Nepal Medical College Journal <p>Nepal Medical College Journal is the official journal of Nepal Medical College Pvt. Ltd (NMC), Attarkhel, Gokarneshwor Municipality-8, Kathmandu, Nepal. P.O. Box 13344, Phone: +977 01 4911008 | 4912118 | Extension 607, Email: <a href=""></a>.</p> <p>It is also available on its own website <a href="" target="_blank" rel="noopener"></a></p> en-US (Prof. Dr. Shiba Kumar Rai) (Sioux Cumming) Tue, 03 Oct 2023 12:36:29 +0000 OJS 60 BMI and sociodemographic characteristic among patients with tuberculosis attending a DOTS clinic at a tertiary care hospital in Kathmandu, Nepal <p>Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis is a serious public health threat in low- and middle-income countries. In tuberculosis, the sociodemographic aspects play a significant role in increasing the susceptibility to infection. The current study aimed to study the BMI and sociodemographic characteristic among patients with tuberculosis attending a DOTS clinic at a tertiary care hospital of Kathmandu. An observational descriptive cross sectional study using census sampling technique was conducted among 170 persons with tuberculosis coming for ATT drugs in Community Medicine OPD of Nepal Medical College Teaching Hospital. The information was obtained using self-constructed structured questionnaire from the study population. The information regarding socioeconomic characteristics, medical and family history, type and clinical presentation of tuberculosis and anthropometric measurement were taken. Out of 170 tuberculosis patient 93 had pulmonary tuberculosis, 71 had extrapulmonary tuberculosis and 6 had both. The different types of tuberculosis showed the association with occupation of respondents, family types, socioeconomic status, family size, BCG scar and social habits before tuberculosis. Weight loss and cough were most common clinical presentation among the participants whereas lymphnode and gastrointestinal tract were most common sites for extrapulmonary tuberculosis. According to BMI, 16.5% of the study population were underweight. Thus, the present study provides valuable information regarding association of sociodemographic factors with tuberculosis and nutritional status of persons with tuberculosis.</p> Supri Raj Shrestha, Niraj Shrestha, Nishchal Dhakal Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Perceived Family Support among elderly residing in Gokarneshwor Municipality, Kathmandu <p>Family support is an essential factor among the elderly to maintain health and wellbeing. Most of the elderly are living with the family and depend on them for care. However support from family has been decreasing with the increasing age. The objective of the study was to assess perceived family support among elderly residing in Gokarneshwor, Kathmandu. A descriptive cross-sectional research design was used for conducting this study among 216 elderly residing in Gokarneshwor Municipality of Kathmandu over a period of July 2022 to October 2022 through non-probability purposive sampling technique. Data collection was done by using face to face interview using valid standard tool for family support scale (FSS). Data was analyzed by using SPSS version 16. The results of this study showed that more than half (55.1%) respondents perceived low family support from their family members. Only 44.9% had high family support. Respondents who had chronic disease were financially dependent perceived low family support. There was significant association between perceived family support and age (p=0.015), educational level (p=0.013) and working elderly (0.001). The study concluded that family support perception from elderly was low and some elderly was perceived high support from their family members. However sleep related care, information and decision making support was perceived less than other variables. Family members should be encouraged to build positive family relationship with elderly and involve them in wise decision making.</p> Mithu Saud, Shrijana Pandey, Ishwori Lama, Shova Shrestha Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Visual Functions among amplyopic patients <p>Apart from decreased visual acuity, amblyopia may be associated with alteration in color vision, contrast sensitivity and stereopsis. The study was conducted to assess visual functions among amblyopic patients. Cross sectional observational study was done with appropriate examination. Best corrected visual acuity, color vision, contrast sensitivity and stereopsis were done among 31 amblyopic patients of age 5-18 years, visiting Department of Ophthalmology in Kathmandu Medical College from October 2021 to March 2022. Among thirty-one patients, male is to female ratio was 1.81:1. Mean age of participants was 9.45±3.49 years. Among patients with stimulus deprivation amblyopia, visual acuity was &lt;6/60, color vision and contrast sensitivity were decreased in 100% and moderate stereopsis (80-200 seconds of arc) was present. Among patients with strabismic amblyopia, visual acuity was decreased (6/12-6/18), color vision and contrast sensitivity were normal in 100% and good stereopsis (&lt;60 seconds of arc) was seen. Among those with refractive amblyopia, visual acuity was 6/6-6/9 in 34.5%, 6/12-6/18 in 44.8% and 6/24-6/60 in 20.7%. Color vision was decreased in 27.3% in ametropic, 9.1% in meridional and normal in anisometropic type. Contrast sensitivity was decreased in 27.3% each in ametropic and anisometropic, and in 63.6% in meridional amblyopia. Good and poor (&gt;200 seconds of arc) stereopsis was found in 24.1% each and moderate in 51.7% of refractive amblyopia. Contrast sensitivity was seen to be decreased with decrease in vision (40.0%, 42.8%, 50.0% and 100.0% in visual acuity 6/6-6/9, 6/12-6/18, 6/24-6/60 and&lt;6/60 respectively). To conclude, visual functions are affected in different types of amblyopia.</p> Sabina Shrestha, Dikchhya Sharma, Aparajita Manoranjan, Subee Joshi, Yuliya Shrestha Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 A hospital-based study of dyslipidemia in patients with subclinical hypothyroidism <p>Overt hypothyroidism usually leads to dyslipidemia. The relationship between overt hypothyroidism and dyslipidemia is well established, to that of subclinical hypothyroidism is controversial. Also, Subclinical hypothyroidism if untreated can lead to overt hypothyroidism. So, the present study was conducted to investigate dyslipidema in patients with subclinical hypothyroidism. The study population comprised of total 111 cases having subclinical hypothyroidism and 111 cases of healthy controls. Those with normal T3 and T4 with thyroid stimulating hormone above 4.68 IU/ml were considered subclinical hypothyroidism and were further evaluated for lipid profile. Highest number of participants in the cases belonged to age group 60-71 (36.0%) whereas in control group it was 40-49 years (32.4%). No significant differences were found between lipid parameters between case and control (p &gt;0.05). Serum triglyceride, high density lipoprotein, very low-density lipoprotein was positively correlated with thyroid stimulating hormone (r=0.152, r=0.056, r=0.152, respectively and p=0.110, p=0.560, p=0.110, respectively) whereas total cholesterol, low density lipoprotein was negatively correlated with thyroid stimulating hormone in the cases (r=-0.089, r=-0.118, respectively) and the relation was not statistically significant (p=0.351, p=0.216, respectively). Among control group, serum total cholesterol, high density lipoprotein, low density lipoprotein were positively correlated with thyroid stimulating hormone (r=0.197, r=0.196, r=0.132, respectively) whereas triglyceride, very low density lipoprotein were negatively correlated with thyroid stimulating hormone (r=-0.009, r=-0.025, respectively). Subclinical hypothyroidism may or may not lead to dyslipidemia. Even euthyroid group can have lipid abnormalities. So, screening for hyperlipidemia in general population is more useful rather than patients with subclinical hypothyroidism.</p> Richa Bhattarai, Asmita Pokhrel, Bishesh Sah, Pragya Malla, Madhav Khanal, Dristi Banskota, Manish Prasad Paudel Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 High Resolution Computed Tomography chest findings among people affected by corona virus disease in a tertiary hospital of Nepal <p>Clinical assessment, chest X-ray (CXR) and chest high-resolution computed tomography (HRCT) are used in the management of Corona virus disease-19 (COVID-19). This retrospective cross sectional study included 251 patients admitted to Nepal Medical College Teaching Hospital (NMCTH) with a diagnosis of COVID‑19 infection confirmed by Reverse Transcriptase- Polymerase Chain Reaction (RT‑PCR). These patients underwent chest HRCT within the first two weeks of hospital admission. Images were evaluated for various HRCT findings &amp; semi- quantitative CT Severity Score (CT –SS) was calculated based on the extent of lobar involvement. Out of 251 patients with positive RT PCR test, 127 were male (50.6%) and 124 female (49.4%). Typical bilateral peripheral subpleural ground glass opacities were demonstrated in 98.8% of patients; followed by thoracic lymphadenopathy (80.8%), interlobular septal thickening (80.4%),vascular changes (44.2%), focal consolidation (28.6%), consolidation with ground glass opacity (15%), pleural effusion (13.1%) bronchiectasis (3.8%), fibrotic changes (3.1%) and reversed halo pattern (0.7%). Calculated CT- SS showed moderate score in 130 patients (51.7%) followed by severe score in 67 patients (26.6%) and mild score in 51 patients (20.3%). HRCT can be used as a one stop radiological investigation for the diagnosis and prognosis of corona virus disease and CT -SS might be beneficial for diagnostic workflow in symptomatic cases.</p> Rumita Kayastha, Riwaz Acharya, Sunil Pradhan, Abhushan Siddhi Tuladhar, Amit Shrestha Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Knowledge of prostate cancer and its screening among males attending Urology OPD in a tertiary care hospital in Kathmandu <p>Prostate cancer is a global burden on public health and it has been ranked as the second most common cancer in males worldwide. The incidence of prostate cancer generally increases with age and men with family history of prostate cancer have an increased risk of getting prostate cancer. The incidence varies across the world, where developed countries have a higher incidence as compared to developing countries. It is well known that early detection of certain grades of prostate cancer leads to a higher remission rate. Starting the screening for prostate cancer at the age of 40 for specific population provides the only way to reduce mortality from prostate cancer. A cross sectional hospital study was conducted using Consecutive sampling of eligible patients in the Urology Outpatient Department (OPD) of a tertiary care hospital in Kathmandu. A total of 378 patients attending Urology OPD were included in the study. A structured questionnaire which was sectioned into sociodemographic characteristics, knowledge of prostate cancer and its screening practices was administered to all the participants. Male more than 60 years of age attending Urology OPD were more (33.3%) followed by age group less than 40 years of age (28.6%). The majority of the patients visiting Urology UPD were from Province 3 (73.0%) and Province 1 (11.1%). Most of these patients were literate (34.9%) but the education level of college or higher were less (17.7%). When knowledge of prostate cancer among the participants were assessed, 55.6% participants replied that they have heard about the prostate cancer and among them, the majority of the participants (28.6%) had heard it from media like TV, radio and internet. The most common symptoms chosen by patients were hematuria (80.2%) and weight loss (72.0%). When asked about the prevention and cure of prostate cancer, 61.1% and 78.6% of them did not know about the prevention and its cure respectively. When knowledge on screening of prostate cancer was assessed, more than half of the participants were found to be aware of screening test and among them 94.4% chose blood test, Serum Prostate Specific Antigen (PSA) as the screening test. Majority of the patients (61.4%) had chosen the age for screening as &lt;40 years and many more (91.3%) wanted to go for screening. Overall, 55.6% had heard about prostate cancer and 30.7% did not know any symptoms of prostate cancer. This study identifies some deficits in knowledge of prostate cancer and screening among participants which can be addressed to increase the knowledge related to prostate cancer. It is thus important that these participants and other men be educated more on these important domains of prostate cancer.</p> Neeraj Subedi, Mohan Khadka, Suman Adhikari Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Comparison of accuracy of panoramic radiograph and lateral cephalogram in determining linear mandibular measurements among orthodontic patients in tertiary dental care center of Kathmandu <p>Mandibular dimensions are one of the key parameters for planning the treatment by an Orthodontist. Lateral cephalograms are usually used to evaluate the skeletal relationship. However, due to the superimposition of both the sides, lateral cephalogram may not be reliable in measuring the right and left sides of the cranial landmarks. Panoramic radiography delivers a wide-ranging view of maxillofacial structures with comparatively lesser radiation exposure than other tools and superimposition of structures is less compared to lateral cephalogram image. OPG and lateral cephalograms of all the patients of age group 16-35 years attending Department of Orthodontics in Nepal Medical College from September 2022 to February 2023, having Angle’s Class I Molar relationship with minimum crowding was taken. Linear measurements (ramus height, total mandibular length and mandibular body length) were measured on OPG and Lateral cephalogram. The data was processed in SPSS version 17 for further analysis. There was no statistically significant difference in mean linear measurements between right and left sides on OPG (p-value 0.77, 0.49 and 0.59 respectively). But there was a statistically significant difference in mean linear measurements between both sides on OPG and lateral cephalograms (p-value &lt;0.001). OPG can be used reliably to measure the mandibular length and ramus height of right and left side but comparison of mandibular length and ramus height between lateral cephalogram and OPG may not be reliable.</p> Anshu Piya, Bikash Veer Shrestha, Anju Khapung, Prakash Bhattarai Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Prescription audit and drug interactions of anti-diabetic drugs at Outpatient Department at a tertiary care teaching hospital in Eastern Nepal <p>Type 2 diabetes mellitus (T2DM) is the third major non-communicable disease in Nepal. Drug utilization studies help in reducing the patient’s expenditure, adverse drug reactions and drug-drug interactions. It would help in understanding of consumption of drugs including newer ones. Objective was to analyze the prescribing pattern and drug interactions of anti-diabetic drugs. A prospective cross-sectional study was conducted among patients having T2DM at Birat Medical College and Teaching Hospital (BMCTH), Biratnagar, Nepal from May 2019- August 2019. WHO core drug use indicators were used to analyze the obtained data. Descriptive statistics like mean, standard deviation, frequency and percentage were calculated using Microsoft Excel 2013. Out of 200 patients, 104 (52.0%) were females and 49.5% were from the age group of 41-60 years. Average number of drugs per patient was 5.74. Biguanides (40.7%) were the most common prescribed oral antidiabetic drugs followed by Sulfonylureas (23.3%). The percentage of drugs prescribed by generic name and from WHO essential drug list was 0.6% and 15.4% respectively. A total of 95 (47.5%) patients has potential drug-drug interaction (DDI) and it was most common in the age group of 41-60 years (43.2%). Among 95 DDI, Metformin+Amlodipine ranked in 1st position (16 encounters). Polypharmacy was prevalent in the present study. Metformin was the most commonly prescribed anti-diabetic drug. The percentage of drugs from the WHO essential medicine list and prescribed by generic names was low. Prevalence of potential DDI was high.</p> Prabina Shrestha, Anil Kumar Sah, Kadir Alam, Deependra Prasad Sarraf, Shyam Kumar Mallik Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Prevalence and pattern of medico-legal cases in emergency department of a tertiary care Centre in Kathmandu, Nepal <p>Medico-legal cases are essential component of medical practice and comprise important cases in emergencies.The objectives of this study was to assess the frequency and pattern of medico-legal cases and to identify the vulnerable gender, age group, outcome and the duration of stay in the Emergency Department of Nepal Medical College Teaching Hospital in Kathmandu. Medico-legal cases visiting emergencies from 1st March 2020 to 28th February 2021 were recorded using a proforma. During this period, a total of 1,176 medico-legal cases were registered (10.5% of the total emergency attendance; n=11,212) with 68.0% males and 32.0% females. Maximum number of cases belonged to the age group of 21 - 30 years (n=378; 32.1%) followed by 31 - 40 years (n=271; 23.0%). Most common medico-legal diagnosis was physical assault (n=389; 33.1%) followed by road traffic accidents (n=379; 32.2%). Majority of cases were accidental in nature (47.5%). Most of cases (56.1%) were discharged, 13.8% cases were admitted in different specialties for further management, 8.3% cases were referred to other centers and 21.7% cases left against medical advice. The length of stay was 15 minutes to 24 hours (mean 2.58 hours, SD 1.61). Most of the cases needed surgical consultation.</p> Urmila Bharati, Upashana Regmi Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Clinico-dermoscopic study of inflammatory dermatoses: a hospital based cross sectional study <p>Dermoscopy is a noninvasive, fast, and reliable diagnostic technique used to magnify and visualize structures on and beneath the skin surface which is difficult to observe by naked eyes, creating a link between macroscopic clinical dermatology and microscopic dermatopathology. The purpose of this study is to evaluate and compare the dermoscopic features of common inflammatory dermatological conditions of skin sharing similar clinical presentation according to the available literature data. All dermoscopic findings were studied using a handheld pocket dermoscopy (Dermlite DL1) with high magnification. Variables used for dermoscopic evaluation were divided into vascular and nonvascular features and specific clues. Descriptive analysis and Chi square test were used where appropriate and p &lt; 0.05 was considered statistically significant. There were a total of 205 patients enrolled in the study. The most common clinical diagnosis was psoriasis seen in 42.0%, lichen planus in 13.0%, contact dermatitis in 12.0%, polymorphic light eruption 7.0%, seborrheic dermatitis 4.0%, discoid lupus erythematosus 5.0%, pityriasia Rosea 5.0%, urticaria 5.0% and others 7.0%. Dermoscopic vascular changes were seen as regular in 52.0% and irregular in 46.0%. The most common type of vessels observed were dotted in 70.0%, linear in 7.0%, and coiled in 2.0%. Non-vascular changes were seen in 61.0%. The commonest type of scales were whitish scales seen in 63.0%. Pigmentary changes were seen in 19.0%. The commonest type of vessels observed were dotted vessels (p value 0.000) in most inflammatory diseases. Features like wickham striae were characteristic of lichen planus (p value 0.000). The characteristic dermoscopic features of various inflammatory disorders with the help of a dermoscope is easy to perform in outpatient without any invasive method and also helpful in guiding management of the patients with follow-up.</p> Deeptara Pathak Thapa, Sushmita Pradhan, Harihar Adhikari, Sajana Bhandari, Prabhat Paudel Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Nutritional status and its associated factors of elderly population living in old age homes of Kathmandu Metropolitan City <p>Nutrition plays an important role in the overall well- being of human beings more so in the elderly. Elderly living at old age homes have a different nutritional status as compared to those living with their families. Thus, this study was conducted to assess the nutritional status of the elderly living in old age homes of Kathmandu Metropolitan City (KMC). A descriptive cross-sectional study was carried among 133 elderly residing in all six old age homes of KMC by using Nepali-translated Nestle’s Mini Nutritional Assessment Tool (MNA). Further collected information was analyzed using chi square test. Regarding nutritional status, 30.8% of the participants had normal nutritional status, whereas 52.7% were at risk of malnutrition and 16.5% were malnourished. Lifestyle related factors such as smoking and physical activity were found to be the factors affecting the nutritional status of elderly people. Significant association was seen between nutritional status and age (p =0.001) and past occupation (p =0.021). A significant proportion of elderly people living in old age homes are at risk of malnutrit ion or are malnourished.</p> Bal Krishna Bhatta, Manisha Karki, Maginsh Dahal, Basanta Pokhrel Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Effect of Routine dental procedures on the pulse rate and peripheral oxygen saturation in pediatric patients <p>Dental treatment can cause anxiety in a child further leading to physiological changes that affects the success of dental care. This cross-sectional study was carried out to assess the changes in the pulse rate and peripheral oxygen saturation in children undergoing routine dental treatment. Total 80 patients of 6 to 12 years old were included in the study who were divided into four groups according the dental treatment they receive. Data was analyzed using SPSS-16. It was observed that the patients undergoing extraction (group IV) had higher mean pulse rate before, during and after the procedures; 100.25±9.33, 101.85±13.52, 98.85±7.63 respectively. Lowest SpO2 was recorded in the patients undergoing pulp therapy before the procedure (96.90±3.66). Pulse rate was higher in females compared to males but it was not statistically significant. The children in extraction group selecting facial image scale 4 had more mean pulse rate before during and after the procedure. The mean pulse rate was high in patients undergoing extraction in both first visit (103.00±9.21) and subsequent visits (101.36±15.28). It was concluded that physiological changes occur during routine dental treatment therefore monitoring should be done in order to prevent any dental emergencies.</p> Sanskriti Khanal, Priyanka Shah, Anju Khapung Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Topography and indexing of the nutrient foramina of the adult long bones <p>The primary source of blood supply for long bones comes from the nutrient arteries that pass through the nutrient foramen. Understanding the location and structure of these foramens is important in surgical procedures to ensure that the bone’s blood supply is not disrupted. To study the morphology and topography of nutrient foramina and to determine the foraminal index of the upper and lower limb long bones. The long bones of the upper and lower limbs including 47 humeri, 38 radii, 38 ulnae, 53 femurs, 57 tibiae, and 44 fibulae were studied. The number and position of primary nutrient foramina were noted and the foraminal index was calculated. Results showed that 82.9% of the humeri had a single nutrient foramen, and 17.0% had double foramina. For the radii, 97.4% had single nutrient foramen and 2.6% had double foramina. A single nutrient foramen was observed in all the ulnae. In the lower limb bone, the femurs had 41.5% of single nutrient foramen, 56.6% had double foramina and only 1.9% had triple nutrient foramina. The tibiae showed 93.0% of the single nutrient foramen and only 7.0% had double foramen. In fibulae, only one nutrient foramen was seen. The mean foraminal index was 57.26 for the humerus, 34.82 for the radius, and 39.32 for the ulna. Similarly, the mean foraminal index of the femur was 44.73, the tibia was 32.32 and the ulna was 46.18. Understanding the location of foramina is crucial inmaintaining bone vasculature during surgical procedures, which can improve the success rates of bone grafting, fracture fixation, and replacement surgeries involving the shoulder, elbow, and knee joints.</p> Umeshwar Prasad Thakur, Pranav Kumar Yadav, Brijendra Kumar Sah, Ram Jiban Prasad, Tirtha Narayan Shah Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 New-onset severe Diabetic Ketoacidosis in a 13-months old Nepali Toddler: a case report <p>Diabetes mellitus (DM) is a glucose metabolism disorder with diabetic ketoacidosis (DKA) being the most common complication associated with significant morbidity and mortality. Unlike other patients with typical symptoms of abdominal discomfort, pain, nausea and emesis of DKA, our patient presented with atypical symptoms such as cough, runny nose and fast breathing. This symptoms would have initially misled with diagnosis of respiratory tract infection, which would have caused delay in the treatment of DKA. In our patient DKA was treated with intravenous fluid replacement followed by intravenous insulin infusion, along with monitoring of blood glucose and electrolyte levels. We would like to emphasize that DKA can be precipitated by simple upper respiratory tract infection in toddlers with undiagnosed type 1 DM. Hence, random blood sugar measurement and urine for ketone bodies test should be performed if feasible in sick patients presenting with respiratory tract illness-like symptoms.</p> Bijay Basnet, Chaitanya Darshan Bhattarai, Rohit Bhatt, Romila Chimoriya, Kushal Adhikari, Birendra Kumar Yadav Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000 Neuroleptic Malignant Syndrome: A potential mimic of acute encephalitis syndrome <p>Neuroleptic malignant syndrome (NMS) is a neurological emergency due to neuroleptic medications which is characterized by fever, muscle rigidity, autonomic instability, and altered mental status. Here we report a case of a 74 years old female who presented with complaints of fever, altered sensorium, restlessness, self-muttering, irritation, muscular rigidity, decreased mobility and diaphoresis. She was under medication olanzapine for schizoaffective disorder. It is a diagnosis of exclusion after detailed examinations and investigations. The patient was managed with bromocriptine and supportive measures. NMS may mimic acute encephalitis syndrome. Therefore, NMS should be included in differential diagnosis with presentation as in our case.</p> Radhay Shyam Yadav, Anup Raj Upreti, Prabin Khatri, Bishal Bharati, Pingala Khadka, Ashryata Manandhar, Sammi Joshi, Khusboo Chaudhary Copyright (c) 2023 Nepal Medical College Journal Tue, 03 Oct 2023 00:00:00 +0000