Ecotourism is a form of nature-based tourism. It is recognized as the sustainable alternative to the mass tourism and is executed to contribute to the protection and enhancement of various component of the environment. As environmental and cultural diversity are considered as the greatest assets to ecotourism, Nepal with high cultural and environmental diversity is prime destinations for ecotourism and other forms of nature-based tourism. Ecotourism contributes to the conservation of biodiversity as a primary source of internal funding in the protected areas. Researches on the aspects of ecotourism in Nepal were focused towards potentiality evaluation, impact assessment and the impact of climate change including others. Despite the significance of ecotourism in the Nepalese economy, research on governance aspects of ecotourism is limited. This article aims to analyze the role of government in ecotourism development in Nepal through policy-based approach. Beside this, data of visitation in the protected areas was evaluated. Tourist number in the protected area was observed to increase in a gradual fashion in response to the growing number of tourists visiting Nepal. Tourism policies of government primarily focus to increase the number of tourists in the country and fail to recognize tourism carrying capacity and environmental implication. Different tourism and other sectoral policies attempt to cover the issues of ecotourism, but, ecotourism specific policy is yet to be drafted. In addition to this, the tourism aspect is addressed by the species conservation action plan for species-level conservation within the country. In all, nine action plans reviewed, the provisions relating to tourism were found to be too general, most of them acknowledging ecotourism as a source of conservation funding but failed to define species-specific policy. A similar trend can be observed in the protected area management plan excluding the Chitwan and Banke National Park. Further study on the implementation status and formulation of new policy to address the holistic issues of ecotourism is an urgent requirement.

Although there were no deaths after PD in our series, the morbidity was higher than that observed in other high-volume centers. To decrease the morbidity associated with PD, various factors must be streamlined, among them, the operative technique and the intensive perioperative management of the patient, as well as uniform definition of complications, use of a multidisciplinary approach, and identification of associated risk factors.

Objective: Oncology clinical practice guidelines (OCPGs) are systematically developed evidence-based recommendations aimed to guide practitioners in decision making during the diagnosis, management, and treatment of cancer patients under specific circumstances, thereby optimizing clinical outcomes. However, little is known about the implementation of those guidelines in low and middle-income countries including Nepal. This research aimed to identify the type of OCPGs used by Nepalese physicians working in oncology departments and to explore barriers and facilitators affecting their use. Methods: Using the total population sampling technique, we conducted an online cross-sectional survey from June 2020 to January 2021 among physicians working in the oncology departments of Nepal. Descriptive analyses were conducted to summarize the research findings.Results: Out of 171 physicians approached for the study, 102 (59.6%) responded to the questionnaire. The sizable proportions of the participants were a senior group of physicians with 27.5% being consultants, 14.7% senior consultants, and 16.7% professors. The most commonly used guideline was the National Comprehensive Cancer Network guideline of the United States (75.5%) followed by the American Society of Clinical Oncology guideline (44.7%). While only 22.6% of physicians reported using OCPGs every time, more than half (56.9%) highlighted that OCPGs are not feasible to implement in Nepal. Insufficient facilities/equipment, physicians' unwillingness to change their usual practice, inability to discuss research with knowledgeable colleagues, and lack of time were commonly cited barriers. Conclusion:Findings of our study highlighted that the OCPGs developed in highincome countries may not be feasible for low resource settings like Nepal. Comprehensive local OCPGs should be developed considering the available resources, feasibility, and financial constraints of patients. Furthermore, a constant sharing and learning environment should be created to enhance the knowledge of practicing physicians and to promote the proper implementation of evidence-based findings.

BackgroundPancytopenia is a rare complication of hyperthyroidism. Various mechanisms have been described such as immunological, bone marrow suppression. The possibility of hyperthyroidism should be considered in patients with unexplained pancytopenia. There are many case reports showing the association between hyperthyroidism and pancytopenia. All of these reports show association between Graves disease and pancytopenia but our case shows association between Multinodular goitre and pancytopenia. Besides it is uncommon to find such association in a surgical patient.Case presentationThis case report describes a 62 yr old hindu female with splenic injury and pancytopenia. On further investigations the patient was found to have hyperthyroidism.ConclusionThough the definite mechanism regarding the association of pancytopenia with hyperthyroidism isn’t clear, various cases have been described in the literature. This case shows the diagnostic dilemma that can occur in patients with pancytopenia. Any patient with unexplained pancytopenia should undergo thyroid function tests to rule out hyperthyroidism.

Breast lump is a very sensitive issue for the patient so a reliable, non invasive and prompt diagnosishelps to lessen the associated anxiety and leads to early definitive treatment. The aim of this studywas to evaluate the acuracy of Triple Test Score (TTS) as a clinical tool for the diagnosis of a palpablebreast lump. This diagnostic test study was carried out in the Department of Surgery of TribhuvanUniversity Teaching Hospital. Of the 117 patients admitted with breast diseases from the breastclinic over thirteen months, 87 had breast lump. Fifty patients underwent Triple Test Score ( physicalexamination, mammography and fine needle aspiration cytology) and were categorized into benign,suspicious and malignant. This was later correlated with the histopathological findings. Nineteenpatients with breast lumps interpreted by TTS as benign correlated with the histopathologicalfindings whereas of 31 malignant lumps, 30 turned out to be malignant and one benign. This givesTTS an over all accuracy of 98% with 100% sensitivity, 95.2% specificity and positive predictive valueof 96.7%. Carcinoma was seen in 29 (58%) cases in the age group of 35 to 70 years. The mean age atdiagnosis of benign and malignant disease was 41.8 and 45.1 years respectively. In conclusion, TTS isan accurate and least invasive diagnostic test based on which definitive treatment can be initiated.Key words : breast lump, carcinoma breast, triple test score