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 <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> en-US <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> editor@jkmc.com.np (Dr. Abhinav Vaidya) sioux.cumming@ubiquitypress.com (Sioux Cumming) Mon, 06 Jun 2022 12:52:50 +0000 OJS 3.3.0.6 http://blogs.law.harvard.edu/tech/rss 60 Nutritional and immunisation status of children visiting hospital during COVID-19 pandemic in Kathmandu, Nepal https://www.nepjol.info/index.php/JKMC/article/view/45486 <p><strong>Background:</strong> The coronavirus disease-2019 (COVID -19) outbreak and lockdown measures have given challenges related to food production, food supply chain, indulgence in low healthy processed food, lack of public transportation, difficulties in accessing emergency and regular health services. Nepal already has high burden of child mortality (39 deaths per 1000 live births) and this pandemic situation has put children at greater risk of facing hunger, malnutrition, lack of routine immunisation, communicable disease outbreak, and many more psychological as well as physical health issues. <br /><strong>Objectives:</strong> This study identifies nutritional status and gap in routine vaccination in children during COVID-19 pandemic thereby help in modelling action plan to prevent an outpouring in malnutrition and vaccine preventable infections in children. <br /><strong>Methods:</strong> This is a hospital-based analytical cross-sectional study done among 138 children of ages one to 59 months old from 1st January 2021 to 1st August 2021 attending paediatric clinic of KMCTH. <br /><strong>Results:</strong> In this study, 20 (14.4%) of the children were stunted, 23 (16.6%) were wasted and 15 (10.8%) were categorised under undernutrition, three (2.2%) were overweight and three (2.2%) were obese. There were significantly more male children stunted than female (p-value = 0.005). Thirty-five (33.3%) of less than 15 months children were reported to have delay of more than two weeks in routine immunisation of children. A significant delay of more than four weeks was observed in 29 (27.6%). <br /><strong>Conclusion:</strong> Indirect impact of COVID-19 pandemic in children like malnutrition and gap in routine vaccination needs to be addressed seriously in Nepal.</p> Pawana Kayastha, Vijaya Kumar Chikanbanjar, Rajesh Kumar Panday, Sunil Raja Manandhar Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45486 Mon, 06 Jun 2022 00:00:00 +0000 Preoperative ultrasonographic prediction of difficult airway in patients undergoing surgery under general anaesthesia https://www.nepjol.info/index.php/JKMC/article/view/45487 <p><strong>Background:</strong> Preoperative assessment of the airway with ultrasound has come up as a viable option to aid the preanaesthetic airway assessment. <br /><strong>Objectives:</strong> To identify reliable ultrasound parameters as predictors of difficult airway in patients undergoing surgery under general anaesthesia. <br /><strong>Methods:</strong> A prospective analytical cross-sectional study was conducted at Kathmandu Medical College in 99 consecutive patients scheduled for elective surgery with general anaesthesia and endotracheal intubation from July 2019 to June 2020 after ethical clearance. Three ultrasound parameters were used for this study. Distance from the skin to the anterior aspect of trachea at the level of vocal cords (ANS-VC), the depth of the pre-epiglottic space (PreE), the distance from the epiglottis to the midpoint of vocal cords (EVC) was measured. The PreE/EVC and hyomental distance ratio (HMDR), which is the distance ratio of hyomental distance at neutral and extended head position were calculated. These ultrasonographic parameters were used to predict difficult laryngoscopy Cormack-Lehane (CL) grading 3, 4. <br /><strong>Results:</strong> Difficult intubation was seen in 23 (23.2%) as CL grade 3. The authors did not encounter CL grade 4. HMDR and PreE/EVC have been shown to have significant association with CL grading, with a specificity of 71% and 77% respectively and a high negative predictive value of 84.3% and 84.2% respectively. Therefore, it is valuable in predicting difficult intubation. ANS-VC did not have a significant correlation. <br /><strong>Conclusion:</strong> Diagnostic predictability of difficult airway is better with HMDR and PreE/E-VC.</p> Mona Sharma, Saurya Dhungel, Buna Piya, Ritika Gautam Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45487 Mon, 06 Jun 2022 00:00:00 +0000 Low-cost vacuum-assisted closure dressing in wound management: An effective alternative for Nepal https://www.nepjol.info/index.php/JKMC/article/view/45488 <p><strong>Background:</strong> Low-cost vacuum-assisted closure (VAC) can be used as an alternative method for wound management. <br /><strong>Objectives:</strong> To observe the effectiveness of low-cost vacuum-assisted closure dressing in wound management. <br /><strong>Methods:</strong> A descriptive cross-sectional hospital-based study was conducted in the Department of Plastic Surgery, Kathmandu Medical College from April 2021 to February 2022 to observe age, sex, indication, type of wound with history of comorbidities, number of dressings, duration of hospital stays, and complications like: bleeding, haematoma, and delay in wound healing . <br /><strong>Results:</strong> A total of 22 patients were included by convenience sampling technique in the study with 21 (95.5%) acute and one (4.5%) case of chronic wound with ulcer. The mean age was 39 ± 18.157 years ranging from 13-76 years. Most of them were males (15, 68.2%). The mean duration of wound presentation was 5.45 ± 9.127 days ranging from 1-45 days. The mean duration of hospitalisation was 20.45 ± 11.467 days ranging from 5-45 days. Eight (36.4%) patients were with comorbidities like Diabetes Mellitus, Hypertension, Peripheral vascular diseases etc., and no mortality was recorded. <br /><strong>Conclusion:</strong> Low-cost Vacuum-assisted closure is a very easy and efficient alternative method for wound care.</p> Amir Bajracharya Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45488 Mon, 06 Jun 2022 00:00:00 +0000 Persistent otorhinolaryngological symptoms in patients following COVID-19 infection https://www.nepjol.info/index.php/JKMC/article/view/45489 <p><strong>Background:</strong> Patients having coronavirus disease 2019 (COVID-19) may have persistent symptoms even after weeks or months of recovery. Although there are several studies on persistence of general symptoms, research primarily focussing on post COVID otorhinological symptoms are scarce. <br /><strong>Objective:</strong> The aim of study was to assess the persistent otorhinolaryngological symptoms among the patients within a period of three months of recovery from COVID -19 infection. <br /><strong>Methods:</strong> An analytical cross-sectional study was carried out in the ENT OPD of Kathmandu Medical College Teaching Hospital Nepal from July 2021 to September 2021. Ninety-one consecutive patients who recovered from COVID-19 were evaluated. The frequency of otorhinolaryngological manifestations at the time of presentation and during the active COVID-19 illness were interpreted and classified as nasal, aural, and throat symptoms. <br /><strong>Results:</strong> The commonest persistent nasal symptoms were the nasal obstruction in 15 out of 43 patients during COVID (15/43, 34.88 %), followed by nasal discharge (2/12, 16.66%), loss of smell (12/73, 16.43%), and frontal headache (8/40, 20%). Twenty patients had persistent aural symptoms and all of them had tinnitus (8/8, 100%) followed by earache (4/7, 57.14%), hearing loss (3/6, 50%) and dizziness (4/14, 28.57%). Thirty-four patients had persistent throat symptoms. The most common was sore throat (23/49, 46.93%) followed by itching (4/13, 30.76%), hoarseness (3/25, 12%), and dry cough (3/52, 5.7%). <br /><strong>Conclusion:</strong> Many ENT OPD patients had variable nasal, aural, and throat complaints at the time of infection which was still persisting in majority of them within three months of recovery from COVID-19.</p> Deepak Regmi, Naresh Manandhar Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45489 Mon, 06 Jun 2022 00:00:00 +0000 Symmetrical comparison of crown size, morphology and gingival shape in maxillary incisors https://www.nepjol.info/index.php/JKMC/article/view/45490 <p><strong>Background:</strong> Maxillary anterior tooth proportion has special value in dental aesthetics. Restorative dentistry often involves correcting tooth size discrepancies. Therefore, dental biometrics should play an important role in the planning of an aesthetic restoration. <br /><strong>Objectives:</strong> To assess and compare clinical crown dimensions and classify crown shape and gingival shape of the maxillary incisors in order to collect anatomical data on the anterior teeth of young population visiting the tertiary centre. <br /><strong>Methods:</strong> This descriptive cross-sectional study conducted in department of Prosthodontics in November 2021 after getting ethical approval among dental students and patients attending the hospital, with permanent healthy dentitions. Impression of maxillary and mandibular arches were made with alginate and poured in dental stone. Measurement of maxillary central incisors was done for length and thickness with the digital vernier calliper. Convenience sampling was done. Data were recorded and analysis done with SPSS v.20. <br /><strong>Results:</strong> The mean value of crown length, crown thickness, mesiodistal width of left central incisor was greater compared to the right side (Left vs Right: 9.01 ± 1.14 mm vs 9 ± 1.14 mm , 7.04 ± 0.67 mm vs 6.96 ± 0.61 mm, 8.25 ± 0.59 mm vs 8.20 ± 0.51 mm). <br /><strong>Conclusion:</strong> Crown length and crown width of maxillary left central incisor were greater compared to maxillary right central incisor. Shape of maxillary incisors determines the shape of the gingiva. The average values of length and widths of the central incisors derived from this study can be a valuable template for prosthodontic and aesthetic planning.</p> Barsha Ghimire, Shaishab Dhital Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45490 Mon, 06 Jun 2022 00:00:00 +0000 Is anterior cruciate ligament reconstruction necessary for the non-sporting population? https://www.nepjol.info/index.php/JKMC/article/view/45491 <p><strong>Background:</strong> Anterior cruciate ligament injury (ACL) is a common injury in both sporting and non-sporting population. All patients with an ACL injury may not require surgery. The criteria for deciding whether a reconstruction should be performed are not absolute and the trend is to offer reconstruction to the sporting population as they require a stable knee to perform in their line of work. The non-sporting population also require a stable knee to perform their daily activities. <br /><strong>Objectives:</strong> To assess functional outcome in the non-sporting patients following reconstruction. <br /><strong>Methods:</strong> A prospective observational analytical study was conducted in the age group from 18 to 55 years, with symptomatic ACL injury who were not involved in sporting activities from July 2020 to December 2021. Fifty patients participated in the study. Convenience sampling technique was used. The IKDC and Lysholm scores were used preoperatively and six months post-operatively to assess the benefit of the treatment. <br /><strong>Results:</strong> Out of 50 patients, four were lost to follow up. Out of total 46 patients, 29 (63.04%) patients were male and 17 (36.96%) patients were female. The mean age of patients was 31.61 ± 7.38 years. The IKDC and Lysholm scores measured preoperatively were 47.07 ± 7.51 and 52.17 ± 7.91 and the six-month post-operative scores were 86.73 ± 5.54 and 90.69 ± 4.63 respectively. <br /><strong>Conclusion:</strong> The patients from the non-sporting population who underwent ACL reconstruction had significantly improved IKDC as well as Lysholm scores compared to their function prior to the procedure.</p> Rajeev Raj Manandhar, Krishna Raj Khanal, Saroj Gautam, Aman Gupta, Himal Khanal, Suraj Bhusal Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45491 Mon, 06 Jun 2022 00:00:00 +0000 Impact of second wave of COVID-19 related lockdown on patients undergoing fixed orthodontic treatment in a dental teaching hospital https://www.nepjol.info/index.php/JKMC/article/view/45492 <p><strong>Background:</strong> Lockdown due to second wave of COVID-19 was implemented, in Kathmandu from April 29, 2021. In most of the dental hospitals, patients’ regular appointments were temporarily suspended and only emergency treatments were considered. <br /><strong>Objectives:</strong> To assess the impact of the COVID-19 related lockdown on the treatment among patients undergoing fixed orthodontic treatment. <br /><strong>Methods:</strong> A descriptive cross-sectional study was conducted among 170 individuals undergoing fixed orthodontic treatment at Kathmandu Medical College Teaching Hospital from 1st July to 30th September 2021 after obtaining ethical approval. A standard pretested self-administered online questionnaire having questions regarding impact of COVID-19 on orthodontic treatment was sent to all the study participants. Data were entered in Microsoft Excel Sheet and analysed in Statistical Package for Social Sciences version 20. Descriptive statistics like mean, standard deviation, frequency, and percentage were calculated depending upon the nature of data. <br /><strong>Results:</strong> Majority of the study participants (113, 66.5%) did not visit orthodontist for more than one month due to second wave of COVID-19 and were very worried (84, 49.4%) for not getting to go for regular follow-ups for their treatment. Most of them were worried thinking that their treatment time will be extended (134, 78.8%), and some (97, 57.1%) participants faced problems like broken brackets and elastics. <br /><strong>Conclusion:</strong> This study concluded that second wave of COVID-19 had some impact on orthodontic patients. This study highlighted the importance of teledentistry for orthodontic consultation and also the need for preparing the patients to deal with orthodontic appliances if required to prevent trauma.</p> Prakash Poudel, Sirjana Dahal Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45492 Mon, 06 Jun 2022 00:00:00 +0000 Efficacy and safety of oral mifepristone in induction of labour in prolonged pregnancy https://www.nepjol.info/index.php/JKMC/article/view/45493 <p><strong>Background:</strong> Induction of labour implies, achieving vaginal delivery by stimulating uterine contractions before spontaneous onset of labour. Prolonged pregnancy exceeding duration of expected date of delivery is associated with increased risk to foetus and most common indication for induction of labour. <br /><strong>Objectives:</strong> To study the safety and efficacy of oral mifepristone in induction of labour in prolonged pregnancy. <br /><strong>Methods:</strong> This experimental study was carried out in Universal College of Medical Sciences Teaching Hospital, Bhairahawa between June 2016 to June 2017 after ethical clearance. Total 102 women were included in the study with 51 participants in the study group (mifepristone) and 51 in the control group (misoprostol). Data were expressed in frequency and mean ± SD and analysed using Independent “t” test and Chi-square test. A p-value of &lt;0.05 was considered significant. Safety and efficacy of the drug was analysed with regards to maternal and perinatal outcome. <br /><strong>Results:</strong> Single dose of mifepristone was sufficient enough for successful induction in 40 (78.43%) women in study group. Time interval from induction to delivery had maximum frequency of 6-12 hours in both groups (p-value 0.13). The active phase of labour lasted for 2-6 hours in 38 (74.5%) women of the study group. Around 27 (42.9%) women of study group required augmentation of labour and 49 (96.1%) women had vaginal delivery. There was no significant difference in perinatal outcome between both the groups. <br /><strong>Conclusion:</strong> Mifepristone combined with or without augmentation is safe, efficient, economical, and convenient induction agent for initiation of labour in prolonged pregnancies.</p> Rubby Das, Nilam Subedi, Subrina Rajbhandari, Gahana Gurung Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45493 Mon, 06 Jun 2022 00:00:00 +0000 Evaluation of marginal bone level after implant placement and before loading, by digital radiography https://www.nepjol.info/index.php/JKMC/article/view/45494 <p><strong>Background:</strong> Marginal bone loss around dental implant is one of the criteria for evaluating implant success. <br /><strong>Objectives:</strong> To evaluate the marginal bone loss around dental implants using digital radiographs and to determine correlation of mesial and distal bone loss around dental implants with gender and location in either arch in a period of 3-6 months after placement and before prosthetic loading. <br /><strong>Methods:</strong> An analytical study was undertaken from July 2021 till December 2021, after ethical clearance, in 18 patients on whom 23 implants had been placed at Dhulikhel hospital. After implant placement first radiograph was taken by CE 0297 size 2 PSP plate and Carestream (CS2100) intraoral periapical radiograph machine using paralleling technique (XcpRinn Device) and second at 3-6 months later. The radiographs were viewed using image viewer software (Vistasoft2.0.1) to calculate the bone level. Calculating the difference in bone level at zero month and at 3-6 months gave us the amount of bone loss which was entered in Excel sheet and transferred to SPSS v.22 for analysis and student unpaired-t test was used.<br /><strong>Results:</strong> The mean bone loss was 0.27 ± 0.2 mm on mesial aspect and 0.13 ± 0.3 mm on distal aspect at the end of the study period. No statistically significant bone loss in relation to gender and location of implant placement was found. <br /><strong>Conclusion:</strong> Within the limitation of the study, no significant difference was found in the mesial and distal aspect of bone loss around dental implant when compared with different parameters.</p> Binam Sapkota, Chandan Upadhyaya, Ujjwal Rimal, Swagat Kumar Mahanta Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45494 Mon, 06 Jun 2022 00:00:00 +0000 Clinico pathological study of Odontogenic cysts and tumors in a Tertiary care Dental hospital of Nepal https://www.nepjol.info/index.php/JKMC/article/view/45495 <p><strong>Background:</strong> Diagnosis of odontogenic cysts and tumours requires detailed clinical, radiographical, and histopathological findings. Fourth edition WHO 2017, classification of Head and Neck lesions, reclassified odontogenic cysts and tumours. <br /><strong>Objectives:</strong> To know relative frequency of odontogenic cysts and tumours according to WHO 2017 classification and to know their clinico-pathological characteristics in selected population of Nepal. <br /><strong>Methods:</strong> An analytical cross-sectional study was done in 163 biopsies. Data were obtained conveniently from records of patients diagnosed with odontogenic cysts and tumours from April 2014-2021. Cases with complete clinical details were included whereas non-odontogenic cysts, oral soft tissue, and salivary gland lesions were excluded. Reclassification according to WHO 2017 classification was done. Age, gender, site, clinical presentations, and histological type were analysed using SPSS v.21. <br /><strong>Results:</strong> In total of 163 biopsies, 120 (73.62%) cases were of odontogenic cysts and 43 (26.38%) cases were of odontogenic tumours. The mean age of occurrence for cysts was 33.35 ± 16.67 years and for tumours was 28.91 ± 13.96 years. Radicular cyst (49/120, 40.83%) and conventional ameloblastoma (23/43 53.48%) were the commonest cysts and tumours. Male (67/120, 55.83%) and female (24/43, 55.81%) predisposition was seen in cysts and tumours. Mandibular middle and posterior region were commonly affected in both cysts (58/162, 35.8%) and tumours (38/53, 71.7%). <br /><strong>Conclusion:</strong> Increased frequency of radicular cysts and conventional ameloblastoma were appreciated with male predisposition in tumours and female predisposition in cysts. Both cysts and tumours were common in second to third decade of life affecting middle and posterior region of mandible.</p> Dipshikha Bajracharya, Bidhata Ojha , Sushmit Koju, Nisha Maharjan Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45495 Mon, 06 Jun 2022 00:00:00 +0000 Operative difficulty grading scale for laparoscopic cholecystectomy at a tertiary care hospital in Eastern Nepal https://www.nepjol.info/index.php/JKMC/article/view/45497 <p><strong>Background:</strong> Predictions of difficult cholecystectomy preoperative make the surgeon prepared, thereby making a more careful dissection, back up from senior surgeons, and a low threshold for early conversion. <br /><strong>Objectives:</strong> To utilise an operative grading scale to predict open conversion, duration of surgery, total length of stay, complications and to validate Nassar score. <br /><strong>Methods:</strong> This was a prospective cross-sectional study done from 2020 July 9 to 2021 January 30 after ethical clearance among all patients of BPKIHS planned for laparoscopic cholecystectomy for symptomatic gallstone disease. Nassar scale was used for risk evaluation of difficult cholecystectomy. The intraoperative outcome parameters were bleeding, bile spillage, stone spillage, presence of bowel or biliary injury, operative time and conversion to open surgery. Postoperative outcomes noted were total length of stay, 30-day complications, reintervention, and mortality. The data were entered in Microsoft Excel sheet 2010 and analysis was done in SPSS v.26. <br /><strong>Results:</strong> Seventy-four patients were analysed. Comparison of Nassar scoring system with outcomes revealed a significant association of rising Nassar grade with bile spillage, stone spillage, bleeding, post-surgical drain placement, conversion to open, duration of surgery, and total length of stay. Operative time was significantly more in male, cholecystitis, and interval cholecystectomy. Conversion to open was significantly associated with Nassar grade 4, acute cholecystitis, and interval cholecystectomy. There was no mortality, 30-day reintervention, and complication. <br /><strong>Conclusion:</strong> Nassar operating scale is simple scale that can be used by all level of surgeons to predict difficult laparoscopic cholecystectomy. Rising grades have significant correlation with difficulty and complications.</p> Nirmal Prasad Sah, Rakesh Kumar Gupta, Laligen Awale, Kunal Bikram Deo, Rupesh Prasad Sah, Abhijeet Kumar, Suresh Prasad Sah Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45497 Mon, 06 Jun 2022 00:00:00 +0000 Gastrointestinal manifestations and outcomes of hospitalised patients with COVID-19 disease https://www.nepjol.info/index.php/JKMC/article/view/45496 <p><strong>Background:</strong> COVID-19 infection usually presents with respiratory symptoms. Many hospitalised patients of COVID-19 present with gastrointestinal symptoms which can alter the clinical outcomes of patients. <br /><strong>Objectives:</strong> To characterise the gastrointestinal manifestations of COVID-19 patients requiring hospitalisation and their correlation with disease severity and clinical outcomes. <br />Methods: This was a single centre prospective, observational, cohort study done at Kathmandu Medical College, a tertiary health care centre after ethical clearance. All consecutive hospitalised patients with COVID-19 disease admitted during May and June 2021 were included in the study after ethical clearance. Diagnosis of COVID-19 infection was done by RT-PCR. Gastrointestinal symptoms of abdominal pain, aguesia, nausea/vomiting, and diarrhoea were recorded on hospital admission and outcomes accessed at discharge. Data were analysed using SPSS v.24. <br /><strong>Results:</strong> A total of 196 consecutive adult patients with COVID-19 infection were included in study. Gastrointestinal symptoms were recorded in 48 (24.5%) patients. The most frequent symptom was nausea/vomiting (23, 11.7%) followed by aguesia (19, 9.7%), diarrhoea (14, 7.1%), and abdominal pain (8, 4.1%). There was no significant association between duration of hospital stay and presence of gastrointestinal symptoms (10.15 vs 10.95 days; p = 0.481). No significance was seen on association of gastrointestinal symptoms with ICU admission and mortality but requirement of mechanical ventilation was significantly higher in patients without symptoms (10.4 vs 23.6%; p = 0.048). <br /><strong>Conclusion:</strong> Significant proportion of patients with COVID-19 infection can have gastrointestinal manifestations. Presences of these symptoms do not have any association with the final clinical outcome of the patient.</p> Shekhar Poudel, Sujan Chandra Poudel, Aakash Mishra, Tulsi Ram Bhattarai Copyright (c) 2022 https://www.nepjol.info/index.php/JKMC/article/view/45496 Mon, 06 Jun 2022 00:00:00 +0000 Brain drain in Nepal and the plight of young health professionals https://www.nepjol.info/index.php/JKMC/article/view/45484 <p>Not available.</p> Subij Shakya Copyright (c) 2022 Journal of Kathmandu Medical College https://www.nepjol.info/index.php/JKMC/article/view/45484 Mon, 06 Jun 2022 00:00:00 +0000