Journal of Nepalgunj Medical College 2022-01-16T15:19:49+00:00 Prof. M.N. Marhatta Open Journal Systems <p>Official journal of the Nepalgunj Medical College and Teaching Hospital, Kohalpur, Nepal.</p> Isolated perforation of fourth part of Duodenum following Blunt Abdominal Trauma 2021-10-19T06:01:42+00:00 Prabir Maharjan Shiv Vansh Bharti Digbijay Bikram Khadka Anup Karki Arun Gnyawali <p><strong>Introduction:</strong> Isolated duodenal injuries are rare in blunt abdominal trauma. These present a significant challenge for management because of the associated injuries and its difficult anatomical accessibility.</p> <p><strong>Case presentation: </strong>A 20years male presented to the Emergency department following a bike accident sustaining injury over face, chest and abdomen, 6hours after the incident. His vitals were unstable so he was resuscitated and admitted in Intensive Care Unit. He had generalized abdominal tenderness without rigidity. Contrast enhanced computed tomography of abdomen and pelvis was suggestive of hollow viscus perforation. He underwent exploratory laparotomy and primary repair for isolated perforation at fourth part of duodenum. He was discharged on his ninth postoperative day.</p> <p><strong>Conclusion:</strong> Rare injuries following blunt abdominal trauma should be considered and early intervention is necessary.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Simplified Technique of Conventional Cholecystectomy in a Patient with Situs Inversus Totalis: A Case Report from Nepal 2021-10-19T06:12:44+00:00 Suresh Kumar Nag <p><strong>Introduction:</strong> Situs inversus is a rare autosomal recessive disorder occurring in 1:5,000 to 1:20,000 indiviuals. Cholecystectomy is a standard treatment for symptomatic gallbladder stone. We report a case of cholelithiasis in patient with inversus totalis who underwent cholecystectomy.</p> <p><strong>Case presentation:</strong> A 48 years old obese female patient with dextrocardia and hypertention presented with a recurrent left upper abdominal pain for two years. Ultrasound abdomen showed gallbladder stone. Conventional cholecystectomy was done with a small left subcostal incision. The postoperative period was uneventful and the patient was discharged on 3<sup>rd</sup> post operative day.</p> <p><strong>Conclusion: </strong>Cholecystectomy is the treatment of choice in patients with a left sided gallbladder stone, like in normal gallbladder and it is safe.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Risk Factors and Short Term Morbidities Associated With Term-Small for Gestational Age Babies Delivered at Nepalgunj Medical College 2021-10-19T05:27:40+00:00 Piush Kanodia Arun Kumar Verma Sumit Adhikari <p><strong>Introduction</strong>: Small for gestational age (SGA) refers to birth weight of neonates less than 10<sup>th</sup> percentile for gestational age or 2<sup>nd </sup>standard deviation below the population norms on the growth charts.</p> <p><strong>Aims:</strong> To identify common risk factors and common morbidities for small for gestational age babies.</p> <p><strong>Methods:</strong> This is a cross sectional descriptive study and it has been conducted at Department of pediatrics, Nepalgunj Medical college which is a tertiary level teaching hospital located in western part of Nepal. All term small for gestational age neonates born during study period from January 2020 to December 2020 were included. Detailed baseline demographic and clinical profile has been collected and recorded in the predesigned Proforma.</p> <p><strong>Results:</strong> The most common risk factors associated with small for gestational age babies in our study were maternal hypertension (14.6%) , maternal GDM(9.6%), Urinary Tract Infection (UTI) in 1<sup>st</sup> or 2<sup>nd</sup> trimester of pregnancy, maternal anemia, smoking, alcohol consumption, hypothyroidism and congenital heart disease. The most common short term complications associated with Small for gestational age babies were hypoglycemia and Meconium aspiration syndrome.</p> <p><strong>Conclusion: </strong>The most common risk factors associated with Small for gestational age&nbsp; babies in our study were maternal hypertension, maternal Gestational diabetes Mellitus (GDM), Urinary Tract Infection&nbsp; in 1<sup>st</sup> or 2<sup>nd</sup> trimester of pregnancy, maternal anemia, smoking, alcohol consumption, hypothyroidism and congenital heart disease. The most common short term complications associated with Small for gestational age&nbsp; babies were hypoglycemia and Meconium aspiration syndrome (MAS).</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Assessment of Functional Outcome of Bicolumnar Dual Plating for Bicondylar Fractures of Tibial Plateau 2021-10-19T05:43:08+00:00 Dinesh Kumar Shrestha Dipendra KC Prateek Karki Sabin Shrestha Sushil Yogi <p><strong>Introduction</strong>: Operative treatment of bicondylar fractures of tibial plateau is challenging and controversial.</p> <p><strong>Aims</strong>: The aim of this study is to reveal the functional outcome of it by using bicolumnar dual plates and screws.</p> <p><strong>Methods: </strong>This is a prospective hospital based interventional study carried out in the department of Orthopaedics of Nepalgunj Medical College Teaching Hospital. Thirty two Schatzker type V or AO (Association of Osteosynthesis) type 41 C1 &amp; C2 fractures were treated between January 2016 and December 2019 with bicolumnar dual plating. The functional clinical outcomes were analyzed and evaluated using modified Rasmussen score.</p> <p><strong>Results: </strong>Thirty two patients were included in the study. Out of which twenty four were male and eight were female. Average age was 32.21 years, eighteen were right sided and fourteen were left sided. Duration of surgery was 106 mins (range 90-120 mins) and the average duration of hospitalization was 7.81 days (range 4-14 days). Five patients of impending compartment syndrome and three patients with common peroneal nerve palsy were managed conservatively and also were included in the study. Two patients with superficial wound infection needed minimal debridement. One patient had varus angulation of 10<sup>0</sup> at third follow up after he fell from bed but surgical intervention were not needed. All fractures united. The average time for fracture healing was 21.5 weeks (range 16-32 weeks). At the Eighteen months follow up, the average knee range of motion was 131<sup>0</sup>(range 110<sup>0</sup>-140<sup>0</sup>). The functional outcome were evaluated using modified Rasmussen scoring system, which was 27.34 (range 22-30).</p> <p><strong>Conclusion: </strong>Bicolumnar dual plating for bicondylar fractures of tibial plateau can provide excellent and stable fixation allowing early range of motion and gives excellent to good functional outcome.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Outcomes of Open Cystolithotomy and Percutaneous Cystolithotripsy in the Management of Urinary Bladder Stone 2021-09-29T06:33:07+00:00 Naresh Man Shrestha <p><strong>Introduction: </strong>Urinary bladder stone occupies only 5% of all urinary tract stone. Various techniques have been used for the management of bladder stone. Open Cystolithotomy is the traditional treatment but a percutaneous approach has been also in practice.</p> <p><strong>Aims: </strong>To confirm the best options between open cystolithotomy and percutaneous cystolithotripsy for the treatment of bladder stone.</p> <p><strong>Methods</strong>: It is a prospective hospital based study from May 2019 to January 2021 in Nepalgunj Medical College. Total 42 patients with inclusion criteria were divided into two groups. Group I was allocated to 21 patients who were treated with open cystolithotomy while Group II were allocated to 21 patients who were treated with percutaneous cystolithotripsy. Two groups were compared for stone free rate, mean hospital stay, mean postoperative scar, mean operation time and rate of post-operative complications.</p> <p><strong>Results:</strong> The stone free rate in Group I was 100 % and in Group II was 90.47 %. Mean Operation time was in Group I and Group II were 40.09+ 2.48 minutes and 31.38+15.65 days, respectively with p&lt;0.05. Mean hospital stay was significantly low in Group II (3.71<u>+</u>1.87 days ) when compared to Group I (7.67<u>+</u> 2.12 days) with p&lt;0.001. Mean scar length of Group I (5.466<u>+</u>2.9 cm) with respect to Group II (1.04<u>+</u>0.09) was significantly long (p&lt;0.01). Rate of complications were not significantly different between two groups (p&gt;0.5).</p> <p><strong>Conclusion</strong>: For management of urinary bladder stones sized up to 4 cm, both open cystolithotomy and percutaneous cystolithotripsy are effective, with a low incidence of complications. However, comparing the surgery time, hospital stay, length of scar between two procedures, percutaneous cystolithotripsy procedure is more beneficial for treatment of urinary bladder stone.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Comparison of Treatment Response before and after Antiobsessivae Therapy among Psychiatric Patients with Obsessive Compulsive Disorder 2021-09-29T08:51:00+00:00 Mohan Belbase Jyoti Adhikari <p><strong>Introduction: </strong>Obsessive compulsive disorder is a common, chronic and disabling disorder marked by obsessions and/or compulsions. This study tries to find the demographic profiles, severity and response of antiobsessive drugs in young and adult patients with obsessive compulsive disorder.</p> <p><strong>Aims:</strong> To study the socio-demographic profile, severity and treatment response to commonly used antiobsessive medications in male and female, and young and adults.</p> <p><strong>Methods</strong>: This is a hospital based experimental study done in patients attending to psychiatry out-patient department over one year from February 2020 to January 2021.&nbsp; Diagnosis of obsessive compulsive disorder was made based on International Classification of Disease- 10 criteria for research. Yale-Brown obsessive compulsive scale check list (adult and children) was applied in those patients and recorded accordingly on baseline (week 0) and patients were treated with specific serotonin reuptake inhibitors or tricyclic antidepressants in therapeutic doses for 6 weeks. On follow up at week 6, they were again reassessed and the scores were recorded and analyzed.</p> <p><strong>Results: </strong>Among the total study subject (N-52), 26(50 %) were male and 26(50 %) were females. Patients in age bracket 20-29 is the most common age group representing 18(34.6 %). Mean age of patients is 30.36±11.93 years (28.65±9.80 in male and 32.04±13.73 in female). Severe form of obsessive compulsive disorder was the most common type that represent 33(63.5%) followed by moderate 16(30.8%) and extreme 3(5.7%). There is a difference of treatment response of antiobsessive therapy in male and female with statistical significance (p= 0.039).</p> <p><strong>Conclusion: </strong>This study shows that obsessive compulsive disorder is most commonly found in 20-29 age group and the severe type is the most common. There is a significant difference in treatment response of antiobsessive therapy in male and female.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Comparative Study of Low Pressure versus Standard Pressure Carbon Dioxide Pneumoperitoneum in Reducing Shoulder Tip Pain Post Laparoscopic Cholecystectomy 2021-09-29T09:12:28+00:00 Pradip Thapa Divas Thapa Anup Sharma <p><strong>Introduction: </strong>Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis. Postoperative shoulder tip pain is common complaint. Evidences suggest that using low pressure pneumoperitoneum (8-10 mmHg) during the procedure rather than standard pressure (12-14 mmHg) decreases the incidence and severity of shoulder tip pain without compromising working space.</p> <p><strong>Aims: </strong>The aim of this study was to evaluate the impact of low pressure and standard pressure pneumoperitoneum on shoulder tip pain post laparoscopic cholecystectomy.</p> <p><strong>Methods: </strong>A prospective hospital based study conducted at Nepalgunj Medical College, Kohalpur from January 2019 to December 2020. Hundred patients were enrolled, fifty each in “low pressure carbondioxide pneumoperitoneum” and “standard pressure carbondioxide pneumoperitoneum” groups, who underwent laparoscopic cholecystectomy. The two groups were compared in terms of incidence and severity of shoulder tip pain, surgeon’s satisfaction score, top-up analgesia requirement, procedural time, conversion to standard pressure, intraoperative complications and length of hospital stay.</p> <p><strong>Results: </strong>There were 45 (90%) females and five (10%) males in low pressure group and 44 (88%) females and six (12%) males in standard pressure group. Fourteen (28%) patients in low pressure and 32 (64%) patients in standard pressure group had shoulder tip pain (p=0.001). The severity of shoulder tip pain was less in low pressure group and was significant at eight hours (p=0.006) and 12 hours (p=0.008). Top-up analgesia was required more in standard pressure group. There were no intraoperative complications but only one conversion to standard pressure. Surgeon’s satisfaction score, conversion to open cholecystectomy and procedural time were comparable in both groups with shorter hospital stay in low pressure group.</p> <p><strong>Conclusion: </strong>Low pressure carbondioxide pneumoperitoneum is safe and effective strategy in reducing incidence and severity of shoulder tip pain after laparoscopic cholecystectomy.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Effectiveness of Percutaneous Pedicle Screw Fixation for Traumatic Thoracolumbar Spine Fracture 2021-09-29T09:42:24+00:00 Sandeep Gurung Gopal Sagar DC <p><strong>Introduction: </strong>Surgical treatment of thoracolumbar fracture without neurological damage has resulted in better clinical and radiological outcome than conservative treatment. Traditional open approach is associated with extensive paravertebral muscle damage and postoperative morbidity so percutaneous pedicle screw fixation is highly valuable alternatives.</p> <p><strong>Aims: </strong>to evaluate the efficacy and outcome of percutaneous pedicle screw fixation in the treatment of traumatic thoracolumbar fracture without neurological deficit.</p> <p><strong>Methods: </strong>This study was conducted in Nepalgunj Medical College, Nepalgunj in a time span of one year; total of 40 patients were included and treated with percutaneous pedicle screw fixation and followed up for 6months. They were evaluated clinically and radiologically.</p> <p><strong>Results: </strong>40 patients with thoracolumbar fractures were managed with percutaneous pedicle screw fixation with a mean operative time of 77.30 min and intraoperative blood loss was 88.38ml. There was significant improvement in cobb’s angle (mean difference 13.92 degree), vertebral body height loss (mean difference 37.7%) and visual analogue scale (mean difference 3.55) postoperatively. These improvements remained statically significant at 6months follow up.</p> <p><strong>Conclusion: </strong>Percutaneous pedicle screw fixation is safe, valid and effective treatment of thoracolumbar fracture without neurological deficit.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Study of Mandibular Foramen in Adult Human Mandible Bones: An Osteological Study 2021-09-29T09:53:42+00:00 Anil Kumar Gupta Gaurav Jung Shah Ram Jiban Prasad <p><strong>Introduction: </strong>The mandibular foramen is located on the medial surface of the ramus of mandible through which inferior alveolar nerve and vessels pass and supply the lower jaw. For dentists inferior alveolar nerve block is important to anesthetize the lower jaw for conducting various surgical procedures.</p> <p><strong>Aims:</strong> To determine the accurate position of mandibular foramen through which inferior alveolar nerve and vessels were passing and supply the lower jaw and its clinical importance.</p> <p><strong>Methods: </strong>This study was conducted on 35 dry mandible bones consisting of 70 mandibular foramens of unknown sex. All the important parameters were studied using vernier caliper.</p> <p><strong>Results: </strong>The mean distance of mandibular foramen from mandibular notch was 21.00 mm on right side and 20.29 mm on left side, from posterior border was 12.63 mm on right side and 12.37 mm on left side, from angle of mandible was 20.60 mm on right side and 20.46 mm on left side, from base of the mandible was 23.57 mm on right side and 23.6 mm on left side, from anterior border was 16.74 mm on right side and 16.89 mm on left side.</p> <p><strong>Conclusion: </strong>The accurate position of mandibular foramen varies. The knowledge of the average distance of mandibular foramen from various landmarks is useful for dental anesthesia and also helps to avoid complications.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Thyroid Function in Molar Pregnancies 2021-09-29T10:14:49+00:00 Kavita Sinha Ram Das Homnath Adhikari homenath27@gmail.ccom <p><strong>Introduction</strong>: Molar pregnancies represent a significant burden of disease on the spectrum of gestational trophoblastic diseases. Vaginal bleeding being the most common occasionally, molar pregnancy is complicated by hyperthyroidism, which may require treatment.</p> <p><strong>Aims: </strong>To determine thyroid function test and association of hyperthyroidism among the cases of molar pregnancy.</p> <p><strong>Methods</strong>: This is a hospital-based cross-sectional study conducted in the department of Obstetrics and Gynecology, Nepalgunj Medical College and Teaching Hospital, Kohalpur. Sixty cases of molar pregnancy were included during the study period from February 2020 to January 2021.Patients having history of known thyroid disorders were excluded.</p> <p><strong>Results: </strong>Prevalence of molar pregnancy in our study was 5.4 per thousand pregnancies in our hospital. Molar pregnancy and hyperthyroidism, both were common in the age group of 21-35 years. Hyperthyroidism was present in 10% patients. Enlarged thyroid was seen in 3.3%, tremor was present in 3.3%, and palpitation in 21.5%. Five (8.3%) patients with hyperthyroidism were underweight. Majority of patients with hyperthyroidism, beta humanchorionic gonadotrophhin level was more than three lakhs and it was mostly associated with complete hydatidiform mole compared to partial hydatidiform mole. Thyroid storm was not experienced in any of the patients.</p> <p><strong>Conclusion</strong>: The rate of molar pregnancy is high. Hyperthyroidism in molar pregnancy is not uncommon. High levels of human chorionic gonadotropin, complete hydatiform mole are directly associated with hyperthyroidism. Awareness of this condition is important for diagnosis and treatment to prevent life threatening complications.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Ligation of Processus Vaginalis During Orchidopexy: Is It Mandatory? 2021-09-29T10:28:57+00:00 Feeroz Alam Khan Prabir Maharjan <p><strong>Introduction:</strong> Undescended testis is one of the commonest presentations in pediatric population. Conventionally, high ligation of the hernia sac was done after vas and vessels were dissected in order to prevent post-operative hernia. However, recent studies have shown that hernia sac ligation was unnecessary.</p> <p><strong>Aims:</strong> To evaluate the role of hernia sac ligation during orchidopexy to prevent the development of postoperative hernia and to compare the mean operative time with and without sac ligation.</p> <p><strong>Methods: </strong>A prospective comparative study was conducted with a total of 94 patients with undescended testis, age ranging from six months to 16 years were included in the study from November 2018 to May 2021. Cases were randomly divided into two groups. In Group A cases, orchidopexy was carried out with sac ligation, while in Group B, the hernia sac was not ligated. Mean operative time was recorded in each case. All the patients were followed up at one, four and eight weeks post-operatively and examined for postoperative hernia.</p> <p><strong>Results: </strong>Of the total 94 cases, there were 18 bilateral and 76 unilateral cases of which 56 were right-sided and 22 left-sided. Most of the patients (45) of the study were between six months and 2 years. None of the patients of either group developed post-operative hernia or any significant complications. The mean operative time for group A and B were 36.72 and 46.96 minutes respectively.</p> <p><strong>Conclusion:</strong> It was concluded that ligation of processus vaginalis was unnecessary during orchidopexy and sac ligation consumed more operative time.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Effects of Maternal Anemia on Neonatal Outcome 2021-09-30T06:26:41+00:00 Jyoti Adhikari Mohan Belbase Shikha Rijal <p><strong>Introduction: </strong>Anemia is one of the most prevalent nutritional deficiency problem affecting pregnant women. It is defined by World Health Organization as hemoglobin (Hb) level of less than 11 g/dl. Hemoglobin level of 9.0- 10.9 g/dl is mild, 7.0-8.9 g/dl is moderate and less than 7 g/dl is severe anemia respectively. Maternal anemia in pregnancy is commonly considered as a risk factor for poor pregnancy outcome and can result in complications that threaten the life of both mother and fetus.</p> <p><strong>Aims: </strong>To find out neonatal outcome delivered to anemic mothers.</p> <p><strong>Methods: </strong>A prospective case control study was carried out among 75 newborns delivered to pregnant women with hemoglobin below 10.9g/dL. Another 75 newborns were taken delivered at the same time, matched age and sex wise as a control group to mothers whose hemoglobin was more than 11g/dl.</p> <p><strong>Results: </strong>Out of total 75 cases 35(46.7%) mothers had mild, 32(42.6%) had moderate and 8(10.7%) had severe anemia respectively. Similarly, the risk of having preterm baby among anemia group was 4.42 times higher than that in control group (p 0.033). The risk of having low birth weight in anemia group was 3.9 times higher than that in control group (p 0.04). The mean of head circumference (HC) among the anemia group was 33.9cm <u>+</u>1.40 (Mean<u>+</u>SD) and among the control group was 34.4cm<u>+</u>1.24(Mean<u>+</u>SD) with a mean difference of 0.5cm (p 0.032). The mean of length among anemia group was 45.3cm<u>+</u>1.97 (Mean<u>+</u> SD) and among the control group was 46.2cm<u>+</u>1.69 (Mean<u>+</u> SD) with a mean difference of 0.9 cm (p 0.003).</p> <p><strong>Conclusion: </strong>Maternal anemia in pregnancy is associated with increased risk of adverse neonatal outcome. Efforts must be made to reduce the prevalence of anemia especially during pregnancy to reduce neonatal morbidity and mortality.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Comparison of Tubeless Mini Percutaneous Nephrolithotomy with Conventional Technique in a Tertiary Care Center 2021-10-03T05:22:15+00:00 Dipesh Kumar Gupta Arun Gnyawali Deepak Jaiswal <p><strong>Introduction: </strong>Mini Percutaneous Nephrolithotomy (mPCNL) is a safe and efficient method for management of nephrolithiasis. Post procedure nephrostomy tube drainage is considered as the standard practice. In recent years, tubeless mPCNL with the use of double J (DJ) stent alone has replaced the placement of the nephrostomy tube.</p> <p><strong>Aims</strong>: This study intends to evaluate the safety and efficacy of tubeless Mini Percutaneous Nephrolithotomy.</p> <p><strong>Methods: </strong>A total of 80 patients with Nephrolithiasis, admitted to Urology Unit of Nepalgunj Medical College, between September 2018 and September 2019 were enrolled in the study and divided into two groups: Tubeless group where tube was omitted and Standard Group where it was placed. The two groups were compared with respect to hemoglobin drop and blood transfusion requirement, hospital stay and analgesic requirement in the post-operative period.</p> <p><strong>Results: </strong>Mean age of the patients was 34.30 ± 13.19 years. Mean stone size was 19.03 mm. The mean change in hemoglobin after standard mPCNL was 1.68 gm/dl and that in the tubeless group was 1.11 (p=0.018). The tubeless group had a significantly (p=0.001) shorter hospital stay (3.05 ± 1.23 days) compared to standard group (3.85 ± 0.86). The postoperative pain as assessed by visual analogue scale, was more in the standard group necessitating additional analgesia. It was significantly higher in the standard group at 12, 24, 48 hours, as compared to the tubeless group.</p> <p><strong>Conclusion:&nbsp; </strong>Placement of nephrostomy tube can be omitted as a routine practice as Tubeless mini PCNL has an added advantage of significantly reduced postoperative pain, less analgesic requirement, shorter hospital stay, less postoperative blood loss.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Covishield Vaccine Coverage and its adverse effects among the Staffs of Nepalgunj Medical College Banke 2021-10-03T05:32:59+00:00 Binod Kumar Yadav Ram Chandra Choudhary Gaurav Jung Shah Saharoj Siddiqui <p><strong>Introduction: </strong>The corona virus disease-19 pandemic is an ongoing global health crisis and the greatest challenge we have been facing right now in the most peculiar ways. It has caused huge loss of lives and has severely affected the global economy and financial markets. Vaccines are a new critical tool to fight this voracious battle. They have been released in several parts of the world. Although the safety and efficacy of these vaccines have been discussed, we know very little about the post-vaccination experience outside clinical trial situations. Adequate information about the effects of the vaccine can aware the public remove misconceptions and increase vaccine acceptability<strong>. </strong></p> <p><strong>Aims</strong>: To know the percentage of Covishield vaccine coverage and its adverse effects among the staffs of Nepalgunj Medical College.</p> <p><strong>Methods:</strong> A descriptive cross-sectional study was conducted among the vaccinated 91 out of 116 staff members of Nepalgunj Medical College (NGMC), Baijanath Rural Municipality-1, Banke.</p> <p><strong>Results: </strong>Out of 91 persons, 15.4%(14) developed headache, 20%(18) developed fever, and 8.7%(17) developed body aches. Of those who developed post-vaccination side effects 47%(16) of the persons were from age group 36-55years,17%(1) of them between age group 55-65 years, and none above 65 years developed fever. 20%(13) of total male and 35%(5) of total female developed fever within 96 hours after receiving first dose of Covishield AstraZeneca vaccine.</p> <p><strong>Conclusion: </strong>Most of the study subjects reported milder side effects which lasted for less than 5 days. No casualties were reported. Local pain and swelling at the injection site, headache and fever were the most common side effects. The side effects were more common in younger individuals and women.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Efficacy of Azoles Antifungals in Treatment of Pityriasis Versicolor 2021-10-03T05:51:02+00:00 Smita Jha <p><strong>Introduction: </strong>Pityriasis versicolor is superficial fungal infection. Topical drugs are often effective in treatment of limited disease while systemic drugs are more suitable in extensive cases. The systemic triazole drugs, itraconazole and fluconazole have shown promising results at different doses.</p> <p><strong>Aims</strong>: To assess the efficacy and safety of oral fluconazole combined with ketoconazole shampoo and oral itraconazole in the treatment of Pityriasis versicolor.</p> <p><strong>Methods</strong>: The study was conducted at department of Dermatology at Nepalgunj Medical College from March 2019 to February 2020. Total 100 patients of both genders with Pityriasis versicolor were randomly allocated into two groups with 50 patients in each group. Patients in Group I received oral fluconazole 300mg a week for two consecutive weeks along with ketoconazole 2% shampoo twice weekly for two weeks while those in Group II received&nbsp; itraconazole 200mg daily for one week. Efficacy was assessed in terms of negative fungal hyphae. The drug is considered safe if no patients were withdrawn for clinical adverse effects or laboratory abnormalities.</p> <p><strong>Results:</strong> In this study age ranged from 18 to 50 years with mean age of 31.1 years in Group I and 31.92 years in Group II. Efficacy was seen in 78% of Group I patients as compared to 54% in Group II patients at two weeks and 94% in Group I and 90% in Group II at four weeks. No significant adverse effects were reported in any of the group.</p> <p><strong>Conclusion</strong>: Fluconazole along with ketoconazole shampoo is more effective than itraconazole in treatment of pityriasis versicolor with minimal side effects, at lesser cost.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Harmless Acute Pancreatitis Score 2021-10-03T05:58:48+00:00 Shiv Vansh Bharti Anup Sharma <p><strong>Introduction: </strong>Acute Pancreatitis is a common disease in our region. It can range from mild to severe disease with high mortality rate. It is critical to identify patients who are at high risk for a severe disease course, since they require close monitoring and immediate aggressive treatment.</p> <p><strong>Aims: </strong>To compare the effectiveness of Harmless Acute Pancreatitis Score with Ranson’s scoring system in predicting the severity of Acute Pancreatitis.</p> <p><strong>Methods: </strong>A prospective cross sectional study was done among 45 patients who were admitted in surgery department over a period of one year with diagnosis of acute pancreatitis. If haematocrit was less than39% in female and less than43% in male, serum creatinine less than two miligram /deciliter and no sign of peritonitis, it was assigned as Harmless Acute Pancreatitis Score Zero. If at least one parameter was abnormal it was assigned as Harmless Acute Pancreatitis Score +. Severe pancreatitis (poor prognosis) was considered in those who required Intensive Care Unit care, who had in hospital mortality and who had hospitalization of more than five days. Patients with on admission Ranson’s score of more than three were suspected to have severe Pancreatitis.</p> <p><strong>Results: </strong>There were total 45 patients, 18 females and 27 males. Twenty four patients were assigned as Harmless Acute Pancreatitis Score zero and 21 patients were assigned as Harmless Acute Pancreatitis Score +. Harmless Acute Pancreatitis Score was able to predict correctly in 18 out of 26 patients who fulfilled the criteria of poor prognosis (p&lt;0.001).</p> <p><strong>Conclusion: </strong>Harmless Acute Pancreatitis Score proved to be a better screening tool compared to on admission Ranson’s scoring system to predict the severity of Acute Pancreatitis, which may help predict the prognosis of the patient.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Effectiveness of Pentoxifylline Therapy for Management of Oral Submucous Fibrosis 2021-10-03T06:13:30+00:00 Dwarika Prasad Bajgai Bela Agrawal Abadhesh Yadav <p><strong>Introduction</strong>: Oral submucous fibrosis is a chronic oral disease characterized by progressive buildup of constricting collagen bands in the cheeks and adjacent structures of the mouth due to chewing of areca nut. This can severely restrict mouth opening and tongue movement causing pain and burning sensation in the mouth.</p> <p><strong>Aims:</strong> This study evaluates the efficacy of pentoxifylline in the management of oral submucous fibrosis.</p> <p><strong>Methods</strong>: A hospital-based study, conducted in the dental outpatient department of Nepalgunj Medical College from October 2019 to September 2020. Forty-nine patients who were diagnosed histopathologically with oral submucous fibrosis were included. The patients were divided into two groups. In group A, patients were given, 200 mg thrice daily for first 30 days, then dose hiked to 400 mg thrice daily for two more months. Group B patients received treatment with multi-vitamin capsules (B-complex one capsule before sleep daily) for three months. All patients were followed up for six months and were assessed for maximum inter-incisor opening, pain on opening of mouth and burning sensation.</p> <p><strong>Results:</strong> There was no statistical difference in mouth opening at baseline and first follow up. The mouth opening was significantly more in group A compared to group B from second follow up which persisted till third follow up (p &lt;0.05). Pain and burning sensation significantly reduced in group A compared to group B from 2<sup>nd</sup> follow up which persisted till 3rd follow up (p &lt;0.05). Few patients had nausea, dyspepsia and vomiting during treatment in group A which resolved within a few days without the need for cessation of the drug.</p> <p><strong>Conclusion:</strong> Pentoxifylline can bring about significant clinical improvements in the symptoms of oral submucous fibrosis like mouth opening, pain and burning sensation, thereby improving the quality of life of the affected individuals.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Role of Computed Tomography in Blunt Abdominal Trauma 2021-10-03T09:13:54+00:00 Digbijay Bikram Khadka Anup Sharma Ashish Bhatta Prabir Maharjan Sandesh Sharma <p><strong>Introduction: </strong>Blunt abdominal trauma is one of the commonly encountered surgical emergencies. The diagnostic modality that helps in optimum management of these patients includes chest and abdominal x-rays, Focused Assessment Sonography for Trauma scan and Computed Tomography. In selected hemodynamically stable patients who are candidates for non-operative management, Contrast Enhanced Computed Tomography is not considered essential and hence avoiding its own radiation hazards and decreasing extra financial burden to the patients.</p> <p><strong>Aims: </strong>To evaluate whether Contrast Enhanced Computed Tomography is necessary or not in case of blunt trauma abdomen.</p> <p><strong>Methods:</strong> This is a hospital based prospective study done in the department of surgery at Nepalgunj Medical College, Kohalpur conducted from October 2020 to March 2021. The patients with blunt abdominal trauma who were hemodynamically stable at the time of presentation and those who became stable after resuscitation were included. These patient’s detailed history was taken, clinical examination done. Focused Assessment Sonography for Trauma scan was done at the time of presentation along with chest x-ray and other necessary blood investigation. Data were analyzed with Statistical Package for Social Sciences version 25 and p-value &lt;0.05 was taken as significant.</p> <p><strong>Results: </strong>Out of total 53 patients, age group between 11-20 and 21-30 years comprising of 13 patients with male: female ratio of 1.94:1 were affected more. Fall injury, being the most common mode, comprised 20 patients. The commonest organ involved was spleen seen in 17 patients (32.1%), liver in 16 patients (30.2%). In 44 (83.0%) patients, Computed Tomography scan was done only in nine patients who were also managed conservatively, except one who underwent laparoscopic evacuation of collected blood. Seventeen (32.1%) patients underwent repeat ultrasonography without any new findings.</p> <p><strong>Conclusion: </strong>Patients with blunt abdominal trauma with stable hemodynamics can be managed conservatively with limited use of Contrast Enhanced Computed Tomography scan.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Outcome of Monteggia Fracture Dislocation in Children Treated With K Wires in Nepalgunj Medical College 2021-10-03T10:26:20+00:00 Sabin Shrestha Dinesh Kumar Shrestha <p><strong>Introduction:</strong> Monteggia fracture dislocations are rare injuries (&lt;5%) where missed treatment results into deformity and dysfunction of forearm and hand. For the better functional result early diagnosis, accurate reduction of radial head and rigid fixation of ulna and immobilization during post-operative period for ligamentous healing around radius is vital. So operative treatment has been the primary method of treatment to prevent deformity and disability in monteggia fracture dislocation.</p> <p><strong>Aims: </strong>The aim of this study was to evaluate the time taken to unite fractures, complications encountered and assess the functional outcome on the basis of K-wire fixation in monteggia fracture dislocation in children.</p> <p><strong>Methods:</strong> A cross-sectional observational study was conducted in Nepalgunj Medical College and Teaching Hospital, Kohalpur, Banke with monteggia fracture dislocation in children.</p> <p><strong>Results</strong>: Thirty-two monteggia fracture dislocation in children between six to 14 years of age were treated with intramedullary K-wires after reduction of radial head. Seven cases had open reduction, and five needed trans-capitellar K-wire supplementation. Mean union time was 8.44±1.94 weeks ranging from seven to 12 weeks. The functional outcome on the basis of Anderson’s scoring system was excellent in 25(78.1%), good in three and optimal in four cases.</p> <p><strong>Conclusion:</strong> Monteggia fracture dislocation is better treated early and early mobilization of elbow joint is needed for better functional results.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Preoperative Biometry and Uncorrected Visual Outcome Following Cataract Surgery at a Teaching Hospital at Western Part of Nepal 2021-10-05T09:43:44+00:00 Bikram Bahadur Thapa Basu Prasad Adhikari Nanda Kumari Gurung Jitendra Kumar Verma <p><strong>Introduction:</strong> Proper preoperative biometry in cataract surgery provides expected postoperative uncorrected visual outcome. Astigmatism is one of the major problems to achieve best postoperative unaided visual acuity.</p> <p><strong>Aims: </strong>To determine the distribution of biometric parameter and unaided visual outcome in the cataract patients operated at Nepalgunj medical college, Banke, Nepal.</p> <p><strong>Methods</strong>: The patients who underwent cataract surgery between January 2019 and December 2020 at Nepalgunj medical college were studied. Patient’s demographic parameter, keratometric value, anterior chamber depth, lens thickness and axial length data, type of surgery, preoperative and post-operative visual acuity and other clinical details were collected and analyzed.</p> <p><strong>Results</strong>: This study enrolled 261 eyes of 261 patients who had undergone cataract surgery. The mean age of patients was 60.8 ± 14.62 years. The mean corneal astigmatism was 1.30±1.43 D. Corneal astigmatism was higher than 1.00 D in almost 40% of cases. With-therule astigmatism was the most common type (46.4%) of astigmatism observed in this study. The mean average keratometry was 44.83±2.05 D. The mean preoperative LogMAR VA of 1.52±0.83 improved to 0.48 ± 0.48 postoperatively without statistically significant differences between manual small incision cataract surgery and phacoemulsification technique (p=0.496).</p> <p><strong>Conclusion</strong>: The biometric data helps to improve surgical procedure and select most appropriate intraocular lens to attain maximal postoperative uncorrected visual acuity following cataract surgery. This study found superior convention incision is better for cataract surgery with equivalent visual outcome following manual small incision cataract surgery and phacoemulsification.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 COVID-19 Pandemic and Lockdown: Psychological Distress Impact amongst PCL Nursing Students of Nepalgunj Nursing Campus, Kohalpur, Banke, Nepal 2021-10-05T10:32:17+00:00 Sanjeeva Dhakal Prabha Kharel <p><strong>Introduction:</strong>&nbsp; The uncontrolled spread of COVID-19 worldwide has confined millions of people to their homes. In addition to being a public physical health emergency, COVID-19 (Corona Virus Disease 2019) has significantly resulted in a large number of psychological distress and impacts. The career oriented professional students are away from their academic environment.</p> <p><strong>Aims:</strong> This study aims to assess the psychological distress impact of the COVID-19 pandemic among the Proficiency Certificate Level Nursing of&nbsp; Nepalgunj Nursing Campus, Kohalpur, Banke, Nepal.</p> <p><strong>Methods: </strong>The online survey with a link directed to students of Proficiency Certificate Level (PCL) Nursing of Nepalgunj Nursing Campus, Kohalpur, Banke, Nepal&nbsp; conducted during lockdown (July 16<sup>th</sup> –July 21<sup>st</sup> 2020) which was open for 6 days. Sociodemographic characteristics are the independent variables. Psychological distress was constructed using the Kessler Psychological Distress Scale (K10) Scale as a dependent variables. Data were analyzed using Microsoft Excel.</p> <p><strong>Results: </strong>The evidence of the survey showed that in total 80.2, % (severely distressed - 30.7%, moderately distressed -29.7%, mildly distressed- 19.8%) of the Proficiency Certificate Level Nursing students of Nepalgunj Nursing Campus, were having psychological distress during COVID-19 pandemic and lockdown assessed by using K10 scale.</p> <p><strong>Conclusion: </strong>The present study showed that Proficiency Certificate Level Nursing students were moderately and severely distressed during lockdown of Covid-19 pandemic.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Clinical and Echocardiographic Assessment of Patients with Dilated Cardiomyopathy 2021-10-18T09:44:51+00:00 Madhu Aryal <p><strong>Introduction</strong>: Cardiomyopathy is the disorder of the heart muscles which can be dilated, hypertrophic or restrictive type. Dilated cardiomyopathy is caused by genetic and non-genetic causes but many of the causes are still not known. Echocardiography is an important imaging technique to diagnose and manage dilated cardiomyopathy.</p> <p><strong>Aims</strong>: This study aims to assess the clinical and echocardiographic findings among patients with dilated cardiomyopathy.</p> <p><strong>Methods</strong>: This is a cross-sectional, observational study conducted in Nepalgunj Medical College from January 2021 to June 2021. A total of 61 patients with dilated Cardiomyopathy were enrolled after obtaining written informed consent. Clinical examination and echocardiographic findings were recorded and data analysis was done using Statistical Package for Social Sciences.</p> <p><strong>Results: </strong>The participants included 31 men and 30 women with dilated cardiomyopathy. The mean age of the participants was 58.49 <u>+</u> 15.46 years. The most common complaint was shortness of breath 84.5% and the most common clinical presentation was bilateral basal crepitation 98.4%. The patients mostly had diastolic left ventricle internal diameter of 5.5-6 cm and ejection fraction of 21-30%. Mitral regurgitation was observed among most 58(95.1%) of the patients.</p> <p><strong>Conclusion: </strong>This study concludes that shortness of breath and bilateral basal crepitation are the most common presentation. Left ventricle dilation, reduced ejection fraction and mitral regurgitation are seen among majority of the patients.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Conventional Dissection and Bipolar Electrocauterization Methods of Tonsillectomy: A Comparative Study 2021-10-18T09:59:39+00:00 Anshu Sharma Shama Bhandari Dhundi Raj Paudel <p><strong>Introduction: </strong>Tonsillectomy is frequently performed surgical procedure. There are several different methods with varied advantages and disadvantages. In spite of the different techniques available there is no consensus and definite evidence for best method. The most commonly performed are conventional dissection and bipolar electrocauterization methods.</p> <p><strong>Aims</strong>: The aim of the study was to compare time required for the completion of surgery, intraoperative and postoperative blood loss along with post operative pain between conventional dissection and bipolar electrocauterization methods.</p> <p><strong>Methods</strong>: This comparative study was conducted from August 2019 to March 2021 in total of 30 patients planned for tonsillectomy in department of Otorhinolaryngology, Nepalgunj Medical College Teaching Hospital.In every patient right side tonsillectomy was done with conventional dissection method and left side tonsillectomy was done with bipolar electrocauterization method.</p> <p><strong>Results</strong>: The mean age was 27.2±13.08 years. The mean duration of surgery was 16.53 ± 2.43 min and 11.10 ± 1.93 min in conventional dissection method and bipolar electrocauterization method respectively. The difference was statistically significant. Intraoperative blood loss was significantly lower in bipolar electrocauterization method with mean intraoperative blood loss of 19 ±4.62 ml in bipolar electrocauterization group and 81.83 ±36.54 ml in conventional dissection method. The pain intensity was statistically similar in both methods at all-time intervals post operatively.</p> <p><strong>Conclusion</strong>: In tonsillectomy, bipolar electrocauterization method has advantage over conventional dissection method in regards to reduced surgical time and intra operative blood loss, without any significant difference in post-operative pain intensity and post-operative hemorrhage.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Anemia among Pregnant Women at Nepalgunj Medical College 2021-10-18T10:15:35+00:00 Durga BC <p><strong>Introduction: </strong>Anemia in pregnancy is major health issue of developing countries responsible for adverse maternal and fetal outcome. According to World health organization pregnant women with hemoglobin level less than 11 gm/dl in first trimester and less than 10.5gm/dl in second and third trimester are considered to be anemic. Iron deficiency anemia is common during pregnancy followed by megaloblastic anemia.</p> <p><strong>Aims:</strong> To find out the prevalence of anemia during pregnancy. To correlate the maternal and fetal complications associated with anemia during pregnancy.</p> <p><strong>Methods: </strong>This is a prospective hospital based study done at department of obstetrics and gynecology Nepalgunj Medical College from July 2020 to January 2021. All pregnant women with hemoglobin level &lt;11 gm/dl were enrolled in the study. Data were collected from antenatal clinic and biochemistry laboratory.</p> <p><strong>Results: </strong>In this study maximum participants were of age group 20-25 consisting of 38.5%. Anemia was more common in multiparous i.e. 60% as compared to primipara i.e. 40%. In this study maximum participant had vaginal delivery (57%) followed by LSCS (29%) then instrumental delivery (14%). These ladies had complications like postpartum hemorrhage (27.7%), preterm labor (16.9%), pregnancy induced hypertension (9.2%). similarly 10.8% had sepsis and 20% had no complications. About 23.1% babies delivered by anemic ladies required neonatal intensive care.&nbsp; Intrauterine growth restriction was seen in 12.3%, preterm birth in 10.3% and 53.8% babies had no complications.</p> <p><strong>Conclusion: </strong>The prevalence of anemia during pregnancy is high leading to adverse maternal and fetal outcome.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Assessment of Physical Fitness in Medical Students 2021-10-18T10:25:48+00:00 Sailesh Chaudhary Rita Khadka Karishma Rajbhandari Pandey Bishnu Hari Paudel Gaurav Jung Shah Hiramani Prasad Chaudhary <p><strong>Introduction</strong>: Physical activity promotes cerebral blood flow during cognitive tasks and possibly enhances performance. It is relevant to find relationship between post exercise recovery heart rate (RHR) and resting pulse rate in medical students.</p> <p><strong>Aims</strong>: To assess physical fitness in medical students.</p> <p><strong>Methods:</strong> In this cross-sectional study, 57 consenting healthy medical students, age 1730 years, underwent 3-Minutes Step Test to assess their physical fitness. Students were divided into four fitness groups based on RHR; good (n=9, RHR=50-84 bpm), satisfactory (n=17, RHR=88-100 bpm), poor (n=12, RHR=102-107 bpm), and very poor (n= 19, RHR=111-157 bpm) groups. The groups were compared using one-way ANOVA. A p&lt;0.05 was considered statistically significant.</p> <p><strong>Results</strong>: Results showed that there were few numbers of students who fall in good fitness group (n= 9, Resting pulse rate mean 72.00 ± 9.29) in comparison to satisfactory fitness group (n= 17, Resting pulse rate mean (68.35 ± 5.95), poor fitness group (n= 12, Resting pulse rate mean 75.67 ± 6.88) and very poor fitness group (n=19, Resting pulse rate mean 78.89 ± 7.67). The level of significance between satisfactory fitness group and very poor fitness group, p &lt;0.05 was statistically significant.</p> <p><strong>Conclusion</strong>: Most of the medical students fall under very poor fitness group. Satisfactory fitness group have less resting pulse rate in compare to very poor fitness group of medical students.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Intrauterine Foetal Death: A Hospital Based Study 2021-10-19T04:28:49+00:00 Kamar Jahan Binod Kumar Mahaseth <p><strong>Introduction</strong>: Foetal death at any stage of pregnancy is not just a tragic event but also a more traumatic for the mental well-being of a mother. It is one of the most wrenching events in the field of obstetrics.</p> <p><strong>Aims</strong>: The study was done to determine the probable risk factors of intrauterine foetal death and role of antenatal care in its prevention.</p> <p><strong>Methods</strong>: The study was conducted&nbsp; in Obstetrics and Gynecology department at Nepalgunj Medical college from July 2018 to July 2020 .Inclusion criteria were&nbsp; intrauterine fetal death&nbsp; of &gt;28 weeks of gestation and baby weighing&nbsp; 1000 grams or more . An exclusion criterion was molar pregnancy.</p> <p><strong>Results:</strong> There were 115(3.52%) intrauterine fetal death during the study period, making it 35 per 1000 cases. In 17(14.78%) the cause of intrauterine fetal death was not known. The other common associated risk factors were prematurity in 14(12.17%) and hypertension in 13(11.30%). Similarly anemia and antepartum hemorrhage were seen in 13(11.30%) each. 11(9.56%) patients had oligohydramnios. Mal presentation was found in 8(6.95%) patients while polyhydromnios in 6(5.21%).The commonest age range in whom intrauterine fetal death was seen was 20-30 (73.90%). 28 (24.34%) patients were at preterm pregnancy ranging between 28-30 weeks whereas 17(14.78) intrauterine fetal death occured at&nbsp; 32-34 weeks. 77 foetuses were preterm and their birth weight was between 1 - 1.5 kg&nbsp; with the mean wt of&nbsp; 1175.73 gms.</p> <p><strong>Conclusion:</strong> Intrauterine fetal death is still common inspite of the improving awareness in importance of regular antenatal care. In majority, the cause of intrauterine fetal death is still unknown. However, where the cause was known prematurity was the commonest.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021 Knowledge Regarding HIV/AIDS among Nepalese Army 2021-10-19T04:43:41+00:00 Roshan Kumar Roy Deepak Kumar Roy Sabal Ghimire Aayush Bist Anuranjan Maharaj <p><strong>Introduction</strong>: A global pandemic threat HIV/AIDS is also matter of concern of developing countries like Nepal where the first case was identified in July 1988 and later became epidemic and then concentrated epidemic among risk group for HIV. Several studies reflected HIV is associated to many factors, Literacy and Socio-economic conditions being at the highest rank. Members of Nepal army are generally with less educational background and few with higher educational status are at higher post. Thus knowledge regarding HIV/AIDS among this group need to be assessed.</p> <p><strong>Aims:</strong> The overall objective of our study was to assess knowledge regarding HIV/AIDS among Nepal army in Banke district.</p> <p><strong>Methods: </strong>A Cross-sectional descriptive study with population size of 146 Army was performed which covered the entire population of Shree Shreemehar Army Camp in Banke, starting from 18<sup>th</sup> June to 27<sup>th</sup> August, 2018. A pre-tested questionnaire containing structural, semi-structural and open ended questions were made as data collection tool. All the soldiers in Army camp were interviewed after receiving consent as an ethical clearance.</p> <p><strong>Results:</strong> All 146 Army of our study were aware about HIV/AIDS mainly via mass media (83.56%). 33 respondents still didn’t know about availability of its treatment. Misconception about its complete cure and vaccination was seen in 12 and 39 respondents respectively. 58 respondents were found knowing about the free health services by government. 141 respondents knew certain things about prevention. 28 respondents admitted of having multiple sex partners and only 24 among them used preventive measure.</p> <p><strong>Conclusion:</strong> Though all the respondents of our study had known about HIV/AIDS still they had misconception regarding its treatment and prevention. Many respondents do not even know about the free health services of government. Few of them still don’t use preventive measure.</p> 2022-01-16T00:00:00+00:00 Copyright (c) 2021