Nepalese Medical Journal <p>Nepalese Medical Journal is published by Health Education Agriculture Nepal (<a title="HEAD" href="" target="_blank" rel="noopener">HEAD Nepal</a>). The journal&nbsp;is an official peer-reviewed, medical journal which is published bi-annually and and doesn’t charge any fee for submission, processing, and publication. The journal receives original material of interest to the practitioners and scientists in the field of medicine related to the recent developments in Medical Sciences and all articles are Open Access.&nbsp;</p> <p>This journal doesn't charge for submission and processing your manuscript. Regarding publication fee, please go to the "About the journal" section.&nbsp;</p> <p><a href="" rel="license"><img src="" alt="Creative Commons Licence"></a><br>All articles published in the Nepalese Medical Journal are licensed under a&nbsp;<a href="" rel="license">Creative Commons Attribution 4.0 International License</a>.</p> <p>Nepalese Medical Journal is indexed on <a title="DOAJ-NMJ" href="">DOAJ&nbsp;</a><a href=";journalId=49291">Index Copernicus</a></p> Health Education Agriculture Development (HEAD) Nepal en-US Nepalese Medical Journal 2631-2093 <p>Copyright on any article published by Nepalese Medical Journal is retained by the author(s).</p><p>Authors grant Nepalese Medical Journal a license to publish the article and identify itself as the original publisher.</p><p>Authors also grant any third party the right to use the article freely as long as its integrity is maintained and its original authors, citation details and publisher are identified.</p><p><a href="" rel="license"><img style="border-width: 0;" src="" alt="Creative Commons Licence" /></a><br />All articles published in Nepalese Medical Journal licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License</a>.</p><p>This license permits use, distribution and reproduction in any medium, provided the original work is properly cited.</p> Patient’s Involvement, Engagement, and Participation in Medical Research: Nepalese Perspective <p>No abstract available.</p> Ajaya Kumar Dhakal Devendra Shrestha Copyright (c) 2022 Ajaya Kumar Dhakal, Devendra Shrestha 2022-06-30 2022-06-30 5 1 10.3126/nmj.v5i1.47142 Recent Advancements in Oral Anticoagulants: A Systematic Review <p>Anticoagulants are medications that are administered to patients with clotting issues. Major issues include atrial fibrillation, venous thromboembolism/deep vein thrombosis, and pulmonary embolism. However, recent studies show the increased use of these medications in the treatment and management of COVID-19. </p> <p>This paper has been designed as a systematic Literature review based on PRISMA strategy. Data were collected by conducting exhaustive research on major electronic databases i.e., SCOPUS, Web of Science, EMBASE, ProQuest, ScienceDirect, and Google Scholar. A total of 52 studies were included in this review. These studies were selected from the period 2011-2021. The overall study revealed the advancements of DOACs or NOACs in comparison to Warfarin, revealed the findings of various food, drug, and another kind of products that interfere with oral anticoagulants, and advancements in terms of treatment of DVT/VTE, pulmonary embolism, and arterial fibrillation by use of oral anticoagulants and the role of anticoagulation in COVID-19.</p> Ram Kripal Sharma Copyright (c) 2022 Ram Kripal Sharma 2022-06-30 2022-06-30 5 1 552 558 10.3126/nmj.v5i1.44920 Speech-language Pathologist: A Team Member for Management of Head and Neck Cancer Patients <p>Head and Neck cancer is one of the most prevalent conditions in the world and so is in Nepal. Head and Neck cancer causes speech, language, and swallowing disorder that affects the quality of life of a patient. A multidisciplinary team is needed for the management of the cancer patient. A Speech Language Pathologist is one important team member involved in the rehabilitation of communication and swallowing issues. The role of Speech Language pathologists should be understood by other medical professionals and need to be integrated into the team to provide a holistic health care facility to an individual with head and cancer.</p> <p> </p> Biraj Bhattarai Copyright (c) 2022 Biraj Bhattarai 2022-06-30 2022-06-30 5 1 559 562 10.3126/nmj.v5i1.37741 Comparative Study of Clinical Profile and Outcome Among Variceal and Nonvariceal Bleeding in a Tertiary Referral Hospital of Nepal During Covid Pandemic <p><strong>Introduction: </strong>Upper Gastrointestinal Bleeding is a common medical emergency that is broadly classified into variceal and non-variceal bleeding. Preendoscopicemperical treatment is based on clinical findings and laboratory parameters. The article aimed to compare these parameters among variceal and non-variceal bleeding.</p> <p><strong>Materials and Methods: </strong>This is a retrospective descriptive study conducted in a tertiary level referral hospital after taking approval from the Institutional review board. The data included was from September 2020 to August 2021. All patients with relevant data who underwent upper GI endoscopy were enrolled. The clinical and laboratory parameters were compared using appropriate statistical tests.</p> <p><strong>Results: </strong>A total of 85 patients were studied with 40 (47.06%) in the variceal and 45 (52/94%) in the non-variceal group. Significantly more patients in the variceal bleeding group had a history of alcohol consumption (85% vs 60%) and smoking history (52.50 % vs 31.10%) compared to the non-variceal group. Jaundice, ascites, splenomegaly, low platelet count, and high INR all were predictors of variceal bleeding (p&lt;0.005). In the variceal group, 39 (97.5%) needed endo therapy compared to only 4 (8.9%) in the non-variceal group.</p> <p><strong>Conclusions: </strong>Clinical and laboratory parameters differ significantly in the variceal and non-variceal groups which can guide the pre-endoscopic management of the patients.</p> Binod Karki Tshering Wagdi Sherpa Rajeeb Kumar Deo Egesh Aryal Binit Upadhyaya Regmi Alisha Adhikari Srijana Katawal Sujit Kumar Mandal Copyright (c) 2022 Binod Karki, Tshering Wangdi Sherpa, Rajeeb Kumar Deo , Egesh Aryal, Binit Upadhyaya Regmi, Alisha Adhikari, Srijana Katawal, Sujit Kumar Mandal 2022-06-30 2022-06-30 5 1 506 509 10.3126/nmj.v5i1.44527 Blepharoptosis: Pattern and its Surgical Management in a Tertiary Eye Hospital of Eastern Nepal <p><strong>Introduction: </strong>Blepharoptosis or drooping of the eyelid is a common disease entity presenting in oculoplasty department. Depending on its severity it causes visual disturbances as well as cosmetic problems. Appropriate management and timely surgical intervention results in a good outcome.</p> <p><strong>Materials and methods</strong>: This is a hospital-based study of a blepharoptosis patient that presented in the Oculoplasty department and underwent ptosis correction by various methods from July 2016- December 2019.</p> <p><strong>Results</strong>: A total of 85 cases with 104 eyes underwent ptosis surgery. The mean age was 24.5 years. Among them, 31.8% were pediatric and 68.2% were adults. Astigmatism was seen in 21.1% followed by myopia in 10.6% and hypermetropia in 4.7%. Amblyopia was seen in 13% of cases. Common surgical procedures performed were frontalis sling suspension 64.7%, followed by levator advancement 33%, and frontalis sling surgery with V-Y plasty 2.3%.</p> <p><strong>Conclusions</strong>: Ptosis is seen to be associated with refractive errors, strabismus, or amblyopia. Proper clinical evaluation of the patient is essential to know the etiology, type, and severity of ptosis. Timely surgical intervention is necessary to prevent morbidity and enhance its outcome.</p> Prerna Arjyal Kafle Diwa Hamal Sabin Sahu Sharmila Chaudhary Copyright (c) 2022 Prerna Arjyal Kafle, Diwa Hamal, Sabin sahu, Sharmila Chaudhary 2022-06-30 2022-06-30 5 1 510 513 10.3126/nmj.v5i1.44429 Pap Smear as a Screening Tool for Cervical Cancer in a Tertiary Care Centre in Nepal: A Retrospective Cross-sectional Analysis <p><strong>Introduction:</strong> Pap smear is a time-tested screening test to diagnose cervical carcinoma at an early stage. It allows clinicians to take intervention measures, prevent the progression of the disease to invasive forms and decrease the burden of carcinoma as a whole. The objective of this study is to determine the values regarding the diagnostic accuracy of Pap smear and establish its role in the health care setting of Nepal.</p> <p><strong>Materials and Methods:</strong> This is a retrospective cross-sectional analysis of the records from April 14, 2018, to April 12, 2020, of the Department of Pathology in a tertiary care hospital in the capital city of Nepal. Ethical approval for the study was taken from the Institutional Review Board and the demographic and clinical data of patients were analyzed anonymously. The consecutive sampling technique as used for data collection and analysis was done in Microsoft Excel 2019 and Statistical Packages for Social Sciences Version 25. The diagnostic accuracy parameters were calculated from a contingency table prepared from the collected data.</p> <p><strong>Results:</strong> Out of 3095 Pap smears, 72 had a positive finding of some sort. 74 cases had a positive finding in the form of a biopsy out of 573. The sensitivity, specificity, positive predictive value, and negative predictive value of Pap smear at the institution were found to be 0.70, 0.94, 0.78, and 0.91 respectively with an overall accuracy of 88.36%.</p> <p><strong>Conclusions:</strong> Pap smear can still play a pivotal role in the diagnosis of cervical neoplastic lesions.</p> Amar Narayan Shrestha Anurag Adhikari Ayusha Poudel Barun Babu Aryal Ganesh Parajuli Suman Gurung Shreejana Baskota Ishu Shrestha Copyright (c) 2022 Amar Narayan Shrestha, Anurag Adhikari, Ayusha Poudel, Barun Babu Aryal, Ganesh Parajuli, Suman Gurung, Shreejana Baskota, Ishu Shrestha 2022-06-30 2022-06-30 5 1 514 517 10.3126/nmj.v5i1.46421 Comparative Study of Modified Alvarado Score and Eskelinen Score in Diagnosing Acute Appendicitis <p><strong>Introduction:</strong> Despite many advances in diagnosis, diagnosing appendicitis remains difficult. Various diagnostic scoring systems have been developed in an attempt to improve the diagnostic accuracy of acute appendicitis. The study aimed to determine the accuracy of the Modified Alvarado and Eskelinen score in diagnosing acute appendicitis and to correlate the histopathological findings with the severity of acute appendicitis.</p> <p><strong>Materials and Methods:</strong> A prospective study was conducted in TUTH including 84 patients with a clinical diagnosis of acute appendicitis managed surgically for 10 months. Modified Alvarado and Eskelinen Score were calculated and histopathological findings were correlated for predicting the severity of appendicitis.</p> <p><strong>Results:</strong> Out of 84 patients Modified Alvarado Score had sensitivity and specificity of 67.79% and 32% when the score was taken as 7 and Eskelinen Score had sensitivity and specificity of 70.17% and 29.62% when the score was taken as 55. However, the sensitivity of the Modified Alvarado Score increased to 92.85% and specificity to 14.28% when the cut-off score was taken as 6. Modified Alvarado Score predicted 67% and 63% of uncomplicated and complicated appendicitis respectively and Eskelinen Score predicted 72% of uncomplicated and 67% of complicated appendicitis when the score was taken as 7 and 55 respectively.</p> <p><strong>Conclusions:</strong> Both Modified Alvarado and Eskelinen Scores have low sensitivity in diagnosing acute appendicitis. With cut off for Modified Alvarado Score taken as 6, sensitivity increased. There was no correlation between the severity of appendicitis with the increase in Modified Alvarado and Eskelinen Score.</p> Isha Dahal Copyright (c) 2022 Isha Dahal 2022-06-30 2022-06-30 5 1 518 521 10.3126/nmj.v5i1.42868 Oral Gabapentin Pretreatment to Attenuate the Haemodynamic Response to Laryngoscopy and Tracheal Intubation <p><strong>Introduction: </strong>Laryngoscopy and intubation are associated with transient sympathetic responses manifesting as a rise in blood pressure and heart rate. This study was conducted to evaluate the role of oral gabapentin pretreatment in the attenuation of such haemodynamic response.</p> <p><strong>Materials and Methods: </strong>Sixty-two patients aged 16 to 60 years weighing 50 to 75 kg undergoing elective surgeries requiring endotracheal intubation were randomized into two groups. group G received 900 mg oral gabapentin and group P received a placebo by mouth two hours before induction of anaesthesia. Patients were induced with propofol, fentanyl, and vecuronium. Laryngoscopy was attempted after four minutes and endotracheal intubation was done. Heart rate, systolic, diastolic, and mean arterial pressure at baseline, before intubation, one, three, five, and ten minutes after intubation were compared between two groups. Patients were observed for any adverse events peri-operatively and post-operatively for the first 24 hours.</p> <p><strong>Results: </strong>There was significant attenuation of the rise in blood pressure and heart rate before and after intubation in both groups compared with their corresponding baseline parameters. A significant decrease in heart rate was observed in the gabapentin group only 10 minutes after laryngoscopy and intubation (p=0.022).</p> <p><strong>Conclusions: </strong>Oral Gabapentin 900 mg two hours before induction is effective in attenuating the rise in blood pressure and heart rate following laryngoscopy and tracheal intubation, though a statistically significant difference was observed only at 10 minutes after intubation, compared with a placebo group. Besides the significant incidence of pre-induction somnolence, there were no serious perioperative adverse effects. </p> Tulsi Ram Shrestha Srijana Podar Suson Ghimire Dhiraj Tamrakar Copyright (c) 2022 Dr. Tulsi Ram Shrestha, Dr. Srijana Podar, Dr. Suson Ghimire, Dr. Dhiraj Tamrakar 2022-06-30 2022-06-30 5 1 522 527 10.3126/nmj.v5i1.45703 The Milan System for Reporting Salivary Gland Cytopathology: A 3-year Retrospective Analysis in Patan Hospital <p><strong>Introduction: </strong>The characteristics of salivary gland lesions identified by fine-needle aspiration cytology are varied and may overlap, which makes diagnosis difficult for cytopathologists. To provide consistency in the reporting of salivary gland cytology and to enhance clinic-pathologic communication, the "Milan system for reporting salivary gland cytopathology" has been introduced, which offers guidelines for diagnosis and treatment based on various categories of malignancy risk.</p> <p><strong>Material and Methods: </strong>In this retrospective study, Fine needle aspiration cytology was done for all salivary gland lesions for three years and were retrieved from the Department of pathology, Patan hospital. All the cases were recategorized according to the Milan system for reporting salivary gland cytology with histopathology follow-up wherever available. Consistency of the two different types of assessment techniques (Milan category and primary cytology diagnosis) were assessed and the k score was calculated</p> <p><strong>Results: </strong>A total of 58 cases were included in the study of which histological follow-up was available in 27 cases. Out of 58 cases, maximum cases 32 (55.1%) were classified under IVA followed by 15.5% cases classified under II, 8.6% of cases under Category IVB), 6.8% under category Vand 5.1% cases under category VI. Kappa's score was 0.58 which represents a moderate agreement.</p> <p><strong>Conclusions: </strong>Milan system for reporting salivary gland cytopathology is a recently proposed six-category scheme, which places salivary gland fine needle aspiration cytology into well-defined categories that limit the possibilities of false negative and false positive cases.</p> Dipti Gautam Rojin Thapa Copyright (c) 2022 Dipti Gautam, Rojin Thapa 2022-06-30 2022-06-30 5 1 528 532 10.3126/nmj.v5i1.46793 Lack of an Association or an Inverse Association Between Cholesterol and Coronary Artery Disease: A Case-Control Study <p><strong>Introduction: </strong>Cholesterol has been blamed as the principal cause of cardiovascular diseases, however, it is a common observation that most coronary artery disease patients do not have strikingly high cholesterol values, often falling within the desirable range, and also many patients with high cholesterol levels do not have any atherosclerotic cardiovascular diseases. Therefore, we decided to investigate whether there is an association between cholesterol levels and coronary artery disease. </p> <p><strong>Materials and Methods: </strong>This is a case-control study conducted on a total of 313 coronary heart disease patients and 369 controls diagnosed by coronary angiogram. Fasting lipid profile was analyzed for both cases and controls. The study extended for a period of three years from 2018 July to 2020 June.</p> <p><strong>Results: </strong>Total cholesterol (p&lt;0.05) and Low-Density Lipoprotein (p&lt;0.05) levels were significantly lower among the cases, while triglyceride and High-Density Lipoprotein levels of cases were similar to the controls.</p> <p>Taking age into consideration, there was no significant difference in the total cholesterol and Low-Density Lipoprotein levels between cases and controls below the age of 60 years, however, above the age of 60 years, total cholesterol and Low-Density Lipoprotein were significantly lower in the cases (p&lt;0.05).</p> <p><strong>Conclusions: </strong>The findings of the present study indicated that either there was no association between cholesterol levels and coronary artery disease or an inverse association when age was taken into consideration, as above 60 years of age the cholesterol level was found to be significantly lower in the patients of coronary artery disease compared to controls.</p> Sanjaya Kumar Shrestha Nikky Maharjan Copyright (c) 2022 Sanjaya Kumar Shrestha, Nikky Maharjan 2022-06-30 2022-06-30 5 1 533 537 10.3126/nmj.v5i1.46471 Effect of Obstructive Sleep Apnea on Sleep Pattern and Blood Glucose Level in Type 2 Diabetes Patients <p><strong>Introduction: </strong>Our physical, mental, and emotional well-being require normal sleep. Disturbances in sleep quality and quantity can result in metabolic disorders. Sleep fragmentation increases sympathetic activity which leads to decreased insulin sensitivity. Obstructive sleep apnea causes sleep fragmentation. That is why this study attempt is made to find the effect of obstructive sleep apnea on sleep pattern and blood glucose level in type 2 diabetes patients.</p> <p><strong>Materials and Method: </strong>Depending on the severity of the Apnea-Hypopnea Index (AHI) recorded by polysomnography, each, volunteer were divided into two groups, a) AHI&gt;10 groups, and b) AHI≤10 groups. Then the comparison of all the parameters between AHI&gt;10 and AHI≤10 groups of diabetic participants was done.</p> <p><strong>Results: </strong>In participants of AHI≤ 10 groups, Sleep efficiency%, Mean TBI SPo2%, sleep Stage III%, and REM% are significantly higher as compared to AHI&gt;10 groups. In participants of the AHI&gt;10 groups, sleep Stage I%, the score of ESS, and fasting blood glucose level are significantly higher as compared to AHI≤ 10 groups.</p> <p><strong>Conclusions: </strong>Increasing AHI is associated with reduced sleep efficiency; a sleep stage of N3%, and a REM sleep phase, which lead to an increase in fasting blood glucose levels in the diabetic group.</p> Santosh Kumar Sah Jay Prakash Singh Rajput Dimpal Rochlani R. S. Inamdar Copyright (c) 2022 Santosh Kumar Sah, Jay Prakash Singh Rajput, Dimpal Rochlani, R.S. Inamdar 2022-06-30 2022-06-30 5 1 538 541 10.3126/nmj.v5i1.43223 Causes of Blindness and Visual Impairment Among Children Studying in Schools for the Blind in Central Development Region of Nepal <p><strong>Introduction: </strong>This study was done to find out the causes of visual impairment in students studying in schools for the blind in the central development region of Nepal.</p> <p><strong>Materials and Methods:</strong> The study was done in six schools for the blind in the central development region of Nepal. It was conducted by a team of Eye care professionals using standard eye examination protocols of the World Health Organization Prevention of Blindness Program in the year 2009.</p> <p><strong>Results: </strong>A total of 133 students (5 - 21 years age group) enrolled in six schools for the blind were examined. 52.6% of children were visually impaired at birth and 12% developed vision impairment within one year of age. Twenty-one students (15.8%) had mild visual impairment, 5 students (3.8%) had severe visual impairment and 101 students (76%) were blind. The main cause of vision impairment was found to be lens-related anomaly 23.3% and retinal diseases, 18% followed by corneal lesions, 16.5%, and problems with the whole globe, optic nerve, and glaucoma accounting for 12.03%, 11.3%, and 7.5% respectively. The etiology could not be identified in 48.1% followed by hereditary causes (31.6%) and childhood factors (12%). Of the total students examined, 37.6% were visually impaired due to avoidable causes; preventable in 22.6% and treatable in 15% of cases.</p> <p><strong>Conclusions</strong>: A high proportion of childhood blindness in schools for the blind in the central development region of Nepal is avoidable.</p> Jyoti Baba Shrestha Pragati Gautam Adhikari Gauri Shankar Shrestha Copyright (c) 2022 Pragati Gautam Adhikari, Jyoti Baba Shrestha, Gauri Shankar Shrestha 2021-06-30 2021-06-30 5 1 542 545 10.3126/nmj.v5i1.42151 Diagnostic Role of Image-Guided Fine Needle Aspiration Cytology <p><strong>Introduction: </strong>With the aid of modern imaging procedures like ultrasonography and computed tomography, fine needle aspiration cytology of deeper structures, small and vaguely palpable swellings, and lesions that are in close proximity to major vasculature are feasible. This study aims to establish the prevalence of image-guided FNAC, evaluate its diagnostic utility, and assess the spectrum of disorders diagnosed with its usage.</p> <p><strong>Materials and Methods: </strong>A retrospective descriptive study was performed in the Pathology department, Om Hospital, and Research Centre from May 2015 to November 2019. The study included all samples of image-guided FNACs which were received for cytological examination.</p> <p><strong>Results:</strong> Image-guided FNAC accounted for 13.03% of all FNACs done during the study period. Female predominance with a male to female ratio of 1:1.4 was noted. The age of the patients ranged from 13 to 85 years with a mean age of 53.6 years. The majority of the FNACs were performed under USG guidance. The lung was the most commonest site followed by lymph nodes and liver. Cytological diagnosis was made in 225 (88.93%) of the total cases. 7 (2.77%) cases were suspicious for malignancy and 21 (8.3%) were inconclusive. The majority of the lesions were categorized as malignant.</p> <p><strong>Conclusions: </strong>Image-guided FNAC has a good diagnostic yield for deeper structures and small and vaguely palpable swellings. A spectrum of lesions, both neoplastic and non-neoplastic can be diagnosed with its usage. The commonest site of aspiration was the lung followed by lymph nodes and liver.</p> Palzum Sherpa Sudhamsu Koirala Copyright (c) 2022 Palzum Sherpa, Sudhamshu Koirala 2022-06-30 2022-06-30 5 1 546 551 10.3126/nmj.v5i1.46803 Right-sided Decortication in a Patient with Left Pulmonary Artery Embolism – A Case Report <p>This case is an anesthesia challenge and management of one-lung ventilation in a patient with pulmonary embolism of the ventilated lung. A 50 years old male with a history of pulmonary thromboembolism of segmental and subsegmental branches of the left pulmonary artery was posted for right decortication. He developed hypoxia (sp0<sub>2</sub>~82-85% ) and PaC0<sub>2</sub>-EtCO<sub>2</sub> difference of ~30 mm Hg on initiation of one lung ventilation indicating significant shunting of blood and V/Q mismatch. We want to emphasize the importance of intraoperative arterial blood analysis to look for (PaCO<sub>2</sub> –EtCO<sub>2</sub>) difference and periodic reinflation of the collapsed lung for management of patients in whom the blood supply to the dependent is compromised. The presence of pulmonary vascular compromise on the dependent side offers a great number of challenges during the management of one-lung ventilation.</p> Tanvi Meshram Darshana Rathod Kamlesh K. Kumari Arun Sahayraja M Copyright (c) 2022 Tanvi Meshram, Darshana Rathod, Kamlesh K Kumari, Arun Sahayraja M 2022-06-30 2022-06-30 5 1 563 565 10.3126/nmj.v5i1.44411 Recurrence of Renal Hydatid Cyst <p>Hydatid cyst is a zoonotic disease caused by Echinococcus granulosus, transferred through the oral-fecal pathway by eating vegetables and food contaminated with dog stool containing eggs of the parasite. Hydatid cyst is most commonly found in the liver; however, dissemination can occur in other organs such as the lung and rarely in the heart, breast, thyroid, soft tissue of the neck, and kidney. The surgical approach remains the treatment of choice in hydatid. Meticulous handling of hydatid is important preoperatively and care should be taken against spillage of the contents and daughter cysts. In this case report, we report a case of recurrence of renal hydatidosis.</p> Robin Bahadur Basnet Prabodh Regmi Baikuntha Adhikari Binod Babu Gharti Surendra Basnet Udita Mishra Copyright (c) 2022 Robin Bahadur Basnet, Prabodh Regmi, Baikuntha Adhikari, Binod Babu Gharti, Surendra Basnet, Udita Mishra 2022-06-30 2022-06-30 5 1 566 567 10.3126/nmj.v5i1.43175 Use of Brain Stimulation to Improve Swallowing in a Brainstem Stroke Patient with Cricopharyngeal Spasm: Case Report <p>In India, post-stroke dysphagia affects between 37 and 78 percent of people. In recent years, research into transcranial magnetic stimulation has enhanced our understanding of the neurological aspects of swallowing, thanks in great part to Hamdy and colleagues' pioneering work. TMS has been shown to help with depressive symptoms, anxiety, and parkinsonian symptoms, however, there is no study on how it can help with swallowing. This case study looked at the effects of transcranial magnetic stimulation and transcranial direct current stimulation in combination with standard swallowing training on swallowing function in brainstem stroke patients with cricopharyngeal spasms.</p> Tanvi Sanghavi Copyright (c) 2022 Tanvi Sanghavi 2022-06-30 2022-06-30 5 1 568 570 10.3126/nmj.v5i1.42251