Journal of Nepal Medical Association <p><strong>About JNMA<br></strong>Journal of Nepal Medical Association (JNMA) is an internationally peer-reviewed, MedLine/PubMed indexed,&nbsp;a general medical journal of Nepal Medical Association. JNMA is the first and oldest medical journal from Nepal since 1963 AD. JNMA is available at <a href="">PubMed</a>, <a href=";query&quot;%3A%7B&quot;filtered&quot;%3A%7B&quot;filter&quot;%3A%7B&quot;bool&quot;%3A%7B&quot;must&quot;%3A%5B%7B&quot;term&quot;%3A%7B&quot;index.issn.exact&quot;%3A&quot;1815-672X&quot;%7D%7D%2C%7B&quot;term&quot;%3A%7B&quot;_type&quot;%3A&quot;article&quot;%7D%7D%5D%7D%7D%2C&quot;query&quot;%3A%7B&quot;match_all&quot;%3A%7B%7D%7D%7D%7D%2C&quot;from&quot;%3A0%2C&quot;size&quot;%3A100%7D">DOAJ</a>, <a href=";btnG=&amp;hl=en&amp;as_sdt=0%2C5">Google Scholar,</a>&nbsp;Index Copernicus, EBSCO, EMBASE and other repositories.&nbsp;<br>JNMA abide by:<br>1. 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Committee on Publication Ethics for practising good publication ethics<br>You can also view our author guideline (printed version) from&nbsp;<a href="">HERE</a>&nbsp;[You need to have Acrobat Reader installed on your computer]<br>*Please go through&nbsp;<a href="" rel="noopener">Author Guideline Video</a>&nbsp;| <a href="" rel="noopener">Manuscript Preparation Video</a>&nbsp;for Nepalese Authors.&nbsp;</p> <p>JNMA is included and associated with</p> <p><a href=""><img src="" alt="Member of OASPA" height="75"></a>&nbsp;,<img src="" alt="Search JNMA article in DOAJ">&nbsp;,&nbsp;&nbsp;<a href=";as_epq=&amp;as_oq=&amp;as_eq=&amp;as_occt=any&amp;as_sauthors=&amp;as_publication=jnma&amp;as_ylo=&amp;as_yhi=&amp;hl=en&amp;as_sdt=0%2C5"><img src="" alt="Search JNMA article in Google Scholar" height="75"></a>,<img src="" alt="Member of OASPA" width="121" height="75">,<img src="" alt="" height="75">,</p> <h1><a href=";Full=journal%20of%20nepal%20medical%20association" target="_blank" rel="noopener">Science Citation Index</a></h1> Nepal Medical Association en-US Journal of Nepal Medical Association 0028-2715 <p>JNMA allow to read, download, copy, distribute, print, search, or link to the full texts of its articles and allow readers to use them for any other lawful purpose. The author(s) are allowed to retain publishing rights without restrictions. The JNMA work is licensed under a <a href="" rel="license">Creative Commons Attribution 4.0 International License</a>. More about <a href="">Copyright Policy</a>.</p> Substance Abuse among Students in a Dental School <p><strong>Introduction</strong>: Substance abuse has become a burning issue among the medical and dental students. Dental students, who later transform into dentists, have a significant role in substance abuse cessation. Thus the study was undertaken to quantify substance abuse among dental students of Kantipur Dental College. <br><strong>Methods</strong>: A descriptive cross-sectional study was conducted using pretested self-administered questionnaire among undergraduate and post graduate students of Kantipur Dental College. Convenience sampling was done and sample size was calculated.<br><strong>Results:</strong> Study revealed 166 (74.10%) as never smokers, 3 (1.30%) as former smokers and 55 (24.60%) as current smokers. Similarly 97 (43.3%) students never used alcoholic drink, 95 (42.41%) consumed alcohol monthly, 29 (12.95%) consumed alcohol 2-4 times a month and 3 (1.34%) consumed alcohol 2-3 times a week. A total of 78 (35%) students used cannabis.<br><strong>Conclusions</strong>: Substantial numbers of students were indulged in deleterious habits of smoking, tobacco and cannabis intake. Students need to be properly counseled to discourage substance abuse and create a healthy society.</p> Shishir Bhatta Manish Raj Sapkota Sujita Shrestha Rabindra Man Shrestha ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 896 899 10.31729/jnma.3900 Prevalence of Color Blindness in Undergraduates of Kathmandu University <p><strong>Introduction</strong>: Color blindness is X-linked recessive inherited disorder that occurs mostly in males and is transmitted through females. Many people with color blindness may remain undetected. Thus the present study aims to evaluate the incidence of color blindness among undergraduates of Kathmandu University. <br><strong>Methods:</strong> A cross-sectional study was conducted among 825 undergraduates, aged 17-25 years, from June to August 2018, in Kathmandu University, Kavre, Nepal. The Ishihara plates were used to evaluate the color vision of students under natural day light condition.<br><strong>Results:</strong> Study revealed that 24 (2.9%) undergraduates were color blind which include 24 male (5%) and no female. Among the color blind, five (20.3%), three (12.5%), two (8.33%) and 14 (58.33%) males were the victims of deuteranomaly, deuteranopia, protanomalia and total color blindness respectively. Color blindness is prevalent among the Brahmin 10 (3.9%), followed by Chettri 10 (2.72%) and Newar 4 (2.24%).</p> <p><strong>Conclusions</strong>: Prevalence of color blindness is found to be higher in males 24 (5%) than females 0 (0%). Total color blindness is the most prevalent in our study. Screening enables the students to become aware of limitations and devise ways of overcoming them.</p> Reena Kumari Jha Sukirty Khadaka Yubina Gautam Manisha Bade Mukesh Kumar Jha Ojashwi Nepal ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 900 903 10.31729/jnma.3913 Effects of Electrical Muscle Stimulation on Waist Circumference in Adults with Abdominal Obesity: A Randomized, Double-blind, Sham-controlled Trial <p><strong>Introduction:</strong> We investigated the effects of electrical muscle stimulationon waist circumference as compared with an identical device providing transcutaneous electrical nerve stimulation as control in adults with abdominal obesity.<br><strong>Methods:</strong> This was a randomized, double-blind, sham-controlled trial. Sixty patients with abdominal obesity received electrical muscle stimulation or transcutaneous electrical nerve stimulation randomly five times a week for 12 weeks. <br><strong>Results:</strong> The electrical muscle stimulationgroup achieved a mean 5.2±2.8 cm decrease in waist circumference while the transcutaneous electrical nerve stimulation group showed only a 2.9±3.3 cm decrease (P=0.005). About 20 (70.0%) of the electrical muscle stimulation group lost more than 4 cm of waist circumference but that only 8 (33.3%) of the transcutaneous electrical nerve stimulation group did so (P=0.008). Furthermore, fasting free fasting acid levels were significantly higher in the electrical muscle stimulation than in the transcutaneous electrical nerve stimulationgroup at week 12 (P=0.006). In the electrical muscle stimulation group, slight decreases in visceral abdominal fat and total abdominal fat areas by computer tomography were observed at 12 weeks, but these decreases were not significant. In addition, patients’ self-rated satisfaction scores with this program were significantly higher in the electrical muscle stimulation group.<br><strong>Conclusions:</strong> The 12-week electrical muscle stimulation program modestly reduced waist circumference in abdominally obese adults without side effects.</p> Eun Jung Choi Yun Jin Kim Sang Yeoup Lee ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 904 911 10.31729/jnma.3826 Dental Age Assessment using Demirjian’s Eight Teeth Method and Willems Method in a Tertiary Hospital <p><strong>Introduction:</strong> Age estimation is an important aspect in forensic anthropology, as it can aid in the identification of the deceased, and can be used in cases of immigration, child abuse and criminal prosecution in living individuals. Dental age estimation is considered reliable and accurate, since tooth development is least affected by environmental factors compared to somatic growth.<br><strong>Methods</strong>: In total, 150 pre-orthodontic treatment radiographs from healthy individuals were assessed. These individuals were aged between 8 to 19 years. Dental age for these individuals was calculated by two methods: Demirjian’s eight teeth method and Willems method. For Willems method, seven teeth on the left side of mandible (except the third molar) were staged according to Demirjian’s staging, and for Demirjian’s eight teeth method, all eight teeth were staged.<br><strong>Results:</strong> The mean chronological ages were 13.6961±1.94384 years in males and 13.9204±2.63541 years in females. The mean estimated ages by Demirjian’s eight teeth method were 12.1856±1.73478 years and 11.7906±2.32344 years in males and females respectively. Similarly, the mean estimated ages by Willems method were 12.8958±1.46838 years in males and 12.6926±2.27807 years in females.<br><strong>Conclusions:</strong> Willems method and Demirjian’s eight teeth method underestimated the chronological age in the given population. Both methods showed excellent correlation with chronological age indicating their applicability in dental age estimation, with development of population specific scores.</p> Nitin Kumar Agrawal Lucina Hackman Samarika Dahal ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 912 916 10.31729/jnma.3876 Accuracy of Visual Tests for Primary Cervical Cancer Screening in Rural Nepal <p><strong>Introduction</strong>: In Nepal, cervical cancer is the most common female cancer. Unfortunately, there is no uniform effective screening system available all around the country. The objective of this study is to evaluate the cytology, Visual Inspection with Acetic Acid and with Lugol’s Iodine alone or in combination to detect a pre-cancerous lesion in rural Nepal.<br><strong>Methods:</strong> It is an analytical cross-sectional study. Convenience sampling technique was used to select participants who were apparently healthy, married, non- pregnant women of aged 20-65 years for cervical cancer screening program. Screening tests were performed on all eligible women (n=2143) after socio-demographic and reproductive health data collection. A biopsy was applied as a gold standard test. Cross-tabulations were used to describe the test sensitivity, specificity, positive predictive value, and negative predictive value at a 95% confidence interval. Diagnostic odds ratio was also calculated. <br><strong>Results:</strong> A majority, 2143 (94%), of women accepted and participated in this study. The sensitivity vs specificity of cytology, VIA, and VILI was 57.1% vs 98.3%, 71.4% vs 88.8% and 78.6% vs 85.1%, and of the co-testing of ‘Both positive VIA and VILI’ and ‘Either positive VIA or VILI’ was 64.3% vs 85.7% and 90.1% vs 83.7% respectively. Negative predictive value of all tests exceeded 99.7%. Cytology had the highest Diagnostic odds ratio (64.9), followed by the co-test ‘Either positive VIA or VILI’ (27.7).<br><strong>Conclusions:</strong> Cervical cancer screening by co-testing ‘Either positive VIA or VILI’ is more useful than cytology; VIA and or VILI are easy, safe, feasible and well-accepted tests in a low resource setting, Nepal.</p> Niresh Thapa Muna Maharjan Girishma Shrestha Narayani Maharjan Deborah Lindell Na Zuo Jing Yang Ninu Maskey Hongbing Cai ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 917 923 10.31729/jnma.3857 Perception of Community and Hospital Personnel on Burn Treatment and Outcome in Nepal <p><strong>Introduction:</strong> Globally, eleven million people sustain burn injuries every year enough to require medical attention. WHO has estimated Disability associated limited years of 84,000 per year just due to deformities and 2100 people die every year due to burn injuries in Nepal. The overall objective of the study is to explore the effectiveness of burn injuries treatment and management approach of hospitals.<br><strong>Methods:</strong> This qualitative study approached to 40 Health Personnel for Key Informants Interviews and 18 Focus Group Discussions with community people at the ten referral hospitals of eight district from May-June 2016. Qualitative data were analyzed using At.Lasti Software. <br><strong>Results:</strong> Female burn victims are brought late to the hospital compared to male patients and false reporting about incident is usually done by her attendants. More than three-fourth (80%) of the hospitals and about one-third male and female from FGD reported that the community people seek home remedy first rather than medical treatment. Majority of the medical doctors and nursing chiefs reported that first degree cases accounts for 50% of the total burn cases with a success rate of 80%. Medical and Nursing staff reported that deformities like hypertrophic scar, keloids, joint stiffness and compartment syndrome are mostly observed during the treatment. Hypothermia and sepsis were the major causes of death in most of the burn patients.<br><strong>Conclusions:</strong> Usually, people who engaged in house and agriculture works, have visited public health posts/hospitals more frequently due to financial constraints and transportation issues where quality of burn care services are unavailable. </p> Jaswan Sakya Sujit Kumar Sah Khakindra Bahadur Bhandari Laxmi Raj Pathak Santosh Bikram Bhandari Sudha Ghimire Bhimsen Devkota Jurgen Hussmann ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 924 930 10.31729/jnma.3889 Resistance Pattern of Carbapenem on Enterobacteriaceae <p><strong>Introduction:</strong> Gram negative bacilli are the important causes of common clinical infections. Carbapenem resistant Enterobacteriaceae are considered as important public health threat and is classified as urgent by the Centers of Disease Control and Prevention because of their progressive geographic dissemination and limited therapeutic alternatives. This study was done to find out the resistance pattern of Carbapenem among Enterobacteriaceae.<br><strong>Methods</strong>: The descriptive cross-sectional study was carried out in Clinical Microbiology laboratory from February 2018 to May 2018 after ethical approval. Organism was identified on the basis of its microscopic observation by performing Gram’s stain and by identification of morphology after its growth in culture media followed by its biochemical reactions. Antibiotic sensitivity test of isolated pathogens was done using Muller Hinton Agar by the standard disk diffusion technique of Kirby-Bauer method.<br><strong>Results</strong>: In our study, total 1055 sample belongs to the family Enterobacteriaceae. From the family Enterobactericeae, 348 (27%) of the bacilli were found to be Carbapenem resistant. Among which most common bacteria was Klebsiella pneumoniae followed by Escherichia coli. All strains of Carbapenem resistant Enterobacteriaceae were sensitive to Colistin, Polymyxin B and Tigecycline. <br><strong>Conclusions</strong>: Among Enterobacteriaceae, around one-third of the bacterial isolates were Carbapenem resistant. However, to reduce drug resistance antimicrobial stewardship programme and proper infection control measures is required.</p> Khilasa Pokharel Bishwa Raj Dawadi Chandra Prakash Bhatta Satish Gupte Beena Jha ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 931 935 10.31729/jnma.4006 Evaluation of Morphological Variations of External Ear between the Nepalese and Indian Students of A Medical College <p><strong>Introduction</strong>: The external ear is made up of the elastic cartilage. It is considered constant from the birth till death. Therefore, it’s morphological variation plays important role in forensic medicine. The objective of this study was to identify this morphological variation among different nationality and the gender.<br>Methods: The study was conducted among 50 Nepali students and 50 Indian students of Manipal College of Medical Sciences. The simple random sampling was done. The morphological variation of external ear including different nature of shape of tragus, anti-tragus, lobe and margin of helix were studied on different gender and nationalities. <br><strong>Results:</strong> The highest distribution in shape of tragus was round in Nepali 42 (84%) and Indian 37 (74%). Most of Nepali students had flat 26 (52%) shape of anti-tragus and medium for Indian 25 (50%). The maximum ear attached lobe were found in both Nepali and Indian 27 (54%) respectively. Most of the Indian students had elongated shape of helix 24 (48%) whereas in Nepalese round shape of helix 31 (62%). The male participants had maximum round shape of tragus 42 (76.3%), flat shape of anti-tragus 28 (50.9%), free ear lobe 28 (50.9%) and shape of the margin of helix were round 29 (52.7%). The female participants had maximum round shape of tragus 37 (82.2%), medium shape of anti-tragus 22 (48.8%), attached ear lobe 27 (60%), and round shape of margin of helix 25 (55.56%).<br><strong>Conclusions:</strong> The morphology of the external ear varies with each individual. However, it shows it couldn’t differentiate their nationalities and gender.</p> Sarbada Makaju Sonam Chaudhary Kanaklata Iyer ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 936 939 10.31729/jnma.3912 Butorphanol in Labour Analgesia <p><strong>Introduction</strong>: Labour is the process where uterine contractions lead to expulsion of product of conception through the vagina into the outer world. Labour pain is one of the most severe pains which has ever been evaluated and its fear is one of the reasons women wouldn’t go for natural delivery. Delivery is a painful experience for all of the women except a few of them. The labor pain results from some physiological-psychological causes. Different pharmacological and non-pharmacological methods have been tried for pain relief in labour. The objective of this study is to see the effect of butorphanol injection in labour pain. <br><strong>Methods:</strong> It is a descriptive cross-sectional study conducted in B.P. Koirala institute of health sciences. We observed 200 pregnant women meeting the inclusion criteria and giving the informed consent who were on 1 mg butorphanol i.m. at the onset of active stage of labour every 4 hourly and on demand. Pain assessment was done by Numerical Pain analogue scale measured from 1 to 10. Fetal heart rate monitoring was done according to the hospital protocol. Caesarean section was performed for obstetrical indication. Neonatal outcome was evaluated by on duty pediatrician and APGAR score were noted at 1 and 5 min.<br><strong>Results:</strong> The pain scores in first, second, third, fourth hour were (8.83±0.773), (9.84±0.544), (9.94±0.338), (9.6±0.298) respectively, where 1st and 2nd hour is statistically significant.<br><strong>Conclusions:</strong> Butorphanol is an effective labour analgesia without significant adverse effects on women and the neonatal outcome.</p> Jyotsna Yadav Mohan Chandra Regmi Pritha Basnet K.M. Guddy Balkrishna Bhattarai Prakash Poudel ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 940 944 10.31729/jnma.3905 Is it Safe to Perform Laparoscopic Cholecystectomy for Acute Calculus Cholecystitis within 7 Days Following Symptom Onset? <p><strong>Introduction:</strong> Although operation within “golden 72 hours” from the onset of symptoms has been suggested for acute calculus cholecystitis, such early surgery is hardly possible in clinical practice because of variable timing of presentation. The aim of this study is to compare the outcomes of patients undergoing laparoscopic cholecystectomy within 72 hours of symptom onset with patients undergoing surgery after 72 hours up to 7 days of symptom onset for acute calculus cholecystitis.<br><strong>Methods:</strong> This is a descriptive cross-sectional study carried out from November 2016 to July 2018. Patients with acute calculus cholecystitis were divided in two groups according to the onset of symptoms. Main outcomes measured were conversion rate, duration of surgery, length of hospital stay and intraoperative complications.<br><strong>Results:</strong> Total 64 patients were evaluated. Among which 18 (28.1%) underwent surgery within 72 hours of onset of symptom. Around 46 (71.9%) underwent surgery after 72 hours of symptom onset. On bivariate analysis there were no significant differences in mean duration of surgery, hospital stay and conversion to open surgery between two groups. <br><strong>Conclusions:</strong> Early laparoscopic cholecystectomy is a safe procedure when done within 7 days of symptom onset. There were no significant difference in conversion rate, operative time, hospital stay, morbidity and mortality.</p> Rajesh Poudel ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 945 948 10.31729/jnma.3655 Diode Laser Turbinate Reduction in Allergic Rhinitis: A Cross-sectional Study <p><strong>Introduction</strong>: Turbinate reduction procedures are recommended for inferior turbinate hypertrophy in allergic rhinitis that fail to respond to medical therapy. Several modalities like turbinectomy, submucosal resection and tissue ablation are available for this purpose. The study aimed to evaluate the effectiveness of diode laser in the treatment of symptomatic inferior turbinate hypertrophy in allergic rhinitis and explore complications related to the procedure.<br><strong>Methods</strong>: This descriptive cross-sectional study was carried out in a tertiary care centre. The study enrolled 60 patients with inferior turbinate hypertrophy with failure of medical therapy. Inferior turbinate reduction was performed under local anaesthesia using diode laser. All the patients were evaluated subjectively for various nasal symptoms using visual analogue score scale preoperatively and during postoperative visit at three months.<br><strong>Results</strong>: The age ranged from 16 to 47 years with median age of 28 years. Twenty nine were male and thirty one were female. There was significant improvement in symptoms like nasal obstruction, nasal discharge, sneezing and decreased sense of smell. Immediate post-operative pain, crusting and persistent nasal discharge were observed as complications of the procedure. However, there was no incidence of mucosal oedema and synechiae formation in our study.<br><strong>Conclusions</strong>: Diode laser turbinate reduction procedure is safe, minimally invasive and effective in relieving the symptoms associated with inferior turbinate hypertrophy in allergic rhinitis resistant to medical therapy and can be performed on a day care basis under local anaesthesia.</p> Priyanka Gupta Toran Kc Deepak Regmi ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 949 952 10.31729/jnma.3870 Histomorphologic Profile of Skin Tumors <p><strong>Introduction</strong>: Skin tumors are not uncommon in the Nepalese community. Accurate diagnosis and categorization of these into different types is important because of its effect on prognosis and management. We conducted this study to find out the frequency of different histological types of skin tumors, correlate with their clinicopathologic profile and to determine the stage of malignant tumors.<br><strong>Methods</strong>: This is a descriptive cross-sectional study of skin tumors during the period February 2015 to January 2017. All the patients who were subjected to skin biopsy for skin tumors were included in this study. The biopsies taken were fixed in 10% formalin and then processed. Four microns thick sections were taken and stained with Haematoxylin and Eosin stain (H&amp;E). <br><strong>Results</strong>: Total of 108 cases of skin tumors were included of which 68 (62.97%) cases were histologically diagnosed as benign and 40 (37.03%) cases were diagnosed as malignant tumors. Keratinocytic tumors were predominant among both benign and malignant skin tumors.<br><strong>Conclusions</strong>: Histopathological examination is the gold standard for accurate diagnosis and prognostic assessment of the patient. Staging of the malignant tumors in excision biopsy specimen needs to be emphasized since it is a predictor of prognosis.</p> Rupendra Thapa Pranita Gurung Suspana Hirachand Sanju Babu Shrestha ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 953 957 10.31729/jnma.3988 Diode Laser Reduction of Symptomatic Inferior Turbinate Hypertrophy <p><strong>Introduction</strong>: Inferior turbinate hypertrophy refractory to medical management is one of the commonest problems encountered by ENT surgeons all over the world. Diode Laser turbinate reduction is a safe, minimally invasive, cost-effective procedure that helps in relieving the symptoms associated with it and can be performed on a day care basis under local anesthesia. The objective of this study is to measure the effectiveness of Diode laser in treatment of symptomatic ITH.<br><strong>Methods</strong>: Fifty patients with symptomatic inferior turbinate hypertrophy, age ranging between 15-45 years were enrolled in the study. Symptom assessment was done with the visual analogue scale. Portable Diode laser was used. Patients were followed up after 1&nbsp;week and 1 month of surgery. During each postoperative visit, symptoms were reassessed using VAS and postoperative morbidity were noted.<br><strong>Results</strong>: Out of fifty patients, all the patients had nasal obstruction and 42 had nasal discharge and by the end of 1 month 43 (86%) and 37 (88%) patients had relief of symptoms respectively. Excessive sneezing was found in 45 patients, 39 (86.6%) patients got benefitted. Out of 18 patients, 15 (83.3%) patients had decreased snoring at 1 month post-op. Similarly, 24 patients had headache, 20 (83.3%) patients had decrease in severity. Hyposmia was seen in 19 patients, 10 (52.6%) patients had improvement in olfaction.<br><strong>Conclusions</strong>: Diode laser turbinate reduction for symptomatic inferior turbinate hypertrophy is one of the safest procedures that can be done under local anesthesia on OPD basis with significant relief of symptoms and with minimal complications.</p> Nain Bahadur Mahato Deepak Regmi Meera Bista ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 958 962 10.31729/jnma.4005 Sustained Drug Free Remission of Lupus Panniculitis with Methotrexate: A Case Report From Nepal <p>Cutaneous manifestations are second most common presenting feature of lupus. Discoid lupus erythematosus is the most common variant amongst all; lupus panniculitis being described in only 2-5% of cases. Most cases of cutaneous lupus are associated with autoantibodies and either precede or follow the systemic manifestations of lupus. There is no proven treatment for cutaneous manifestations of lupus including lupus panniculitis. Available non-randomized studies show efficacy of hydroxychoroquine in most cases, whereas methotrexate and other immunosuppressant are used in relapsing cases.</p> <p>We describe a case of lupus panniculitis presenting as an isolated manifestation of lupus with negative autoantibody titers which responded well to methotrexate. We observed that lesions went into drug-free remission in 1year and did not recur on 1year follow-up. There was no residual skin atrophy or scarring. Drug-free remission in isolated cases of lupus panniculitis variant could be possible with timely intervention in the absence of autoantibodies</p> Binit Vaidya Rikesh Baral Hritu Baral Shweta Nakarmi ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 963 966 10.31729/jnma.3885 Rare Case of Female with Pelizaeus Mertzbacher Disease Due to Deletion of Proteolipid Protein 1: A Case Report <p class="western"><span style="font-family: 'Times New Roman', serif;">Pelizaeus Merzbacher Disease (PMD) is a rare X-linked central nervous system (CNS) disease involving the proteolipid protein 1 (PLP1) gene. Patients exhibit signs for instance nystagmus, hypotonia, ataxia. We report a three year old female patient with chief compliant of developmental delay. </span><span style="font-family: 'Times New Roman', serif;">On physical examination, patient was alert but had poor eye contact while sitting in a stroller. </span><span style="font-family: 'Times New Roman', serif;">Since no chromosomal evaluation was performed, a chromosomal microarray testing was performed. Review of geneticist report indicated that patient carries a deletion of at least 2.26 Mb within cytogenetic band Xq22.1 to Xq22.2 which is known to contain 39 genes. Out of the 39 genes, PLP1 is associated with known clinical disorder; PMD. Our case highlights the second only known female with PMD due to deletions of PLP1 gene. For a patient with developmental delay, the importance of performing genetic testing and/or radiological imaging early on is strongly recommended. </span></p> Masanosuke Kinoshita William Roston ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 967 969 10.31729/jnma.3824 Diffuse Alveolar Haemorrhage as Initial Presentation of Systemic Lupus Erythematosus: A Case Report <p>Diffuse alveolar hemorrhage results from accumulation of red blood cells in the alveolar space originating from alveolar capillaries. Alveolar hemorrhage in Systemic Lupus Erythematosus is rare but catastrophic and can rapidly progress to respiratory failure. We report a 22-year old lady who presented with dyspnoea on exertion, hemoptysis, bilateral leg swelling and oliguria. Diffuse alveolar hemorrhage was confirmed by bronchoalveolar lavage fluid analysis. Serologic tests and renal biopsy confirmed lupus nephritis. She was treated with systemic immunosuppressive therapy and plasma exchange, to which she had a favourable response. Lupus presenting as alveolar hemorrhage is rare which warrants prompt diagnosis and treatment to prevent complications.</p> Ashesh Dhungana Prajowl Shrestha Bhakta Dev Shrestha Anil Baral Gita Sayami ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 970 973 10.31729/jnma.3903 Sirenomelia: A Case Report <p>Sirenomelia is primarily a congenital anomaly where a normally paired lower limb is replaced by a single midline limb and is characterized by single umbilical artery. Such cases though considered rare do occur at our set-up and to make health workers aware regarding the condition, so that they can be managed well when encountered, lays the importance of reporting such case. A referred case of Sirenomelia from Dhading district hospital was presented to Emergency department of Paropakar Maternity and Women’s Hospital on 6th March 2016 of 18 year “Young Primigravida at 34 week and 5 days of gestation in second stage of labor” following ultrasonography diagnosis for better management. After confirming the diagnosis, preterm vaginal delivery was performed with a live baby of 1250 gm consisting of multiple congenital anomalies and poor Apgar score. Such cases do occur at our set-up so that if anomaly scanning is done routinely,&nbsp;</p> Pramod Kattel ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 974 976 10.31729/jnma.3884 Amelogenesis Imperfecta: A Case Series from the Community <p>Amelogenesis Imperfecta is a hereditary disorder affecting the formation of enamel structure. Two female children and one male (11 years, 12 years and 6 years respectively) reported with chief complaint of yellowish discoloration of teeth since their childhood. They reported that they had similar discoloration in their deciduous teeth. Examination showed generalized deposits of plaque and calculus, yellowish discoloration of the teeth with chipping off of the incisal and cuspal enamel structures. OPG revealed thin lining of enamel with thick dentin layer and pulp chamber. PA view revealed unfused anterior fontanels and lateral cephalogram indicated vertebrae in growing phase. The patients were instructed to maintain proper oral hygiene and regular follow up till the growth cessation. Permanent skeletal, functional, esthetic needs is addressed after growth completion. Oral rehabilitation through multidisciplinary approach can certainly provide a good prognosis and patient was counseled and motivated to maintain good oral hygiene.</p> Abanish Singh Santosh Kumari Agrawal Ashish Shrestha Tarakant Bhagat ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 977 979 10.31729/jnma.3709 Prolonged Intubation Induced Tracheoesophageal Fistula in Suspected Meningococcal Sepsis with ARDS: A Case Report <p class="doublespace">Tracheoesophageal fistula is an abnormal communication between trachea and esophagus. Benign acquired types are rare with the incidence of less than 1%. Prolonged endotracheal intubation remains the most common cause. We are reporting a 28 years old female patient presented with chief complaint of a cough after each meal intake in the outpatient clinic. She had a recent history of admission in the intensive care unit with prolonged intubation (11 days). Her general physical examination, laboratory examination, and chest x-ray were normal. Esophagogastroscopy was performed and revealed communication between upper esophagus and trachea approximately at 14-17cm embedded in longitudinal mucosal folds of the esophagus. She was referred to the higher center for surgical repair. Though, a rare complication, high suspicion is necessary to accurately diagnose the disease in a patient with the history of prolonged intubation.</p> Ramesh Rana Rikesh Sapkota Binesh Shakya Samir Gautam ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 980 982 10.31729/jnma.3890 Early Undifferentiated Arthritis: A Developing Country Perspective from Nepal <p>Early undifferentiated arthritis is a group of inflammatory joint disease of less than 3 months duration that do not classify under any of the specific rheumatic or connective tissue disorder. Previously, inflammatory arthritis used to be treated only when there was a clear evidence of damage or deformity occurring with it. Use of disease modifying anti-rheumatic drugs were considered potentially harmful early in the course of arthritis which could be self-limiting. However, with the abundance of data on outcomes of early arthritis and identification of factors that can help to predict those outcomes lead to earlier use of such DMARDs. Better understanding of serological tests like anti-CCP antibodies and imaging modalities like high frequency ultrasound with power doppler and magnetic resonance imaging has increased the diagnostic and prognostic yield of such early arthritis cases. It is now imperative that the risk be assessed early in the course of disease and early DMARDs be instituted for better outcome in these cases.<br>This review analyses the historical evolution of evidence in the management of early undifferentiated arthritis and summarises the treatment approach, monitoring and disease outcomes till date.</p> Binit Vaidya Rikesh Baral Shweta Nakarmi ##submission.copyrightStatement## 2018-12-31 2018-12-31 56 214 983 990 10.31729/jnma.3893