Medical Journal of Shree Birendra Hospital <p>Official Journal of NAIHS (Nepalese Army Institute of Health Sciences). Full text articles available.</p> <p>MJSBH is now accepting online submission of manuscripts.We recommend that you review the <a href="/index.php/MJSBH/about">About the Journal</a> page for the journal's section policies, as well as the <a href="/index.php/MJSBH/about/submissions#authorGuidelines">Author Guidelines</a>. Authors need to <a href="/index.php/MJSBH/user/register">register</a> with the journal prior to submitting, or if already registered can simply <a href="/index.php/index/login">log in</a> and begin the 5 step process.</p> en-US <p>Copyright on any research article is transferred in full to the Medical Journal of Shree Birendra Hospital upon publication. The copyright transfer includes the right to reproduce and distribute the article in any form of reproduction (printing, electronic media or any other form).</p><p><a href="" rel="license"><img style="border-width: 0;" src="" alt="Creative Commons Licence" /></a><br />Articles in the Medical Journal of Shree Birendra Hospital are Open Access articles published under a <a href="" rel="license">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a> (CC BY-NC-ND).</p><p>This license permits use, distribution and reproduction in any medium, provided the original work is properly cited, is not changed in any way, and is not used for commercial purposes.</p> (Dr Bikash Shrestha) (Sioux Cumming) Wed, 25 Jul 2018 13:24:02 +0000 OJS 60 Professionalism in Medical Education: Where Are We? <p class="p1"><span class="s1">The importance of professionalism in the field of medicine in Nepal is highlighted worryingly often in the terrifying news articles that shower the public with accounts of malpractice and unprofessional behaviour, contributing to the growing rift between patients and medical professionals. We need to look back at our undergraduate and post graduate training program to try to answer two very important but often overlooked questions : Whether professionalism has been sufficiently integrated in Medical Education or not and if yes, is the mode of delivery of this concept efficient enough?</span><span class="s1">More importantly, are we assessing this important competency and are we making sure that it is being acquired by our doctors? The focus on professionalism in medicine, and medical education, has developed in response to<span class="Apple-converted-space">  </span>possible malevolence towards patients on the part of doctors that are inept in dealing with the humanities of medicine.</span></p><p class="p1"><span class="s1">Professionalism has six important inbuilt elements viz. altruism, accountability, duty, honour or integrity, excellence and respect for others. The physician–patient relationship is the reflection of professionalism and it is central to the delivery of high-quality medical care; it has been shown to affect patient satisfaction as well as a variety of other biological, psychological and social outcomes.</span><span class="s3"><sup>1 </sup></span><span class="s1">All these professional behaviours and attitudes must be developed during the acquisition of medical education.<span class="Apple-converted-space">  </span>Hence, it is crucial to make sure that the medical graduates are well aware of, and meet the principles of professional practice i.e. maintaining good clinical practice, successful relationship with patients/parents and effective team work with colleagues.</span></p><p class="p1"><span class="s1">Yes, professionalism has always been a backbone of medical education. Since the earliest days of medical practices, the professionalism of a doctor has been valued almost as much as their intellect. So, medical education has always gone hand in hand with the principles of professionalism. Throughout medical education, professionalism has been taught almost exclusively through faculty role modelling but with the advancements of medical education, it seems almost irresponsible to leave the inculcation of professionalism at such primitive standards. Medical institutions can no longer rely on the intuition of their faculty to instil professionalism solely through their actions. It is now up to medical institutions to apply standardised methods to adequately gauge professionalism in their students. It is now up to us to absolutely guarantee that professionalism has not only been taught but actually instilled in our students. It is high time that professionalism becomes an integral part of the curriculum.</span></p><p class="p1"><span class="s1">Medicine is a community based discipline. Without a sound doctor/patient relationship in the society, neither the patient nor the doctor can get his/her point across. Communication is of paramount importance in medicine and is the essence of diagnosis and treatment. A community that isn’t compliant to and supportive of medical professionals further exacerbates the existing insufficiencies in the health of the society. This worrying trend is a red flag for emerging medical educationists and curriculum designers around the nation. Without early intervention in the foundations of medical education in our nation, we risk tarnishing the reputation that the medical profession has garnered because of the social goodwill associated with it. Appropriate attitude, aptitude and knowledge are<span class="Apple-converted-space">  </span>all equally important aspects that a physician must posses. <span class="Apple-converted-space">     </span></span></p><p class="p1"><span class="s1">Professionalism should be viewed at three different levels. At individual level attributes, capacities and behaviours are considered. The next consideration is interpersonal domain that focusses on teacher student interactions in different contexts. Professionalism is implied at societal and institutional level where notions such as social responsibility and morality but also political agendas and economic imperatives reside. Furthermore, there are interactions amongst these all three domains/levels. For example, an individual's professional behaviour may be influenced by the context; similarly, the individual within an institution may influence its collective professional values to the others.</span><span class="s3"><sup>2</sup></span></p><p class="p1"><span class="s1">Teaching professionalism: It is quite a difficult task. The question “How to teach professionalism in medical school?” is even more difficult to answer. There is no concrete method nor is there a blueprint to a sure fire solution. Role modelling and mentoring are important ways of imparting concept of professionalism during medical training but these merely are not enough to guarantee results. Thus, professionalism must be integrated directly into the syllabus for there to be a noticeable change. There is a need for didactic lectures too. Although they may seem primitive, a didactic lecture on professionalism will give medical students something to think about. Without cognitive stimulation on a certain topic, it sometimes becomes harder to grasp, no matter the amount of role models they may be surrounded by.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1">In years one and two of undergraduate training, medical ethics, importance of professionalism, related laws can be taught as a cognitive component. In year three and four, the application part could be taught as case presentations, reflections and portfolio. During internship and post graduation, it should be through more complicated cases and through journal clubs.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1">Assessment of professionalism: For the immense significance that professionalism possesses in medical education, the assessment hasn’t followed suit. Merely including professionalism in the syllabus is not nearly enough. Research has shown that ‘that which is not assessed is never learnt.’ Therefore it is extremely essential for appropriate assessment tools to be integrated in the curriculum that can gauge the professionalism of our medical students. Professionalism should be assessed longitudinally right from the beginning until internship period and even beyond. It requires combinations of different approaches and at different levels including but not limited to professionalism at individual, interpersonal and institutional/societal levels.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1">Some of the components of professionalism are related to the inherent personality traits. Assessment of these traits (cognitive, personality, behaviours) prior to admission may be relevant to later professionalism aspect of the medical graduates. There are several assessment tools like observed clinical encounter (Mini-CEX, P-MEX), collated views of co-workers (360 degree evaluation), records of incidents of professional lapses (incident reporting form), simulations (cases with ethical dilemma) and patient surveys (patient assessment questionnaire).</span><span class="s3"><sup>3</sup></span></p><p class="p1"><span class="s1">Without professionalism we cannot call ourselves professionals. It seems that nowadays, many of us are really not. There is a huge lack of professionalism in medical education right now, and this must change if we are to continue to produce true medical professionals. What we need now is an absolute paradigm shift in our attitudes towards the ethical competency of our medical practitioners and focus on the ethical side of our education system as well as the technical side.</span></p> Hem Sagar Rimal ##submission.copyrightStatement## Wed, 25 Jul 2018 13:22:15 +0000 Analysis of Cesarean Section Using Robson’s 10-Group Classification at a Tertiary Level Hospital in Nepal <p class="p1"><span class="s1"><strong>Introduction: </strong>Obstetric Services commenced at the teaching institute where this study was conducted from Aug 2012. Hence, a review of the data of C-section in this hospital is needed for standardisation of the obstetric services in terms of the rate of C-section, its various clinical indications and maternal and fetal outcomes.</span></p><p class="p1"><span class="s1"><strong>Methods: </strong>This is a retrospective study carried out over a period of 5 years from Aug 13, 2012 to Aug 11, 2017. All hospital deliveries conducted during the study period were included in this study and the patients’ details obtained from hospital records. All data obtained was recorded in master charts and analysed using SPSS version 23. The caesarean rate, its indications were calculated and categorised into groups according to Robson’s 10-group classification.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Results: </strong>A total number of 4892 deliveries were conducted over this 5-year study period. C-section was performed in 1104 patients, giving a C-section rate of 22.57%. The most common indications were previous C-section (25.4%), fetal distress (14.3%) and breech presentation (10.3%). Robson’s Group 1 was the highest contributors to the overall CS rate, contributing 28% of all C-sections, followed by Group 5 (26.8%) and Group 3 (15.5%).</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>Nulliparous and multiparous women in term pregnancy in labor and women with previous C-section contribute to more than 70% of overall C-sections at our centre. Hence, close monitoring of these groups of patients, increasing the use of instrumental delivery and practice of vaginal birth after C-section can significantly reduce the C-section rate in our centre.</span></p><p><span style="font-size: medium;"> </span></p> Rosy Vaidya Malla, Chanda Hamal, Bibhusan Neupane, Ratna Khatri ##submission.copyrightStatement## Wed, 25 Jul 2018 13:22:36 +0000 Awareness and Knowledge About Screening Tests for Cervical Cancer in Patient Attending Obstetrics and Gynaecology Out Patient Department at a Tertiary Care Hospital in Lalitpur <p class="p1"><span class="s1"><strong>Introduction: </strong>Cervical cancer is the leading cause of cancer deaths for women worldwide. Early diagnosis of cervical cancer may be done by a simple and cost effective technique of Pap smear. The morbidity and mortality could be significantly reduced with an active cervical cancer screening programme.</span></p><p class="p1"><span class="s1"><strong>Methods:</strong> A cross sectional interview based study was done among 200 patients attending Obstetrics and Gynaecology OPD of one of the tertiary care hospital at Lalitpur, to assess the knowledge and awareness of patient regarding screening methods of cervical cancer and its prevention and early detection.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Results: </strong>Among all the participants, 76.5% (n-153) were literate and 23.5% (n-47) were illiterate. Only 41% had heard about the Pap test and only 1% had heard about other methods of screening test like VIA(Visual Inspection with Acetic acid). Only 16% think that infection of the genital tract and 12.5% think that multiple partners is the leading cause of cervical cancer. Among them 51% (n-102) think that regular screening will prevent cervical cancer. But only 22.5% (45) had done Pap smear once and 67% did not know the risk factor of cervical cancer.<span class="Apple-converted-space">  </span>Only 7% had heard of HPV vaccination but did not know<span class="Apple-converted-space">  </span>details about it.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>There is very low level of knowledge about cervical cancer, Pap smear and HPV among the participants attending Obstetrics and Gynaecology OPD. For using Pap smear as a preventive method for cervical cancer, it is necessary to inform women about cervical cancer and the Pap smear test. An aggressive campaign with in depth teaching about cervical cancer by media and health care providers is mandatory.<span class="Apple-converted-space"> </span></span></p> Meenu Maharjan, Heera Tuladhar ##submission.copyrightStatement## Wed, 25 Jul 2018 13:22:45 +0000 Baseline Study of Sputum Microscopy for Diagnosis of Tuberculosis in Western Region of Nepal <p class="p1"><span class="s1"><strong>Introduction:</strong> Tuberculosis is a major health issue in Nepal. Early detection of tuberculosis is essential to identify the case which limits the transmission of tuberculosis and builds an effective approach of tuberculosis control policy. Therefore, the present study is aimed to assess the case of tuberculosis by sputum smear examination.</span></p><p class="p1"><span class="s1"><strong>Methods</strong>: A prospective study was conducted in a tertiary care hospital of Western Nepal. Two sputum samples were collected from each suspect – spot specimen on the first day and one early morning specimen on the second day. The standard protocol of Ziehl Neelsen stain was applied to detect the acid fast bacilli.</span></p><p class="p1"><span class="s1"><strong>Results: </strong>Out of 280 smears from suspected patients, only 30 showed smear positivity (10.7%). Among the total identified positive case of tuberculosis (30/280), the highest rate was observed in the age group of 56-65 years. Males (56.7%) were highly affected by tuberculosis than females (43.3%). The minimum age of the suspects was two years and maximum age was of 105 years with mean age of 53.6 years.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>It is concluded that prevalence of tuberculosis is high in patients attending tertiary care hospital in Western region of Nepal, which is slightly higher than the annual report of National Tuberculosis Program 2017. Incidence of pulmonary tuberculosis is higher in males as compared to females.</span></p> Amrita Dhakal, Samata Nepal, Alok Atreya, Basista Rijal ##submission.copyrightStatement## Wed, 25 Jul 2018 13:22:53 +0000 Comparison of Membrane Filtration and Replica Plate Technique to Detect Fecal Coliform <p class="p1"><span class="s1"><strong>Introduction:</strong> Membrane filtration (MF) is one of the widely used technique on a routine basis. On the other hand, replica plate (RP) technique can be used to transfer existing bacterial colonies in two plates which even allows pinpointing the original colony. The aim of this study is to comparatively detect the cfu/100 mL of fecal coliform using membrane filtration and replica plate techniques.</span></p><p class="p1"><span class="s1"><strong>Methods: </strong>In the study, a total of 25 bottled water were selected from the local market in Kathmandu valley. The total coliform count was detected using MF, while fecal coliform was detected using both MF and RP technique.</span></p><p class="p1"><span class="s1"><strong>Results: </strong>It was found that the average cfu/100 mL for total coliform, fecal coliform (MF) and fecal coliform (RP) were 143.38, 49.82 and 51.00 respectively. Pearson correlation coefficient calculated between total coliform and fecal coliform (MF), total coliform and fecal coliform (RP), fecal coliform (MF) and fecal coliform (RP) were found to be 0.695, 0.733 and 0.990 respectively; implying a positive correlation<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>It has been demonstrated that intrinsic and extrinsic factors influence colony forming units. Furthermore, RP is a more sensitive method for screening fecal coliforms although both MF and RP can be efficiently used.</span></p> Bikram Gautam, Rameshwar Adhikari ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:01 +0000 Effect of Body Position on Post-Lumbar Puncture Headache and Urinary Retention After Spinal Anaesthesia in Orthopaedic Cases: Concerns in Post-Operative Ambulation and Rehabilitation <p class="p1"><span class="s1"><strong>Introduction:</strong> Postural headache occurs in up to 70% of the patients who receive spinal anaesthesia. They further experience difficulty in bladder voiding. Both of these complications deter the orthopaedic patients who undergo procedures in the lower limb from having early mobilisation. It is widely suggested that a period of bed rest is necessary to avert spinal headache whereas early mobilisation aggravates the condition. The aim of our study was to compare the effect of body position on post-lumbar puncture headache and urinary retention after spinal anaesthesia in orthopaedic patients.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Methods: </strong>We did a prospective randomised single-center study in a leading teaching institute of our country. There were 200 patients. Initially they were randomly divided into two groups- study and control- to see if there was any correlation between body position and PLPH. Since the body posture post-operatively was not found to be initiating factor for PLPH, whole of the 200 patients were analysed together for other criteria.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Results: </strong>We had 37 patients (18.5%)<span class="Apple-converted-space">  </span>who had PLPH among the 200 patients. The number of patients developing the condition in study and control groups were 17 and 20 respectively. A total of twenty-three patients (11.5%) needed catheterisation in post-operative ward, the age group mostly needing Foley’s catheter was 41-60 yrs. More patients in control group (16 out of 100) given bed rest<span class="Apple-converted-space">  </span>to prevent PLPH needed<span class="Apple-converted-space">  </span>urinary catheterisation.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>Body position after spinal anaesthesia does not contribute to onset of PLPH. Moreover, the incidence of urinary catheterisation was more in<span class="Apple-converted-space">  </span>patients given bed rest , which delayed mobilisation. We conclude that the patients need not be given strict bed rest in supine position after the lower limb procedures to facilitate early bladder voiding and mobilisation.<span class="Apple-converted-space"> </span></span></p> Nirab Kayastha, Amit Joshi, Bhuwan Kunwar, Santosh Khadka ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:08 +0000 Fate of Forgotten DJ Stent <p class="p1"><span class="s1"><strong>Introduction:</strong> Double J stent is one common armamentarium used in urological procedure. It can serve both therapeutic and prophylactic function. However the use of double J stent is invariably associated with minor to some of major complications. Forgotten DJ stent is one untoward issue of stenting patient that is largely preventable and entails complex urological procedure to remove it.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s2"><strong>Methods: </strong>We performed descriptive study where data were collected prospectively from </span><span class="s1">patients who have double J ureteral stent in situ after urological procedure. Stent left more than three months was defined as forgotten DJ stent. Demographic characteristics, clinic-radiological data and details of management were noted to evaluate the mode of presentation, associated complications and mode of treatment. The reason behind forgetting those stent was asked with study population and presented.</span></p><p class="p1"><span class="s1"><strong>Results: </strong>The total of 27 cases of forgotten DJ stent cases were recorded during period of December 2013 to January 2018. Mean age of patient was 46.6 ± 12.25 years. The longest indwelling time was 10 years. Stent syndrome was common mode of presentation followed by encrustation. Majority (92.5%) of the patients were managed with endourological approach and 26% (7) of cases required more than one modalities of treatment.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>The forgotten stent is an avoidable condition through proper patient counselling. When required the management necessitates simple cystoscopic to complex endourolgical intervention.<span class="Apple-converted-space"> </span></span></p> Bikash Bikram Thapa, Naryan Thapa, Bharat Bahadur Bhandari ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:18 +0000 Ocular Morbidity Among Leprosy Patients at a Leprosy Centre <p class="p1"><span class="s1"><strong>Introduction:</strong> Leprosy is one of the dreaded communicable disease due to its profound morbidity. In earlier days in Nepal, a different settlement was designated for leprosy patient and their families. Khokana of Lalitpur district of Nepal is one of them. The study was conducted to determine ocular morbidity among leprosy patients who had completed multi drug therapy. <span class="Apple-converted-space"> </span></span></p><p class="p2"><span class="s1"><strong>Methods: </strong>It was descriptive, quantitative and cross sectional study conducted at Khokana Leprosy Centre in Lalitpur district of Nepal. Leprosy patients who had completed multi drug therapy and consenting for the study were enrolled. Convenience sampling was done and the sample size was 70. After detail ophthalmic evaluation, socio-demographic profile of the participants and their ocular morbidities were documented and analysed.</span></p><p class="p1"><span class="s1"><strong>Results: </strong>Major findings were superciliary madarosis (78.57%), ciliary madarosis (61.4%), different grades of cataract (67.10% right eye and 60% left eye), pseudophakia (30% right eye and 37.10% left eye), tylosis (44.3%), corneal hypoesthesia (10% unilaterally and 15.7% bilaterally) and dry eye (10%). Entropion was present in 2.9% both unilaterally and bilaterally. Ectropion was present in 5.7% unilaterally and 10% bilaterally. Trichiasis was present in 1.4% unilaterally and 2.9% bilaterally. Similarly, eyelid nodule was present in 7.1% unilaterally and 1.4% bilaterally. Incomplete closure of the lids was present in 8.6% unilaterally and 2.9% bilaterally. Exposure keratitis was present in 7.1% unilaterally and 1.4% bilaterally, corneal opacity in 2.9% unilaterally and 1.4% bilaterally and corneal perforation in 2.9% unilaterally. Chronic iridocyclitis was present in 2.9% cases. Retinal pearls were seen in 2.86% of cases. According to WHO criteria of blindness, 2.9% patients were blind in the present study. 14 persons were unilaterally blind and among them, two had severe visual impairment in the other eye, eight had other eye moderate visual impairment and four had other eye mild visual impairment.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>Lid abnormalities, corneal abnormalities and cataract were the commonly encountered ocular morbidities among treated leprosy patients</span><span class="s2">.</span></p> Sabina Shrestha, Chunu Shrestha, Sushan Man Shrestha, Aparajita Manoranjan, Arun Prasad Dhungana ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:26 +0000 Risk Stratification of Coronary Heart Disease in Postmenopausal Women Using Framingham Scale in Eastern Nepal <p class="p1"><span class="s1"><strong>Introduction:</strong> Cardiovascular disease (CVD) is one of the leading causes of mortality and morbidity in both developed and developing countries. CVD risk rises to double fold in women after menopause. We aim to stratify menopausal women of our region for having coronary heart disease in next 10 years.<span class="Apple-converted-space">   </span></span></p><p class="p2"><span class="s1"><strong>Methods: </strong>One year cross sectional study was conducted in General Out Patient Department (GOPD) of a tertiary care centre of Eastern Nepal. The Standard ATP calculator was used and the relevant necessary data was introduced into the calculator and the automated result was collected.<span class="Apple-converted-space"> </span></span></p><p class="p1"><span class="s1"><strong>Results: </strong>Among 272 participants, above 50% had Framingham score 1 to 5%. And the risk was greater within first five years after menopause in 50 to 59 years of age group. Similarly, with advancing age and longer duration of menopause the risk became significantly higher.</span></p><p class="p1"><span class="s1"><strong>Conclusions: </strong>Besides the established risk factors for CVD, postmenopausal state is additional risk for women and this study emphasises this factor as risk of CVD even in our set up.</span></p> Sujeeta Bajracharya, Bijendra Kumar Rai, Rajani Giri, Rinku Joshi ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:36 +0000 A Case Report on Fever of Unknown Origin in a School Going Child– An Uncommon Answer in a Common Question <p class="p1"><span class="s1">Fever is one of the commonest complaints in paediatrics outpatient as well as inpatient department. Fever of unknown origin (FUO) is a diagnosis of exclusion given to the febrile condition lasting more than three weeks with temperature 38.3</span><span class="s2"><sup>0</sup></span><span class="s1">C or more with unknown cause despite of one week in patient care. Here we present a case of FUO in a child which was investigated thoroughly and managed on the line of enteric fever. However, the patient remained febrile. Hence, further investigations were undertaken and finally, bone marrow culture grew a very uncommon organism- <em>Escherichia coli. </em>The child was treated as per the sensitivity and responded well to treatment and was discharged after improvement. Here, we would like to present this case of FUO to highlight the possibility of bone marrow invasion by an uncommon organism as a source of fever in children.</span></p> Dhan Bahadur Shrestha, Suju Mool, Sijan Karki ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:44 +0000 Primary Fallopian Tube Carcinoma Discovered as an Incidental Finding - A Case Report <p class="p1"><span class="s1"><strong>Introduction:</strong> Primary malignant tumour of fallopian tube is very rare. The reported incidence of tumour varies from 0.1 to 1.8% of all gynaecological cancers. There is no specific clinical feature and therefore the disease is often misdiagnosed as ovarian neoplasm or other gynaecological tumours. A preoperative diagnosis even by radiological assay is many times difficult because the features are similar to ovarian neoplasm, tubo-ovarian abscess or hydrosalpinx. We report a case of 45 years old female who presented with multiple episodes of pervaginum bleeding since past one year and was diagnosed as primary fallopian tube carcinoma on histopathology examination.</span></p> Mrinalini Singh, Sanjay Das, Shilpi Shaukin ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:51 +0000 Manuscript Writing Workshop for Authors – 2018 <p>The workshop covered various aspects of medical research, writing and publishing including planning a research project, statistics, referencing, literature search, the art of writing, formatting of scientific manuscripts, submission, peer review and editorial process and ethical issues in medical research including plagiarism. The workshop included hands on practice on submission process of a manuscript in an actual journal.</p> Rishi Pokhrel, Barhsa Bajracharya ##submission.copyrightStatement## Wed, 25 Jul 2018 13:23:57 +0000