The most common fear among the participants about anesthesia was the&nbsp;fear of pain during surgery.<br><strong>Conclusion:</strong> The study showed poor knowledge of patients regarding anesthesia.</p> Sushila Lama Moktan Ujma Shrestha Mona Sharma Manan Karki ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 76 80 10.3126/jkmc.v8i2.28168 Awareness and practice regarding cervical cancer screening among women visiting a tertiary hospital of Kathmandu https://www.nepjol.info/index.php/JKMC/article/view/28169 <p><strong>Background:</strong> Cervical cancer is the leading female cancer in Nepal. Fortunately, it is preventable by detecting<br>precancerous lesions and by various screening tools for early invasive cancers. Screening can be possible if women are&nbsp;aware of the problem. Despite the existence of effective screening using Pap smear, the uptake of screening is poor.<br><strong>Objectives:</strong> The objective of this study was to assess the awareness and practice regarding cervical cancer screening&nbsp;among women visiting tertiary hospital.<br><strong>Methodology:</strong> A descriptive cross – sectional study was conducted to assess the awareness and practice regarding&nbsp;cervical cancer screening among women attending in gynaecological outpatient department of Kathmandu Medical&nbsp;College Teaching Hospital. A total of one hundred and fifty two women were selected purposively for the study.&nbsp;Structured questionnaire was designed and data collection was done through face to face interview technique during&nbsp;the period of September to November 2018. The collected data were analyzed by using Statistical Package for Social&nbsp;Science version 20.<br><strong>Results:</strong> Among 152 respondents, majority of the respondents (59.2%) were aware that multiple sexual partners is one of&nbsp;the risk factors of cervical cancer. 38.8% were aware that cervical cancer can be prevented by regular cervical screening.&nbsp;Majority of the respondents: 152 (44.7%) had given correct response regarding meaning of cervical cancer screening and&nbsp;42.8% were aware of Pap smear test for cervical screening. Only 31.6% had performed cervical cancer screening at least&nbsp;once. Overall mean percentage knowledge was 3.08 with SD 0.96.There was weak correlation between knowledge and&nbsp;practice.<br><strong>Conclusion:</strong> This study concluded that majority of respondents had inadequate knowledge and practice regarding&nbsp;cervical cancer screening. Thus, cervical cancer screening health camps and awareness program should be conducted&nbsp;at community to national level for women, to increase the level of knowledge and practice regarding cervical cancer&nbsp;screening.</p> Puspa Parajuli Narayani Paudel Sunita Dahal ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 81 86 10.3126/jkmc.v8i2.28169 Maxillary sinus - A tool for sex determination in the Nepalese population https://www.nepjol.info/index.php/JKMC/article/view/28170 <p><strong>Background:</strong> In forensic science, skeletal examination is often done with primary focus on identification. Complete&nbsp;identification is a rare event in this type of examination. However, anthropological identification can be done in skeletal&nbsp;examination. Skull is the second best for determination of sex next to pelvis. Maxillary sinuses are paranasal sinuses, and&nbsp;a feature for sexual dimorphism which remains intact in partially charred. The study of maxillary sinus is best done on&nbsp;Computed Tomography.<br><strong>Objectives:</strong> The primary objective of this study is to evaluate bilateral maxillary sinus for sexual dimorphism using&nbsp;Computed Tomography.<br><strong>Methodology:</strong> A total of 104 CT head cases were studied of which 52 were male and 52 female. The anterior posterior&nbsp;length, transverse width and height of bilateral maxillary sinus were measured in male and female through their DICOM&nbsp;images using inbuilt electronic calliper. Descriptive analysis for mean, paired t test to compare right and left maxillary&nbsp;sinus in both male and female, and student t test for compare male and female were used for analysing the value&nbsp;measured and calculated.<br><strong>Results:</strong> Male maxillary sinus (Right 12.76±4.62 &amp; Left 12.39±3.81) was found be to larger than that of female (Right&nbsp;12.16±4.78 &amp; Left 11.80±4.49). Right and left maxillary sinus of both the sexes showed no significant difference when&nbsp;paired t test was used. Using independent t-test showed no sexual dimorphism between the two sexes.<br><strong>Conclusion:</strong> Maxillary sinus is not good tool for sex determination in Nepalese population. However further studies could&nbsp;be done on larger population sample, as smaller sample size could be the limitation of this study.</p> Pankaj Kumar Singh Ram Chandra Paudel Ritesh G Menezes Kishor Khanal ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 87 91 10.3126/jkmc.v8i2.28170 Early identification of patients at risk of acute severe pancreatitis with Systemic Inflammatory Response Syndrome score at admission https://www.nepjol.info/index.php/JKMC/article/view/28171 <p><strong>Background:</strong> Clinically, the Systemic Inflammatory Response Syndrome (SIRS) is identified by two or more symptoms&nbsp;including fever or hypothermia, tachycardia, tachypnea and change in blood leukocyte count. The relationship between&nbsp;SIRS symptoms at the time of presentation and severity of pancreatitis is yet to be determined though progression of SIRS&nbsp;in subsequent days has already been correlated.<br><strong>Objectives:</strong> To determine the severity of pancreatitis with SIRS score at the time of admission.<br><strong>Methodology:</strong> A retrospective cohort study of patients admitted to Department of Surgery, Kathmandu Medical College&nbsp;Teaching Hospital (KMCTH) with diagnosis of Acute Pancreatitis (AP) from December 2014 to January 2016 was conducted.&nbsp;Clinical, biochemical and imaging data were collected from the medical record section. Patients with diagnosis of acute&nbsp;pancreatitis as per Revised Atlanta Classification 2012 were included in the study. SIRS score at time of admission was&nbsp;correlated with Modified Marshall scoring system for organ dysfunction. Patients were grouped into severe and nonsevere&nbsp;group. Sensitivity, specificity and predictive values of SIRS score at admission for organ failure were calculated.<br><strong>Results:</strong> Among the 41 patients admitted with diagnosis of acute pancreatitis irrespective of cause, the sensitivity of SIRS&nbsp;score ≥2 at admission in predicting severe pancreatitis was 60 %, specificity was 20%, positive predictive value was 28%&nbsp;and negative predictive value was 20 %, with p-value of 0.52 and odds ratio of 1.6 (CI: 0.376-6.808).<br><strong>Conclusion:</strong> SIRS score at admission cannot be solely used in predicting acute severe pancreatitis. Patients can be&nbsp;stratified in resource deficit setting for timely referral to tertiary centre.</p> Uttam Laudari Abishek Thapa Tanka Prasad Bohara Shail Rupakheti Mukund Raj Joshi ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 92 95 10.3126/jkmc.v8i2.28171 Lifestyle patterns on prevention of coronary artery disease among hypertensive clients, attending a tertiary hospital, Kathmandu https://www.nepjol.info/index.php/JKMC/article/view/28172 <p><strong>Background:</strong> Hypertension is one of the major risk factors for cardiovascular disease, especially for coronary artery&nbsp;disease. Healthy lifestyles will delay the progression of coronary artery&nbsp;disease.<br><strong>Objectives:</strong> To find out the life style pattern on prevention of coronary artery&nbsp;disease among hypertensive clients.<br><strong>Methodology:</strong> This is a descriptive; cross sectional research design based on quantitative approach. Non probability&nbsp;purposive sampling was used to select 202 respondents attending Outpatient Department at Manmohan Cardiothoracic&nbsp;Vascular and Transplant Centre, Kathmandu. Data was collected by interview technique using semi-structured&nbsp;questionnaire by researcher herself. Descriptive and inferential statistics were used to analyze the data.<br><strong>Results:</strong> Findings of the study showed that 7.90% of hypertensive clients consumed ≥ 5 servings of fruits and vegetables&nbsp;per day, whereas 97.52% were engaged in vigorous intensity work and current tobacco and alcohol consumers were&nbsp;28.57% and 33.80% respectively. Adherence to all four healthy lifestyle pattern (Diet, Physical Activity, Tobacco Use and&nbsp;Alcohol Consumption) was 32.7%, whereas more than half (58.9%) of the clients adhered to three lifestyle pattern. There&nbsp;was significant association between dietary pattern and economic status (p = 0.018) and ethnicity (p = &lt;0.001); and&nbsp;tobacco use and sex (p = &lt;0.001).<br><strong>Conclusion:</strong> Adherence to healthy lifestyle pattern of hypertensive clients was inadequate. Thus, health education and&nbsp;other interventions to promote healthy lifestyle pattern are suggested.</p> Anju Kumari Mahato Mandira Onta Tulashi Adhikari Mishra ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 96 102 10.3126/jkmc.v8i2.28172 Awareness regarding diabetes mellitus among individuals attending a hospital, Bhaktapur https://www.nepjol.info/index.php/JKMC/article/view/28173 <p><strong>Background:</strong> Diabetes mellitus is the most prevalent metabolic condition and one of the major health and socioeconomic&nbsp;problems worldwide. Awareness of risk factors and prevention of diabetes plays a major role for prevention of diabetes&nbsp;mellitus in general population.<br><strong>Objectives:</strong> To assess level of awareness regarding diabetes mellitus risk factors and preventive measures among&nbsp;individuals who attended General Practice outpatient department at Kathmandu Medical College Teaching Hospital,&nbsp;Duwakot, Bhaktapur.<br><strong>Methodology:</strong> This is a descriptive study conducted in Department of General Practice and Emergency of Kathmandu&nbsp;Medical College Teaching Hospital. The study included 370 patients attending General Practice outpatient department&nbsp;from November 2018 to April 2019. The data collected was entered in the Statistical Package for the Social Sciences&nbsp;software and analysed for results. Ethical clearance was taken from Institutional Review Committee of Kathmandu&nbsp;Medical College.<br><strong>Results:</strong> The study included 370 participants; the mean age was 40.83±12.21 years. More than half of the participants&nbsp;(56.5%) were females and 43.5% were males. The most commonly mentioned risk factor was lack of physical activity and&nbsp;obesity. Almost 80% participants correctly stated that physical activity could help prevent diabetes mellitus. There was&nbsp;no statistical significance between awareness and educational level of participants.<br><strong>Conclusion:</strong> This study showed that proper awareness programs need to be carried out in rural and urban communities&nbsp;to prevent diabetes and its complications. In this study, patient awareness about risk factors and preventive measures&nbsp;was not appreciable. Association of awareness with age, sex and education level was not statistically significant.</p> Rita Kafle Binita Pradhan Ram Krishna Chandyo ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 103 107 10.3126/jkmc.v8i2.28173 Radiofrequency ablation as a concomitant procedure for the treatment of atrial fibrillation during cardiac surgery https://www.nepjol.info/index.php/JKMC/article/view/28174 <p>Atrial fibrillation is the most common type of arrhythmia with increasing burden for stroke and thromboembolic&nbsp;events. Medical treatment of&nbsp;atrial fibrillation has not shown promising results, so alternative method of treatment is emerging out. Cox-Maze procedure has been used for decades for the treatment of atrial fibrillation. Surgical treatment of atrial fibrillation with traditional Cox-Maze procedure is a complex and technically challenging procedure limiting its use in clinical practice. Recently, radiofrequency ablation is being used as a modification of Cox-Maze procedure. However, its effect in the treatment of atrial fibrillation in not reported uniformly and in large number of patients. Therefore, our aim of study was to assess the impact of concomitant radiofrequency ablation in the treatment of atrial fibrillation during cardiac surgery. We performed literature review on PubMed Central to evaluate effect of concomitant radiofrequency ablation for atrial fibrillation treatment. About 303 papers were found using the reported search, of which 15 represented suitable to fulfill our query. The authors, date, patient group, study type, relevant outcomes and results of these papers are tabulated. We conclude that radiofrequency ablation surgery of left atrium at&nbsp;the time of other cardiac procedures is a comparatively straightforward procedure with satisfactory freedom from atrial fibrillation, acceptable morbidity, mortality, and minor procedure related complications. Careful patients selection by sticking to the - Rule of 5, i.e. left atrial diameter less than 55 mm and atrial fibrillation duration no more than five years, is recommended to optimize the result of atrial fibrillation surgery.</p> Kaushal K Tiwari Tommaso Gasbarri Stefano Bevilacqua Manish Jawarkar Mausam Shah Chirag Doshi Mattia Glauber ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 108 115 10.3126/jkmc.v8i2.28174 West syndrome - Diagnostic dilemma in a month old infant without typical electroencephalographic features: A case report https://www.nepjol.info/index.php/JKMC/article/view/28175 <div>Infantile spasm constitutes 2% of childhood epilepsies but 25% of epilepsy with onset in the first year of life. The rate&nbsp;of infantile spasm is estimated to be 2.5-6.0 cases per 10,000 live births. Its prevalence rate is 1.5-2.0 cases per 10,000 children aged 10 years or younger. Ninety percent of infantile spasms begin in infants younger than 12 months with a peak onset at age 4-6 months.&nbsp;</div> <div>We report a case of 45 days old male child who had onset of flexor spasms since one month of age which is an unusual age of onset of West syndrome. The symptoms were initially thought as a simple startle response by the mother. This is a rare case because of its age of onset and lack of typical electroencephalographic features. Although the electroencephalography showed abnormal pattern suggesting seizure disorder, the frequently encountered pattern of hypsarrhythmia seen in children with infantile spasm was not seen in this case. It was difficult to assess developmental regression in a month old child who in subsequent visits had some degree of developmental delay. Hence fulfilling two of the three criterias for the diagnosis.</div> Kiran Subedi Rydam Basnet Bikash Bhandari Sonsy Gongal Ashik Rajak ##submission.copyrightStatement## 2019-06-30 2019-06-30 8 2 116 117 10.3126/jkmc.v8i2.28175