Nepal Medical College Journal https://www.nepjol.info/index.php/nmcj <p>Nepal Medical College Journal is the official journal of Nepal Medical College Pvt. Ltd (NMC), Attarkhel, Gokarneshwor Municipality-8, Kathmandu, Nepal. P.O. Box 13344, Phone: +977 01 4911008 &nbsp;| &nbsp;4912118 &nbsp;| Extension 607, Email: <a href="mailto:nmcjournal@nmcth.edu">nmcjournal@nmcth.edu</a>.</p> <p>It is also available on its own website <a href="http://jnmcth.nmcth.edu/index.php" target="_blank" rel="noopener">http://jnmcth.nmcth.edu/index.php</a></p> Nepal Medical College Pvt Ltd en-US Nepal Medical College Journal 2676-1319 Effect of Hyperbaric Oxygen Exposure on Bacterial Toxin Antigen and Collagen Induced Arthritis in Animal Model https://www.nepjol.info/index.php/nmcj/article/view/26441 <p>Anti-cyclic citrullinated peptide antibody (ACPA) is a specific autoantibody that binds with citrullineamino acid in rheumatoid arthritis (RA). Interleukin-17a (IL-17a) is one of the cytokines that play an important role in chronic inflammation during the process of autoimmune diseases. Bacterial toxin antigen and collagen induced arthritis (ACIA) is the gold standard of RA animal model. The aim of this study was to see the effect of hyperbaric oxygen (HBO) exposure on ACIA animal models. ACIA model was made by combined antigens (bacterial toxin and collagen). A total of 24 male Balb/Cmice modelled on ACIA were divided into three groups. Eight mice did not receive HBO exposure (control group, indicated as G1), eight mice (indicated as G2) received HBO exposure for 10 days while remaining eight mice (indicated as G3) for five days. G2 mice were exposed to HBO 2.4 ATA oxygen 100% for 90 minutes (30 minutes each with two intervals of five minutes breathing with normal air) for 10 consecutive days while G3 mice were exposed only for five days. The indicators of arthritis i.e. ACPA and IL-17a were measured by enzyme-linked immunosorbent assay (ELISA) technique. A significant decrease in ACPA and IL-17a levels was seen in both HBO exposed groups (G2 and G3) compared to G1 (p&lt;0.05). There was no significant difference in levels of ACPA and IL-17a in G3 mice and G2 mice (p &gt; 0.05). HBO reduced inflammation in ACIA by decreasing ACPA andIL-17a levels through improvement of hypoxic conditions and showed therapeutic potential for the treatment of RA.</p> Titut Harnanik J. Soeroso M.G. Suryokusumo T. Juliandhy ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-24 2019-11-24 21 3 167 172 10.3126/nmcj.v21i3.26441 Overview of Preoperative Cardiology Consultation at a Tertiary Care Centre https://www.nepjol.info/index.php/nmcj/article/view/26443 <p>Preoperative cardiac consultations are regularly performed during pre-anaesthetic checkup. However, the efficiency and usefulness of these consultations are unclear. The objective of this study is to assess the indication and usefulness of preoperative cardiac consultation. In this cross sectional study, 100 patients sent for preoperative cardiac consultation were evaluated. Baseline characteristics, Revised Cardiac Risk Index (RCRI), comorbidities were recorded. The motive for referral and outcome of the consultation were evaluated. Evaluated patients consist of male (45%) and female (55%) with age ranging from 18 to 89 years (average 51.28 ± 14.6 years). Most common co morbidities were hypertension (53%) and diabetes (30%). High proportion (49%) of patients we resent for cardiac consultation with suspicion of abnormal ECG. Most of the patient had RCRI of 0 and1 (45% and 28% respectively), while 14% and 13% had RCRI of 2 and 3 respectively. “Clearance for surgery” was the most common reason for consultation (60%) followed by risk stratification (41%) and optimization of cardiac disease (40%). Twenty four percent of patients were sent with suspicion of cardiac co morbidity. Twenty six percent were sent without any specific cause. Only 27% of the patient had increased risk of major adverse cardiac events. Further management was not needed in 58% patients. Only 12% patients had a new diagnosis. Preoperative cardiac consultation can be useful in detecting newer cardiac comorbidities and optimization in some patients. However, most preoperative cardiac consultation does not alter the perioperative management</p> S. Thapa M. Basnet ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-24 2019-11-24 21 3 173 177 10.3126/nmcj.v21i3.26443 A Comparative Study between Two Different Doses of Dexmedetomidine for Attenuation of Hemodynamic Response to Laryngoscopy and Tracheal Intubation. https://www.nepjol.info/index.php/nmcj/article/view/26444 <p>Laryngoscopy and end tracheal intubation are stressful situation for the patients, as these procedures are capable of producing tachycardia, hypertension and arrhythmias. This study was conducted with the objective of arriving at an optimal dose of dexmedetomidine that can attenuate the hemodynamic response to laryngoscopy and intubation with minimal side effects. The current study was conducted in 60 patients, posted for elective surgery under general anesthesia withendotracheal intubation. The patients were divided into two groups: Group A and Group B. Group A received dexmedetomidine 0.5 μg/kg and group B received dexmedetomidine 1 μg/kg intravenously over 10 min prior to induction of anesthesia. The anesthesia technique was standardized in both the groups. Heart rate, systolic, diastolic and mean arterial pressure were monitored and recorded at 5min and 10 min of completion of infusion of study drug, after induction, and at 1 min, 2 min, 5 min after intubation. The baseline heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were statistically similar in both the groups. After the infusion of the study drug the mean heart rate, mean systolic blood pressure, mean diastolic blood pressure, mean arterial pressure at all times were comparable in both the groups. Episodes of hypotension and bradycardia were also statistically similar in both the groups. Attenuation of hemodynamic response to laryngoscopy and intubation by dexmedetomidine is similar with the two doses: 0.5 &nbsp;μg/kg and 1 μg/kg. Both the doses of dexmedetomidine were devoid of any significant adverse effects.</p> Chitra Thapa S. Gauchan ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-24 2019-11-24 21 3 178 183 10.3126/nmcj.v21i3.26444 Perception of Stigma among Caregivers of Mentally Ill People https://www.nepjol.info/index.php/nmcj/article/view/26454 <p>The lives of people with mental illness are altered by the symptoms of the illness, attitudes of people that view symptoms as threatening and uncomfortable, which foster stigma and discrimination within social circles. The catch of the study was to assess the stigmatizing beliefs among Caregivers of persons with mental illness. A descriptive and exploratory study was conducted with purposive sampling technique among 50 caregivers with interview method of mental illness patient with purposive sampling technique at Nepal Medical College teaching Hospital, Jorpati, Kathmandu, Nepal in Oct 2017- Nov 2017. The study revealed that the most of caregivers (62%) feel burdened financially, and about 64% think that people with mental illness are dangerous. Most of the caregivers (70%) think that the mentally ill people are violent. More than half (54%) of the caregivers think voluntary organizations are not doing adequate work in the field of mental health and 72%feel health organizations are giving less priority to mental illness as compared to other disorder. Most of the caregivers (66%) think that their occupational life has been interfered by the family member’s illness, and 56% don’t think that there are adequate law or rules regarding mental illness. In conclusion, care givers experience stigma such as concealment, negative experience, emotional stigma as well as work related stigma which affects the health and recovery of mentally ill persons. Compliance to medicine was poor and relapse rate was high which also have impact on the life of caregiver.</p> Srijana Pandey ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 184 189 10.3126/nmcj.v21i3.26454 Profile of Cosmetic Consultation in a General Dermatology Clinic https://www.nepjol.info/index.php/nmcj/article/view/26456 <p>Cosmetic Dermatology has garnered tremendous interest all over the world. With the advent of modern technologies and developments, demand for non-surgical aesthetic procedures is on a rise. The purpose of the study is to know the types of cosmetic consultations and procedures being done in a General Dermatology setup. Patients who visited outpatient dermatology department of a multi-specialty, Nidan Hospital, Lalitpur, between May 2017 to April 2018 were included. Details of patients’ demographic profile were filled in a preset performa. Other information related to cosmetic consultation including dermatological diagnosis, awareness of cosmetic procedures and cosmetic procedures etc were also included. 160 patients attended the dermatology outpatient during the study period. Seventy four percent of them were females. Thirty six percent of the cases were between 26years and 35 years. Forty three percent of the cohort were working. Majority of them had Bachelors degree (57%). Twenty six patients who attended the OPD wanted cosmetic consultation. The type of cosmetic consultation, majority sought for was wrinkles (37%). Among the cosmetic procedures performed, chemical peeling was done in 59%, mesotherapy in 16%, mole removal in 12% and remaining 13% underwent topical treatment. Statistical significance was seen between Cosmetic consultation and economic status (p=0.000) and between cosmetic consultation and employment status (p=0.007). Almost a quarter of patients attending a general dermatology OPD sought cosmetic consultation. Females, young adults who are employed, well-educated and from good socio-economic status seek cosmetic services.</p> Deeptara Pathak Thapa S Pradhan ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 190 194 10.3126/nmcj.v21i3.26456 A Comparative Study between Endoscopic and Microscopic Tympanoplasty https://www.nepjol.info/index.php/nmcj/article/view/26457 <p>A study to compare tympanoplasty between endoscopic and microscopic approach was conducted at NMCTH. Patients diagnosed as chronic otitis media – mucosal type with age of 13 years and above were included in the study. Audiometric test was done before and 6 weeks after surgery. Seventy cases were included for the study with random allocation of cases each in endoscope group and microscopic group respectively. Graft uptake results were assessed after 6 weeks and postoperative hearing were evaluated and compared within and between the two groups. In endoscopic group and microscopic group, the graft uptake rate was 91.4% and 88.5% respectively with no significant difference (p = 0.71) in the graft uptake rate between the groups. The mean pre and post-operative air bone gap in endoscopic group and microscopic group were 34.59 dB±8.02, 21.97±8.60 dB and32.42±10.08 dB, 18.55±8.49 dB respectively. This showed a highly significant difference in both groups(p &lt; 0.001), showing improvement in the hearing after surgery in both the groups. The mean air bone gain were 12.62 dB and 13.87 dB in endoscopic and microscopic group respectively, with no significant difference between the groups (p = 0.553). The graft uptake rate and hearing results with endoscopic technique is comparable to that of microscopic technique. However, the endoscopic technique requires shorter operative time than the microscopic technique. Therefore, we recommend the use of endoscope for tympanoplasty in hospital as well as in camps.</p> Anup Dhungana R. R. Joshi A. S. Rijal K. K. Shrestha S. Maharjan ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 195 198 10.3126/nmcj.v21i3.26457 Gastric Cancer in Nepal A Locally Advanced Disease https://www.nepjol.info/index.php/nmcj/article/view/26458 <p>The goal of this study is to describe the distribution of gastric cancer by age, gender, duration of symptoms, nutritional status and staging of the disease based on operative findings and correlation between the data. This was an observational study. The study was conducted at Department of Surgery, Nepal Medical College Teaching Hospital from December 2012 to December 2017. All patients who were admitted to the department with a diagnosis of stomach cancer and underwent palliative or curative intent procedure were reviewed and analyzed. Out of the 80 patients, 51(63.7%) were male and 29 (36.3%) patients were female. The disease was commonest in the 6th and 7th decades of life. Majority of the patients were of Tibetoburmese (Mongolian) origin with 44 (55%). Majority of patients, 60 (75%) patients had long duration of illness of more than 6 months. Most of the patients had albumin level less than 3gm/dl. Gastric carcinoma is a male predominant malignancy usually of old age and commonly observed in the Tibeto-Burman group of people. Overwhelming majority diagnosed at an advanced stage and had poor prognosis.</p> Rabin Koirala N. Acharya S. Khanal A. Rajbhandary ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 199 203 10.3126/nmcj.v21i3.26458 The Effect of Piracetam on Valproic Acid Induced Congenital Malformations in Swiss Albino Mice https://www.nepjol.info/index.php/nmcj/article/view/26459 <p>Valproic acid (VPA) is an antiepileptic drug which is widely used in humans and is a well known teratogenic agent when used during pregnancy. Piracetam is a nootropic or cognitive enhancer drug used to treat cognitive impairment in aging, brain injuries as well as dementia. In the present study, these two drugs VPA and Piracetam were administered orally to Swiss albino mice in the doses of400 mg/kg and 800 mg/kg body weight respectively from gestational day (GD) 6-11 in order to see the protective effect of Piracetam against VPA induced teratogenesis. The fetuses were collected on GD 18 after uterotomy and observed for gross malformations if any. In VPA treated group the malformations observed were exencephaly, cranioschisis, limb and tail defects, haemorrhage, resorptions and retardation. No such anomalies were observed in control and Piracetam treated groups. However,in VPA+ Piracetam treated group some resorptions and growth retardation were noted. This group showed highly significant (p &lt; 0.001) protection against the teratogenic effects of VPA treated group though the developmental parameters were significantly reduced (p &lt; 0.001) in comparison to those of group I (control) and group III (receiving piracetam). These findings suggest that Piracetam, if given in higher doses might protect the development in utero against the teratogenic effects of VPA.</p> Shamsher Shrestha M. Singh S.P. Mishra ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 204 209 10.3126/nmcj.v21i3.26459 Surgical Technique can Prevent Arm Lymphoedema After Level III Clearance for Breast Cancer https://www.nepjol.info/index.php/nmcj/article/view/26460 <p>Clearance of the axillary tissue during operation is still the mainstay of treatment for node positive breast cancer. Level III axillary nodal clearance is supposed to increase the risk of lymph edema of arm, along with other factors. However, preservation of the fascia over the axillary vein during surgery reduces the risk of lymph edema greatly. In this study we measured the incidence of armlymphoedema that occured after Level III axillary clearance for breast cancer. During surgery, dissection over the anterior surface of axillary vein was limited to preserve the fascia covering axillaryvein. Other factors commonly implicated in the development of post-operative arm lymphoedema were also documented and their effect analysed. Forty three patients underwent operation for breast cancer including complete axillary clearance up to Level III. The incidence of lymphoedema was 25.5% (11 out of 43 patients). None of these patients had severe lymphoedema. On multivariate analysis, no other associated factors like BMI, chemotherapy and nodal metastases had any bearing on the development of lymph edema. We conclude that Level III axillary clearance of axilla is safe and not excessively morbid in terms of developing arm lymphoedema provided the fascia over axillary veinis preserved.</p> Saurav Kumar Ghosh D.R. Burman ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 210 213 10.3126/nmcj.v21i3.26460 Variations of Renal Artery in Cadavers https://www.nepjol.info/index.php/nmcj/article/view/26461 <p>Each kidney is usually supplied by a single renal artery which is a lateral branch of abdominal aorta at the level of L1.The arteries supplying the kidneys show variation in the number, source and branching pattern which also include the presence of an accessory or additional and aberrant renal arteries. The additional renal artery towards the lower pole will cross the corresponding ureter and even cause ureteric obstruction. The segmental branches of renal and additional renal arteries are end arteries thus the accidental damage to these arteries can cause ischemia or necrosis and other pathological conditions. The main objective of this study was to note the variations of the arteries supplying the kidneys. An observational study was conducted on thirty kidneys of fifteen cadavers which included the kidneys of both sides. The study was conducted in Department of Anatomy of Nepal Medical College Teaching Hospital during the period between July 2018 to June 2019 and the variations were recorded as (a) single main renal arteries were found in 80% specimens on both sides (b) early division of main renal arteries were found in 16.66 % on both sides (c) origin of main renal arteries were at higher level on left side in 16.66 % (d) presence of additional renal arteries were found in 20% on both sides. This study will be helpful to cryosurgeons and also to radiologists performing various interventional radiological procedures.</p> Chhiring Palmu Lama A. Pradhan ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-25 2019-11-25 21 3 214 219 10.3126/nmcj.v21i3.26461 Etiology and Pattern of Drug Induced Liver Injury in a Tertiary Care Hospital of Nepal https://www.nepjol.info/index.php/nmcj/article/view/26466 <p>Drug induced liver injury (DILI) is one of the common cause of liver toxicity. Most of the drugs used today are hepatotoxic. DILI accounts for approximately one-half of the cases of acute liver failure and mimics all forms of acute and chronic liver disease. It is the single most common adverse drug reaction leading to a halt in the development of new medication by pharmaceutical company, failure of new drug to obtain regulatory approval, and withdrawal or restriction of existing drug from the market. The aim of this study is to evaluate common causes and patterns of DILI in our setting. Twenty-seven patients were enrolled in the study. Ant tubercular drugs were most common cause of DILI, accounting for 48.2%. Other common causes of DILI were paracetamol (14.8%) and NSAID’s (11.1%). The most common pattern of liver injury seen was mixed pattern which was present in63%, followed by cholestatic and hepatocellular pattern. Hence, we should be very careful while prescribing these frequently used drugs.</p> Anuj K.C. S. Jha S. Thapa ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 220 223 10.3126/nmcj.v21i3.26466 A Comparative Study on Efficacy of Amoxicillin and Azithromycin in Prevention of Postoperative Sequelae Following Third Molar Surgery https://www.nepjol.info/index.php/nmcj/article/view/26467 <p>Amoxicillin is the commonly prescribed antimicrobial for prevention of post-operative complications following surgical extraction of mandibular third molar. However recently, the use of macrolideantibiotics had been encouraged in dentistry. The aim of this study was to compare the efficacy of Amoxicillin and Azithromycin in preventing post-operative sequelae following third molar surgery. An open- labeled randomized controlled study was carried out in Department of Oraland Maxillofacial surgery, college of Dental Sciences and Hospital, Nepal Medical College (CODSHNMC), Attarkhel, Kathmandu, Nepal from May 2018 to June 2019. One hundred and twenty patients undergoing surgical extraction of impacted mandibular third molar were randomized by lottery method into two groups: Group A received Amoxicillin and Group B received Azithromycin. Both the groups were assessed postoperatively on 1st, 3rd and 7th days for post-operative complications- pain, swelling, trismus and pus discharge. The present study revealed no significant differences between the efficacy of Amoxicillin and Azithromycin in preventing postoperative sequelae following surgical extraction of impacted third molar. Amoxicillin and Azithromycin were therefore found to be equally effective. Thus, Azithromycin can be used as an alternative drug to Amoxicillin in case of resistance and intolerance to Amoxicillin.</p> Rashmi Shakya Gurung K. Bimb D. Shrestha ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 224 229 10.3126/nmcj.v21i3.26467 Correlating Spirometric Parameters with Breath-Holding Time and Maximum Chest Expansion in Healthy Young Adults https://www.nepjol.info/index.php/nmcj/article/view/26468 <p>The spirometric measurements are very sensitive, accurate and reliable parameters, which have diagnostic as well as prognostic values. We aimed to find the reliability of two simple measurements, namely chest expansion and voluntary breath holding, which are often suggested as tools for screening and monitoring of respiratory diseases. A cross-sectional descriptive study was conducted on students of Nepal Medical College. Measurements of spirometry (forced vital capacity, FVC in liter; forced expiratory volume in first second, FEV1 in liter; and peak expiratory flow rate, PEF in liter persecond), cirtometry (average of maximum chest expansion, CE in centimeter), and breath-holding time (maximum voluntary apnea at end-inspiration, MVAIT and maximum voluntary apnea at end expiration, MVAET in second) were performed. Degrees of correlation (Pearson’s r) were determined between different parameters; setting level of significance at 95%. Total 308 students (M=164, 53.25%;F=144, 46.75%) participated. Owing to very highly significant differences between males and females, gender-separate correlations were determined. In males, CE correlation was very highly significant (p=0.000) with FVC and FEV1 but not with PEF. MVAET correlated significantly with FVC, FEV1 and PEF; MVAIT correlation was not significant with any parameters. In females, CE correlation was significant with FVC and FEV1 but not with PEF; MVAET and MVAIT correlations were not significant with any of the parameters. In conclusion, the correlation of CE with different spirometric parameters is significant but not very strong (0.3&lt;r&lt;0.5). Also, gender differences exist. Therefore, using CE and breath-holding time may not be appropriate to assess respiratory ventilatory function.</p> Mrigendra Amatya D.B. Pun ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 230 234 10.3126/nmcj.v21i3.26468 Screening of Thyroid Disorder among Pregnant Ladies in a Tertiary Hospital of Nepal https://www.nepjol.info/index.php/nmcj/article/view/26470 <p>Thyroid disorders (TD) are the second most common endocrine disorders seen in pregnancy. Many physiological changes in pregnancy lead to hypothyroidism in pregnancy. Hypothyroid in pregnancy is associated with many adverse maternal and fetal outcomes. Objective of this study was to find the prevalence of TD in pregnancy in Nepal Medical College Teaching Hospital (NMCTH), Antithyroid Peroxidase Antibody (TPO-Ab) positive cases with hypothyroidism and to evaluate maternal fetal outcome in hypothyroid pregnancies. This was a prospective hospital based observational study. The study was done in Department of Obstetrics and Gynecology, NMCTH from August 2018 to July 2019. Among 420 pregnant ladies 71.0% were euthyroid, 25.7% were hypothyroid (25.2%of subclinical and 0.5% overt), 3.3% were hyperthyroid (0.7% of overt) and 6.4% were TPO-Abpositive with hypothyroidism. Inspite of treatment, Gestational hypertention, Pre-eclampsea and LSCS is significantly high in hypothyroid pregnancy than euthyroid pregnancy. High prevalence of hypothyroidism in this study necessitates universal screening of TD at first trimester of pregnancy.</p> Biloni Shrestha P. Adhikari ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 235 239 10.3126/nmcj.v21i3.26470 A Case of Bilateral Acute Angle Closure Attack with Some Unusual Clinical Features https://www.nepjol.info/index.php/nmcj/article/view/26471 <p>Bilateral acute angle closure attack is a rare ocular emergency. Early diagnosis and immediate intervention can have a profound effect on patient’s visual outcome and ocular morbidity. A 70 year old female presented with vomiting about 7 to 8 episodes along with sudden diminution of vision in both eyes for last 3 days. Initially she was examined by physician where all the routine blood tests and upper GI endoscopy was advised which failed to reveal the cause. She was then referred to our department for ophthalmic evaluation. On ocular examination she was diagnosed as a case of bilateral acute angle closure attack with some unusual clinical features. After treatment with hyperosmotic agent, anti glaucoma drugs and Nd: Yag peripheral laser iridotomy, intraocular pressure came down to normal limits and the patient regained good vision.</p> Pranisha Singh A.P. Rijal A. Rizyal S. Karmacharya ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 240 243 10.3126/nmcj.v21i3.26471 Prolonged Coma after Pituitary Macro- adenoma Surgery: A Case Report with Short Literature review https://www.nepjol.info/index.php/nmcj/article/view/26472 <p>Prolonged coma after surgery of pituitary macro-adenoma with apoplexy, often previously unnoticed, is rare and not well reported complication. A 65 year male presented with complaints of headache and blurred vision since few months. Brain MRI was done and it reported macro- adenoma with pituitary apoplexy. Right pterional craniotomy was done following total excision of tumor. Patient developed whole body seizure at first day of surgery and went to prolonged coma.</p> M. Karki A.J. Thapa Yam Bahadur Roka ##submission.copyrightStatement## http://creativecommons.org/licenses/by/4.0 2019-11-26 2019-11-26 21 3 244 248 10.3126/nmcj.v21i3.26472