https://nepjol.info/index.php/jbpkihs/issue/feed Journal of BP Koirala Institute of Health Sciences 2021-07-12T08:01:54+00:00 Dr. Krishna Pokharel jbpkihs@bpkihs.edu Open Journal Systems <p>The Journal of BP Koirala Institute of Health Sciences (JBPKIHS) is an official journal of the B. P. Koirala Institute of Health Sciences. The journal was known as&nbsp;<a title="HREN" href="https://www.nepjol.info/index.php/HREN" target="_self">Health Renaissance</a>&nbsp;before 2018.&nbsp;</p> https://nepjol.info/index.php/jbpkihs/article/view/33982 Mental Health Status among Adolescents of High Schools: A Cross-sectional Study 2021-07-11T10:36:48+00:00 Baishali Dass dbaishali19@gmail.com Binita Kandangwa mekandangwa@gmail.com Rita Pokharel rita.pokharel@bpkihs.edu <p><strong>Background: </strong>Adolescents are prone to develop various psychosocial problems with a long-standing impact. We aimed to investigate the mental health status among adolescents from high schools in Dharan sub-metropolitan city.</p> <p><strong>Methods: </strong>In this descriptive cross-sectional study, we enrolled 150 adolescents from two different schools of Dharan, using a stratified random sampling technique. The Pediatric Symptoms Checklist for Youth was used to assess their mental health status. A score of 30 or more was considered as a mental health problem. Poverty, family dispute, punishment, and personal and family history of a psychiatric condition were considered as potential predictors of mental health problem. The chi-square test was applied to identify the predictors of mental health problem.</p> <p><strong>Results: </strong>The final analysis included 141 samples. More than 60% of the students belonged to the age group 13-15 years, and 52.5% were females. About 59.6% were Janajatis, and 61% were Hindus. The majority (63.8%) were living below the poverty line. The majority (83.7%) had no dispute in the family. All the students had received punishment, and 51.1% had received it at home. One-third of the students had mental health problem. The presence of mental health problem was significantly associated with nuclear family status (p = 0.04), and history of a family dispute (p = 0.04).</p> <p><strong>Conclusion: </strong>Mental health problem was common among adolescents, and it was associated with the nuclear family structure and the presence of family dispute.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/37234 Serum Vitamin D Level in Patients Undergoing Coronary Artery Catheterization 2021-07-11T10:36:50+00:00 Bikash Nepal bikashnepal52@gmail.com Ajit Sah bikashnepal52@gmail.com Biplave Karki bikashnepal52@gmail.com Jeet Prasad Ghimire bikashnepal52@gmail.com Aditya Mahaseth bikashnepal52@gmail.com Swapnil Pandit bikashnepal52@gmail.com Ajit Sah bikashnepal52@gmail.com Surendra Uranw surendra.uranw@bpkihs.edu Naveen Kumar Pandey nav_dey31@yahoo.com Prashant Shah bikashnepal52@gmail.com Prahlad Karki prahlad.karki@bpkihs.edu <p><strong>Background: </strong>Vitamin D deficiency may be a risk factor for coronary artery disease (CAD). We aimed to measure the prevalence of vitamin D deficiency in CAD and its association with severity of angiographic proven CAD.</p> <p><strong>Methods: </strong>This prospective, cross-sectional study included 106 consecutive patients who were admitted for typical angina and had signs of myocardial injury (ECG findings and/ or elevated troponin I or CK-MB) and who underwent coronary angiography at the university hospital of BPKIHS from August 2020 to April 2021. Patients were categorized into angiographic proven CAD group and angiographic normal coronary artery group. Serum vitamin D level was classified as normal (≥ 30 ng/ml) and deficiency (&lt; 30 ng/ml).</p> <p><strong>Results:</strong> Out of 106 patients, 78 patients (73.6%) had vitamin D deficiency and 28 (26.4%) had normal vitamin D level (p = 0.39). Vitamin D level (mean ± SD) in patients with angiographic normal coronary artery and angiographic proven CAD were 25.94 ± 11.63 ng/ml and 26.07 ± 12.90 ng/ml respectively (p = 0.97). Prevalence of vitamin D deficiency was 75.0% and 64.3% in significant CAD group and normal coronary artery group respectively (p = 0.39). Similarly, frequency of vitamin D deficiency were 68.6%, 78.3% and 88.90% in single, double, and triple vessel disease respectively (p = 0.21). The vitamin D level (mean ± SD) in single, double and triple vessel disease were 27.31 ± 14.02 ng/ml, 25.69 ± 12.72 ng/ml, 23.08 ± 9.45 ng/ml respectively.</p> <p><strong>Conclusion:</strong> The prevalence of vitamin D deficiency in both angiographic normal coronary artery and angiographic proven CAD were high but comparable. There was no association of vitamin D deficiency with severity of angiographic proven CAD.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36993 Detection of Carbamazepine Level among Patients Visiting Psychiatric and Pediatric Services of a Tertiary Hospital in Eastern Nepal 2021-07-11T10:36:52+00:00 Dipesh Raj Panday dipesh.pandey@bpkihs.edu Gajendra Prasad Rauniar gprauniar2004@yahoo.com Dilli Sher Rai dillisher.rai@bpkihs.edu Karishma Rajbhandari Panday karishma@bpkihs.edu Madhur Basnet madhur.basnet@bpkihs.edu Shyam Prasad Kafle kafle.shyam11@gmail.com <p><strong>Background:</strong> Carbamazepine plasma level is directly related to dose, therapeutic effect, and toxicity. We aimed to observe its plasma level and relationship with dose among psychiatric and pediatric patients.</p> <p><strong>Methods:</strong> This observational study was performed in the Therapeutic Drug Monitoring Laboratory of a university hospital for a period of 1.5 years. Twenty-six consenting patients visiting either psychiatric or pediatric service and taking carbamazepine same dose for &gt; 8 days (i.e. &gt; 6 half-lives) were enrolled. The primary outcome was plasma carbamazepine level as determined by a High-Performance Liquid Chromatography machine. The secondary outcome included its correlation with dose assessed by the Spearman rho’s correlation coefficient.</p> <p><strong>Results:</strong> The mean dose received by the patients was 13.31 ± 5.39 mg/kg/day in pediatrics and 8.33 ± 2.29 mg/kg/day in psychiatry.&nbsp; The plasma levels [median (IQR)] were 10.01 (6.27, 13.35) mg/L and 10.53 (5.17, 15.19) mg/L respectively in pediatric and psychiatric patients. Thirteen patients (50%) had therapeutic, 10 (36.46%) had above therapeutic, and 3 (11.54%) had subtherapeutic plasma level. Neurocysticercosis (23.1%) in pediatrics and partial seizure (69%) in psychiatry were the most common diagnosis. Symptom-control was achieved in 19 (73.1%) patients. The plasma carbamazepine level did not correlate with dose either in pediatric patients (p = 0.42) or in psychiatry patients (p = 0.63).&nbsp;</p> <p><strong>Conclusion:</strong> The plasma carbamazepine levels [median (IQR)] in pediatric and psychiatric patients were 10.01 (6.27, 13.35) mg/L and 10.53 (5.17, 15.19) mg/L respectively. The plasma level was normal in half of the recruited patients and did not correlate with dose.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/33227 Role of NT-proBNP in Detection of Left Ventricular Diastolic Dysfunction in Asymptomatic Type 2 Diabetes Patients with Preserved Ejection Fraction: A Cross-sectional Study 2021-07-11T10:36:54+00:00 Naveen Kumar Pandey nav_dey31@yahoo.com Prahlad Karki prahladkarki@hotmail.com Prashant Shah prashant0063@hotmail.com Madhab Lamsal madhab.lamsal@bpkihs.edu <p><strong>Background: </strong>Left ventricular diastolic dysfunction (LVDD) represents the first stage of diabetic cardiomyopathy and is initially subclinical. Early diagnosis enables earlier treatment and stops further progression of the disease. Tissue Doppler Imaging (TDI) is a new diagnostic modality with high sensitivity and specificity to know ventricular diastolic function. N-terminal pro brain natriuretic peptide (NT-proBNP) is a cardiac neurohormone that can be used to identify the changes in ventricular diastolic function. We aimed to estimate the concentration of NT-proBNP and correlate its value with TDI for LVDD in asymptomatic type 2 Diabetes Mellitus.</p> <p><strong>Methods: </strong>In this comparative cross-sectional study, we enrolled 100 asymptomatic type 2 diabetic patients and 100 healthy people aged 30-60 years. In both groups, NT-proBNP levels were measured and the presence of LVDD was determined by TDI. The primary outcome parameter was the level of NT-proBNP in diabetics and healthy people. The secondary outcome parameter was the correlation of NT-proBNP level with various grades of LVDD.</p> <p><strong>Results: </strong>In patients with LVDD, NT-proBNP levels [median (IQR)] were 123 (102,194) pg/ml in diabetics and 72 (67, 77) pg/ml in the control group. In patients without LVDD, NT-proBNP levels [median (IQR)] were 69 (59, 76) pg/ml in diabetics and 57 (49, 63) pg/ml in the control group. The level of NT-proBNP was significantly higher in those with LVDD (p &lt; 0.001). NT-proBNP concentration significantly increased as grades of LVDD increased.</p> <p><strong>Conclusion:</strong> NT-proBNP is a good marker for detection of preclinical LVDD in patients with uncontrolled diabetes prone to develop cardiovascular complications.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36107 Cerebral White Matter Hyperintensities in T2 Weighted Magnetic Resonance Images of Elderly Patients- Correlation with their Mental Status 2021-07-11T10:36:56+00:00 Niraj Regmi regmi.niraj@gmail.com Abu Saleh Mohiuddin salehmohiuddin@yahoo.com Abu Taher mataherdr67@gmail.com Mahfuz Ara Ferdousi salehmohiuddin@yahoo.com <p><strong>Background:</strong> White matter hyperintensities (WMH), focal and/or diffuse areas of hyperintense signals on T2 weighted magnetic resonance imaging (MRI), are the most common incidental finding in elderly patients. However, their clinical significance is usually overlooked. We aimed to find out the correlation between the degree of cerebral WMH in MRI with the mental status of elderly patients, assessed by Mini-Mental Status Examination (MMSE) score.</p> <p><strong>Methods:</strong> This cross-sectional study was conducted for two years on eighty eligible elderly patients (&gt; 60 years) referred to the Department of Radiology and Imaging for MRI of the brain. Demographic variables like age and sex, MMSE score, and MRI variables like location and number of WMHs were studied. The Pearson’s correlation coefficient was used to calculate the correlation between the extent of periventricular WMHs and MMSE score.</p> <p><strong>Results</strong>: A significant negative correlation (r = -0.78; p &lt; 0.001) was found between decreased MMSE and the extent of periventricular WMH. A significant negative correlation was also found when periventricular hyperintensities were evaluated individually for frontal caps (r = -0.68; p &lt; 0.0001), band opacities (r = -0.55; p&lt;0.0001) and occipital cap (r = -0.59; p &lt; 0.0001). However, subcortical WMH was not significantly corelated with MMSE score (r = +0.018, p = 0.0897).</p> <p><strong>Conclusion</strong>: A significant negative correlation exists between the extent of periventricular WMH seen at brain MRI with cognitive decline in elderly subjects. However, no such correlation exists between subcortical WMH and mental status.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/37764 Awareness Regarding Health Insurance Policy Scheme of Government of Nepal among Local Residents of Dharan Sub-Metropolitan City 2021-07-11T10:36:58+00:00 Roshni Thapa roshnithapa2016@gmail.com Shyam Lamsal shyam.lamsal@bpkihs.edu Angur Badhu roshnithapa2016@gmail.com Sharmila Shrestha sharmila.shrestha@bpkihs.edu <p><strong>Background: </strong>An expensive care discourages people from using health services. The health insurance policy scheme of the government of Nepal aims to provide quality health care services without a financial burden to its citizens. We aimed to assess its awareness among local people of Dharan and also find its acceptance and association with various demographic variables.</p> <p><strong>Methods: </strong>This cross-sectional study was conducted among 249 households in 5 wards of Dharan sub-metropolitan city. Using a semi-structured questionnaire, a face-to-face interview was taken either from the financial decision maker/ financial supporter of the family. The socio-demographic characteristics, awareness and perception towards the health insurance policy scheme and its acceptance were assessed. The chi-square test was used to find the association of their awareness with different demographic variables.</p> <p><strong>Results: </strong>The majority (70.7%) of the families were aware of the health insurance policy scheme. The most frequent source of knowledge was their friends/ family members (43.7%) followed by insurance service providers (32.4%). Only 36.6% of the families were enrolled in the health insurance policy scheme while 34.1% were not enrolled despite their knowledge about the scheme. Elderly (&gt; 60 years), dependent, those without formal <em>education, </em>or those living below the poverty line were less aware regarding the health insurance policy (p &lt; 0.05).</p> <p><strong>Conclusion: </strong>About 29% of families had no idea about health insurance policy scheme and 34.1% were not enrolled in it despite being aware of the scheme. Friends/ family members and insurance service providers were common sources of information.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36324 Outcome of Neonatal Hyperbilirubinemia from a Tertiary Care Hospital in Eastern Nepal: A Cross-sectional Study 2021-07-12T08:01:54+00:00 Shyam Prasad Kafle kafle.shyam11@gmail.com Mukesh Bhatta mukace@hotmail.com Ramesh Shrestha stharamesh007@gmail.com Sarita Sitaula dr.sarita.sitaula@gmail.com Namu Koirala koiralanamu@gmail.com Anupam Koirala anupam111.koi@gmail.com <p><strong>Background</strong>: Timely detection and treatment of pathological hyperbilirubinemia in newborns can prevent acute bilirubin encephalopathy and its consequences. We aimed to identify its occurrence, presentation time, phototherapy duration, need for exchange transfusion, and outcome.</p> <p><strong>Methods</strong>: In this cross-sectional study, we enrolled all the babies admitted for pathological neonatal hyperbilirubinemia in the university hospital of BPKIHS in a one-year duration. Babies with life-threatening congenital malformations or conjugated bilirubin &gt; 20% of total serum bilirubin or &gt; 2 mg/dl were excluded. Obstetric profile of mothers, clinical and laboratory parameters of babies, onset time of pathological jaundice, duration of phototherapy, need for exchange transfusion or intravenous immunoglobulin were recorded. Neonatal outcome was classified as good and poor and its association with potential predictors analyzed.&nbsp;</p> <p><strong>Results</strong>: One-hundred and fifty babies developed neonatal jaundice requiring treatment. The most common causes included ABO and Rh setting. No cause was found in 26 (18%) babies. One-hundred and eight babies (72%) were only managed with phototherapy whereas 42 (28%) required both phototherapy and double volume exchange therapy. The majority (84.5%) had good outcome without any residual neurological deficit at discharge. Babies with total serum bilirubin &gt; 20 mg/dl at presentation, duration of phototherapy &gt; 44.8 h, ABO setting, hemolysis, and out born status significantly developed &nbsp;poor outcome (p &lt; 0.05).</p> <p><strong>Conclusion: </strong>About 15% of the babies with hyperbilirubinemia had acute bilirubin encephalopathy at discharge suggestive of poor outcome. Babies with high bilirubin at presentation, longer duration of phototherapy, ABO settings, hemolysis, and out born status developed poor outcome.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36101 Knowledge Regarding Care of Low Birth Weight Babies among Nurses Working in Pediatric Wards of a University Hospital in Eastern Nepal 2021-07-11T10:37:02+00:00 Upendra Yadav upendrayadav@bpkihs.edu Basant Kumar Karna basantkarn@bpkihs.edu <p><strong>Background: </strong>Birth weight is the single most important factor determining a newborn’s survival chance. Recent development in neonatal care demands nurses to have updated knowledge regarding the care of low birth weight (LBW) babies. We aimed to assess the knowledge regarding care of LBW babies among nurses.</p> <p><strong>Methods:</strong> In this descriptive cross-sectional study, we enrolled 54 nurses working in pediatric wards of BPKIHS. To assess their knowledge regarding the care of LBW babies, a pre-tested self- response questionnaire was administered with focus on six domains: knowledge about care of LBW babies, the kangaroo mother care, adequacy of breast feeding, vaccination, bathing of LBW babies, and prevention of infection. The chi-square test was used to examine the association between different categorical variables and their knowledge.</p> <p><strong>Results:</strong> The majority (83%) had a Proficiency Certificate in nursing education, 11% had a Bachelor of Science in nursing education and only 6% had completed Bachelor in general nursing. More than half (55.6%) of the nurses had a job experience of 1-5 years. The overall knowledge score (mean ± SD) among the nurses on care of LBW babies was 86.5 ± 2.3. Nurses with Bachelor level of education had better knowledge score (85.5&nbsp;± 15.4) compared to those with proficiency&nbsp;level of education (75.1&nbsp;± 15.9) (p = 0.003).</p> <p><strong>Conclusion:</strong> The knowledge regarding the care of LBW babies among the nurses working in pediatric wards of BPKIHS seemed excellent. Knowledge was better in nurses with higher educational level.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36081 Mental Health Problems in Nepalese Migrant Workers and their Families 2021-07-11T10:37:09+00:00 Pashupati Mahat kevanthorley@doctors.org.uk Kevan Thorley kevanthorley@doctors.org.uk Karuna Kunwar kevanthorley@doctors.org.uk Smriti Ghimire kevanthorley@doctors.org.uk <p>In this cross-sectional study, we aimed to describe the mental health problems of Nepalese migrant workers and their family members at home in Nepal. Families of migrant workers left behind in Nepal from nine project districts were interviewed to assess the psychosocial problems and offered appropriate psychosocial counselling. We assessed 747 individual members. Ninety-five returned migrant workers received psychosocial counselling, 67% of whom were male. The majority (56%) of the returnees suffered from anxiety, 23% had depression and 11% had serious mental illness. The left-behind family members amounted to 653, 93% of whom were female. The majority (56%) had anxiety, 26% had depression, 7% expressed suicidal ideation or had attempted suicide, 2% had severe mental illness. We concluded that majority of returning workers and left behind family members suffered from anxiety and depression.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36337 Fasting or Starving our Patients to an Inhumane Extent? A Plea for Some Common Sense 2021-07-11T10:36:47+00:00 Krishna Pokharel drkrishnapokharel@gmail.com <p>NA</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/37267 Challenges in Care of Individuals with Autism Spectrum Disorder during the Covid-19 Pandemic: A Perspective from UK, India and Nepal 2021-07-11T10:37:10+00:00 Pawan Sharma pawan60@gmail.com Paakhi Srivastava paakhisrivastava@gmail.com Sundar Gnanavel sundar221103@yahoo.com Lokesh Saini drlokeshsaini@gmail.com Priyanka Madaan doc.priyanka72@gmail.com <p>NA</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36091 Social Responsibility for Health during COVID-19 Pandemic 2021-07-11T10:37:03+00:00 Dhana Ratna Shakya drdhanashakya@yahoo.com Ravi Ram Shrestha raviramshrestha@gmail.com Sarun Koirala sarun.koirala@bpkihs.edu Santosh Upadhyaya Kafle drsantoshkafle@gmail.com Prasanna Subedi petrolinwego@gmail.com Ayush Anand ayushanandjha@gmail.com Aparna Ghimire aparna.ghimire@bpkihs.edu Kishor Gurung kgurung95@gmail.com Krishna Pokharel krishna.pokharel@bpkihs.edu <p>Health is a fundamental right for which concerned sides should bear the responsibility at the individual, societal, state, and international level. Not only curative but preventive, promotive, and rehabilitative services should also be availed in accessible, affordable, and acceptable form. The quest for health becomes more intense during adverse periods like a pandemic. The whole world has witnessed the COVID-19 pandemic, the unprecedented pandemic of this century. This quest is more dismal in developing nations like Nepal when even resource-<br>rich countries are laid down by it. The quest of health demands, hence more during this pandemic, for the bearing of the responsibility by all. Here, we have made an attempt to draw together the general and some specific responsibilities of various direct stakeholders in this pandemic with multifaceted mayhem. We have incorporated here, the responsibilities of the public, COVID and non-COVID patients, media personnel, health science students, professionals, institutions, state, and media to ensure or safeguard the health of self and others in this pandemic.</p> 2021-05-27T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/36948 Delayed Presentation of a Penile Fracture: A Case Report 2021-07-11T10:37:05+00:00 Ashok Kumar Yadav dr_yadavashok@yahoo.com Sudhir Kumar Singh drsinghsudhir@gmail.com Raju Chapagain chapagainraju18@gmail.com Prem Das drpremdas01@gmail.com Jag Mohan Osti jagmohan.osti@gmail.com Durga Neupane neupanedurga26@gmail.com <p>Penile fracture is a urological emergency caused by blunt trauma to an erect penis. We report a case of a 40-year-old male who presented with a complaint of a painful swelling of the penis for 4 days. On examination, a flaccid swollen tender penis with bluish discoloration over the shaft and scrotum was noted. A clinical diagnosis of delayed penile fracture was made which was managed immediately surgically under spinal anesthesia. Our<br>report emphasizes that penile fracture is diagnosed solely on a reliable history and clinical examination. It has outstanding outcome despite delayed presentation if treated promptly.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences https://nepjol.info/index.php/jbpkihs/article/view/37071 Acanthamoeba Keratitis- Camouflage Entity in Eastern Nepal: A Case Series 2021-07-11T10:37:07+00:00 Sanjay Kumar Singh sanjay.singh@erec-p.org Karthik Ambur karthik.ambur@gmail.com Prija Poudyal kgktssbh@gmail.com Sagun Malla sagunmalla22@gmail.com Amit Rajbanshi rajbanshiamit@gmail.com <p><em>Acanthamoeba</em> keratitis is a sight-threatening corneal infection and is a growing clinical problem in the world. Though <em>Acanthamoeba</em> keratitis is considered uncommon and rarely reported in Nepal, we encountered six cases in 2019. All patients had redness, photophobia, decreased vision, and pain with ring infiltrate. Ten percent potassium hydroxide mount revealed <em>Acanthamoeba</em> cyst in all cases. Non-nutrient agar overladen with <em>Escherichia coli</em> revealed feeding tracks and Polymerase Chain Reaction revealed T4 genotype <em>Acanthamoeba</em> in four cases. Amoebicidal treatment was started with chlorhexidine 0.02% eye drop half-hourly and supplementary treatment included moxifloxacin eye drop, a combination of polymyxin B sulfate, neomycin sulfate, and bacitracin eye ointment. After treatment, one patient had the best-corrected visual acuity of 6/9 while others had a visual outcome of hand movement. A high level of clinical suspicion and wet mount examination of specimen from infected corneal tissue are essential to aid in rapid diagnosis.</p> 2021-06-30T00:00:00+00:00 Copyright (c) 2021 Journal of BP Koirala Institute of Health Sciences