Journal of Kathmandu Medical College <p>The official journal of Kathmandu Medical College, Sinamangal, Kathmandu. Full text articles available. Content also available on the journal's own&nbsp;<a href="">website</a>.</p> <p>JKMC is a multidisciplinary, peer reviewed, open access, quarterly journal which publishes a wide range of scientific works including original research paper, case reports, reviews, editorials, book reviews and articles from medical students. It includes work from basic science, clinical science, dental, nursing and other related medical fields.</p> <p>Journal of Kathmandu Medical College does NOT charge authors for article submission and processing fees.</p> Kathmandu Medical College en-US Journal of Kathmandu Medical College 2091-1785 Bradycardia during laparoscopic surgeries: A cross-sectional study <p><strong>Background:</strong><span style="font-weight: 400;"> Bradycardia occurring during laparoscopic surgery potentially leads to cardiac arrest and adverse outcomes. Apart from the vagal reflex for its genesis, the knowledge on frequency and risk factors is limited.&nbsp;</span></p> <p><strong>Objectives:</strong><span style="font-weight: 400;"> To identify the bradycardia frequency and time points for its occurrence during laparoscopic surgeries.</span></p> <p><strong>Methodology:</strong><span style="font-weight: 400;"> In this hospital-based cross-sectional study, anaesthesia-related incident reports on bradycardia were collected from January to December 2019. Bradycardias (heart rate less than 60/minute) that occurred during laparoscopic surgeries were analyzed to characterize patient factors, the time point for occurrence, circumstantial events, management strategies, and outcomes.</span></p> <p><strong>Results:</strong><span style="font-weight: 400;"> Among 801 laparoscopic surgeries, 28 (3.4%) bradycardic incidents were identified, with one progressing to cardiac arrest. All bradycardias occurred in 26 patients undergoing laparoscopic cholecystectomy under general anaesthesia, with two patients each experiencing two bradycardic episodes. The mean patient age was 45 (±16.3) years and 17 (65.3%) were women. Fifteen (57.6%) patients had no co-morbidity. Controlled hypertension and hypothyroidism co-existed in seven (26.9%) and three (11.5%) cases respectively. Bradycardia occurred once each (3.5%) during laryngoscopy and endotracheal intubation. Six (21.4%) and twenty (71.4%) bradycardias respectively occurred before and during pneumoperitoneum. The mean of minimum heart rates was 43 (±8.8) per minute. Anticholinergics were administered in 25 (89.2%) incidents. Stopping surgery and pneumoperitoneum deflation included other major management strategies. The cardiac arrest case received chest compressions and adrenaline. Surgery resumed in all cases without adversity.</span></p> <p><strong>Conclusion:</strong><span style="font-weight: 400;"> Bradycardia occurs during laparoscopic surgery, more frequently during pneumoperitoneum and in healthy and younger females. Immediate cessation of surgical stimuli and atropine administration possibly prevent bradycardia from progressing to cardiac arrest.</span></p> Binod Gautam Ashmita Maharjan Suson Ghimire Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 5 12 Macular profile of eyes developing macular holes in cases of central retinal vein occlusion treated with Bevacizumab <p><strong>Background: </strong><span style="font-weight: 400;">Anti-vascular endothelial growth factors are commonly used for treatment for central retinal vein occlusion.</span><span style="font-weight: 400;"> There have been numerous reports regarding both the benefits and disadvantages of its use. Recently, a rather surprising complication- development of macular holes have started emerging.</span></p> <p><strong>Objectives: </strong><span style="font-weight: 400;">The purpose of this study was to evaluate if the patient's profile, baseline optical coherence tomography parameters, status of the vitreous and subsequent response pose a risk for macular hole formation in cases of central retinal vein occlusion central retinal vein occlusion following treatment with bevacizumab.&nbsp;</span></p> <p><strong>Methodology: </strong><span style="font-weight: 400;">This prospective exploratory analytical study was conducted at a tertiary eye care center of Nepal and evaluated 97 eyes with central retinal vein occlusion undergoing treatment with bevacizumab.</span></p> <p><strong>Results:</strong><span style="font-weight: 400;"> Full Thickness Macular Hole&nbsp; developed in eight (8.24%) of the central retinal vein occlusion eyes treated with bevacizumab. Elderly age and eyes with cystoid edema at baseline were found to have greater risk of developing macular hole following treatment (OR: 8.97 , p&lt;0.05). Twelve eyes (12.3%) of the eyes treated developed vitreoretinal interface anomalies and were the result of dramatic decrease in central macular thickness . All of them had cystoid macular edema at baseline. Five of them (42%) developed full thickness macular hole.</span></p> <p><strong>Conclusion: </strong><span style="font-weight: 400;">Anti-vascular endothelial growth factor agents have been widely accepted as the first line of choice for treatment of macular edema secondary to central retinal vein occlusion. Cystoid macular edema, eyes of the elderly and those showing dramatic decrease in central macular thickness with the development of anomalous vitreoretinal interface are potential risk factors for full thickness macular hole.</span></p> Anadi Khatri Pratap Karki Sagun Narayan Joshi Bal Kumar Khatri (KC) Muna Kharel Amrit Banstola Saurav Man Shrestha Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 13 19 Difference in knowledge and attitude of students towards medical ethics in preclinical and clinical phases of medical course in Gandaki Medical College, Pokhara <p><strong>Background: </strong><span style="font-weight: 400;">Medical ethics is a core component in the standardization of medical practice of any nation. Due to this reason, knowledge related to this subject should be imparted to the medical students. Only then, the aim of providing a strong base in the medical field and making of an ideal doctor will be possible.</span></p> <p><strong>Objective: </strong><span style="font-weight: 400;">The study was conducted to compare the status of knowledge and attitude of medical ethics before and after the medical ethics theory class among medical students of Gandaki Medical College, Pokhara.</span></p> <p><strong>Methodology: </strong><span style="font-weight: 400;">This was a cross sectional study conducted in Gandaki Medical College, Pokhara</span></p> <p><span style="font-weight: 400;">from 1</span><span style="font-weight: 400;">st</span><span style="font-weight: 400;"> to 31</span><span style="font-weight: 400;">st</span><span style="font-weight: 400;"> August, 2018. A total number of 232 medical students were divided into two groups depending on whether they had attended medical ethics classes or not. Five point Likert scale was used in the responses of the participants and analyzed.</span></p> <p><strong>Results: </strong><span style="font-weight: 400;">The study found that there was significant difference between two groups regarding the importance of consent for all minor operations (p=0.010), general physical examination (&lt;0.001), genital examination of males (p&lt;0.001) and females (p&lt;0.001), treatment of children and adults in emergency and non-emergency without their consent. Similarly, students after medical ethics class compared to the ones not having attended any class strongly disagreed that euthanasia is legalized in Nepal (p-value&lt;0.001).</span></p> <p><strong>Conclusion: </strong><span style="font-weight: 400;">Students after medical ethics theory class had a better understanding of medical ethics compared to the students who did not. Furthermore, active teaching methods like group discussions, role play and pedagogy can be incorporated to have a more effective impact on the students.</span></p> Neelu Hirachan Alok Atreya Tanuj Kanchan Nirmala Shrestha Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 20 24 Astigmatic change after pterygium excision with autologous limbal conjunctival graft <p><strong>Background:</strong><span style="font-weight: 400;"> Pterygium induces a significant amount of astigmatism. Pterygium excision with conjunctival limbal autograft results in significant reduction in astigmatism by inducing a reversal of pterygium induced corneal flattening thereby improving the vision.</span></p> <p><strong>Objectives:</strong><span style="font-weight: 400;"> The aim of this study was to investigate the amount of corneal astigmatism in patients with pterygium before and one month (4 weeks) after surgery.&nbsp;</span></p> <p><strong>Methodology:</strong><span style="font-weight: 400;"> The prospective observational study was conducted in 31 patients who underwent pterygium excision with limbal autograft in Kathmandu Medical College Teaching Hospital</span> <span style="font-weight: 400;">during the study period of 12 months duration. Patients with recurrent pterygium, pseudopterygium, history of ocular trauma, history of ocular surgery, corneal scarring were excluded from the study. After surgery, patients were followed for four weeks. Findings were recorded in the proforma and statistical analysis was done in SPSS version 19.&nbsp;&nbsp;</span></p> <p><strong>Results:</strong> <span style="font-weight: 400;">Pterygium was seen in all age groups with majority being in the active age range of 41-50 yrs. Females were most commonly affected. </span><span style="font-weight: 400;">Significant difference in corneal astigmatism was noted postoperatively with a p value being 0.01.</span></p> <p><strong>Conclusion:</strong><span style="font-weight: 400;"> The technique of pterygium excision with limbal conjunctival autograft not only reduces the chances of recurrence but also helps in reducing the induced corneal astigmatism which is responsible for decreased vision in patients with pterygium.</span></p> Dikchhya Sharma Gunjan Prasai Om Krishna Malla Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 25 30 Knowledge, attitude and practice of dental students, interns and practitioners to the use of amalgam in a dental institution of Kathmandu, Nepal <p><strong>Background: </strong><span style="font-weight: 400;">Dental practitioners of Nepal have been using amalgam for years for restoration, but the concern for mercury related health issues and inventions in metallurgy science have recently led to its decreased use.&nbsp;</span></p> <p><strong>Objectives: </strong><span style="font-weight: 400;">To assess the knowledge, attitude and practice of students, interns and dentists to the use of dental amalgam in a dental institution of Kathmandu, Nepal.</span></p> <p><strong>Methodology: </strong><span style="font-weight: 400;">A cross-sectional study was conducted in a dental institution of Kathmandu among 192 Dental students, interns, dental officers and dental specialists selected by census sampling method. Self-administered questionnaire consisting of 16 questions related to amalgam war, its use and safety was used. Data collected were analyzed using Statistical Package for Social Sciences version 20. Frequency and percentage were calculated for each response according to different professional levels.&nbsp;</span></p> <p><strong>Results: </strong><span style="font-weight: 400;">Most of the respondents including all the dental officers did not use amalgam frequently for restoration (141, 73.44%). Mercury toxicity was their major concern that restricted amalgam use (60, 31.25%). Most of them, (135, 70.31%) agreed on stopping the use of amalgam. They were comfortable to use composite resin as an alternative to amalgam (185, 96.35%). Majority (123, 64.06%) considered amalgam to be an unsafe material and were bothered about the environmental issues of mercury in the dental office (152, 79.16%).</span></p> <p><strong>Conclusion: </strong><span style="font-weight: 400;">This study concludes that amalgam was less frequently used for restoration due to the increasing concerns of mercury toxicity. Further studies on safety of other materials that can replace amalgam with long term follow up are necessary before they are considered as a definitive alternative for amalgam. </span></p> Punam Basnet Dixit Siddharth Dixit Sirjana Dahal Prakash Poudel Siddharth Ghimire Tribhuwan Koirala Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 31 36 Intestinal stomas: A clinical study in a Teaching Hospital, our experience <p><strong>Background</strong><span style="font-weight: 400;">: An intestinal stoma is an opening of the intestine on anterior abdominal wall made with an intention of either decompression of an obstructed colon or diversion of stool. Intestinal stomas may be temporary or permanent, depending on their role.&nbsp;&nbsp;</span></p> <p><strong>Objectives:</strong><span style="font-weight: 400;"> The objective of this study was to determine the common indications and types of intestinal stomas, and outcomes of patients operated at Manipal Teaching Hospital, Pokhara, Nepal.</span></p> <p><strong>Methodology</strong><span style="font-weight: 400;">:&nbsp; A retrospective cross-sectional study was conducted in 105 patients of intestinal stomas from February 2017 to March &nbsp; 2020 in a teaching hospital after approval from institutional review committee. Data were derived from medical records of patients and operation logbooks with the consecutive sampling method. Data were analyzed with the help of the Statistical Package for Social Sciences (SPSS) version20 and p value &lt; 0.05 was considered significant.&nbsp;</span></p> <p><strong>Results</strong><span style="font-weight: 400;">: Total of 105 patients with intestinal stomas was included for the study of which 82.9% (n=63) were emergency operations and 17.1% (n=13) were elective. There were 46 (43.80%) cases of ileostomy, 9(8.5%) jejunostomy and 50(47.6%) colostomy patients. Major indications of stoma formation were trauma 33.3% (n=35) and intestinal obstruction 22.8% (n=24). Complications were observed in 39 (37.14%) of the patients, with wound infection 11.8% (n=9) and peristomal dermatitis 11.8% (n=9) for </span><span style="font-weight: 400;">ostomates being the commonest. </span><span style="font-weight: 400;">Higher complications were seen with ileostomy as compared to colostomy (p=0.02) and loop ileostomy still higher than end ileostomy (p=0.00).&nbsp;</span></p> <p><strong>Conclusion: </strong><span style="font-weight: 400;">Common indications for intestinal stomas were abdominal trauma, enteric perforation, intestinal obstruction and colorectal carcinoma. Main complications included local skin problems, wound infection and retraction.</span></p> Om Bahadur Karki Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 37 42 Outcome of combined surgical and intralesional steroids injection therapy for management of ear keloid <p><strong>Background: </strong><span style="font-weight: 400;">Ear&nbsp;keloid is one of the challenging problems that affect people of different races with substantial aesthetic outcomes. Various types of treatment modalities, including intralesional corticosteroid injection are advocated to lower recurrence following excision.</span></p> <p><span style="font-weight: 400;"><strong>Objectives:</strong> To investigate the efficacy of a combined excision and postoperative intralesional triamcinolone acetonide (TA) injection for treating ear keloid patients.</span></p> <p><strong>Methodology: </strong><span style="font-weight: 400;">This was a descriptive study done to observe the outcome of combined approach of surgical and intra-lesional steroids injection therapy for ear keloids. Age, sex, site, size, duration, recurrence, and aesthetic outcome were evaluated.</span></p> <p><strong>Results:</strong><span style="font-weight: 400;"> A total of 18 patients representing 19 ear keloids, with one case having bilateral and 3 pediatric cases were included from February 2018 to January 2019.The mean age was 22 years with female to male ratio of 5:1, site were left sided 9 (50%), right 8 (44%) and 1(6%) bilateral. About 10 (53%) cases were at helix, and 9(47%) at ear lobule. Mean length of ear keloid was 1.53 cm with range of 0.5-3cm and mean breath 1.39cm with the range of 0.5-2.5 cm. The mean duration of ear keloid was 9.47 months. 2 (11%) cases showed a history of recurrence. Injection triamcinolone acetonide hypersensitivity was noted by 1 (5.3%) patient. Evaluation for all patients with aesthetic outcome was mean ± standard deviation (4.38±1.025).</span></p> <p><strong>Conclusion: </strong><span style="font-weight: 400;">Management of ear keloid using the combination of surgical excision and intra-lesional steroids injection therapy can be a good alternative option with low recurrence rate.</span></p> Amir Bajracharya Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 43 48 A morphometric analysis of pedicles of lumbar vertebrae by using computed tomography scan <p><strong>Background: </strong><span style="font-weight: 400;">The vertebral column is the central pillar of the body which has cervical, thoracic, lumbar, sacral and coccygeal parts. Out of these, the lumbar part is made up of five lumbar vertebrae which lies between the thoracic part above and the sacral part below.&nbsp;</span></p> <p><strong>Objective: </strong><span style="font-weight: 400;">The study aimed to measure pedicle dimensions of lumbar vertebrae by using computed tomography scan.</span></p> <p><strong>Methodology: </strong><span style="font-weight: 400;">This is a descriptive cross-sectional study which was conducted on 115 images of computed tomography scan collected from the Department of Radio-Diagnosis, Dhulikhel Hospital between May and October 2019 after receiving ethical approval from the Institutional Review Committee. All the scans available in the department were taken for the study. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Data analysis was done in the Statistical Package for the Social Sciences version 16 (SPSS 16.0).</span></p> <p><strong>Results: </strong><span style="font-weight: 400;">The pedicle chord length and breadth progressively decrease from L1 to L5 vertebral levels and pedicle thickness gradually increases from L1 to L5 vertebrae on both sides in both genders. </span><span style="font-weight: 400;">The pedicle chord lengths were found significantly different whereas breadth and thickness were insignificantly different between males and females at all lumbar vertebral levels except at L1 for breadth.</span></p> <p><strong>Conclusions: </strong><span style="font-weight: 400;">The pedicle chord length and breadth gradually decreases whereas thickness increases from L1 to L5 vertebral levels amongst Nepalese population.</span></p> Dil Islam Mansur Subindra Karki Dilip Kumar Mehta Pragya Shrestha Sunima Maskey Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 49 55 How to avoid the violation of ethics in research and publication? <p>Not available.</p> Sujaya Gupta Ashik Rajak Copyright (c) 2021 Journal of Kathmandu Medical College 2021-01-14 2021-01-14 9 1 1 4 A rare clinical presentation: Adult-onset Still’s disease <p><span style="font-weight: 400;">Adult -onset Still’s disease (AOSD) is a rare, idiopathic, inflammatory disorder of unknown etiology and pathogenesis that presents in 5 to 10% of patients as fever of unknown origin (FUO )exclusion characterized by generalized migratory joint ache, blanchable rash, fever and other systemic manifestations. We report an interesting case of a 23 year old Nepalese lady from Okhaldunga who presented with one-month duration of FUO along with sore throat, fever, vomiting, generalized joint ache, erythematous blanchable rash, headache and visual impairment. On examination there was hepatomegaly and investigations showed raised liver enzymes, serum ferritin and fibrinogen.After extensive workup, potential differential diagnoses were ruled out She was diagnosed to have Adult -onset Still’s disease based on Yamuguchi criteria after exclusion of other potential differentials.The patient partially responded to prednisolone and later methotrexate was prescribed which improved her symptoms. The case history, incidence, pathogenesis, clinical manifestations, differential diagnoses, diagnostic workup, treatment modalities, and prognosis of AOSD are discussed in this case report.</span></p> Prakash Banjade Prakash Poudel Jaishi Jonas Malla Copyright (c) 2020 Journal of Kathmandu Medical College 2020-03-31 2020-03-31 9 1 56 59 Caesarean section in morbidly obese parturient: Technical difficulties <p><span style="font-weight: 400;">Approximately one third of women of reproductive age group are obese. Obesity significantly increases caesarean section rate. Not only is obesity associated with unfavourable clinical outcomes for both mother and childalso, performing caesarean sections in morbidly obese patients is a challenge for obstetricians, anaesthetists and the caregivers. In view of increased risks while performing Caesarean delivery in morbidly obese patient, this case report reviews the techniques and incisions used; the anaesthetic, logistical and practical challenges faced by the obstetricians while performing an emergency caesarean section in a women with BMI of 45.78kg/m2 who was also a diagnosed case of chronic hypertension with Grade I hypertensive retinopathy. </span></p> Tanya Das Rachana Saha Rosina Manandhar Copyright (c) 2021 Journal of Kathmandu Medical College 2021-01-14 2021-01-14 9 1 60 62