Grande Medical Journal http://thegmj.com/index.php/1 <p>Grande Medical Journal (GMJ) is a bi-annual, open, peer-reviewed interdisciplinary journal that encompasses all fields of medicine and clinical practice. GMJ will be published both in print and online. It will be freely accessible via the journal's website www.thegmj.com and at NepJOL with open access to the full text of all its articles. There will be no subscription fees to the readers or processing fees for the authors.</p> <p>GMJ seeks to publish original, high-quality, peer-reviewed papers including original clinical and editorials, clinical reviews, and correspondence on matters that will provide comprehensive coverage on all aspects and subspecialties of medicine. GMJ will be initially published twice a year with contributions from national and international physicians and scientists.</p> <p>The journal's articles are licensed under a <a href="https://creativecommons.org/licenses/by/4.0/" rel="license">Creative Commons Attribution 4.0 International License - CC BY.</a></p> Academic & Research Department, Grande International Hospital en-US Grande Medical Journal 2661-6238 Pandemic in the age of click bait algorithms & our collective conscience http://thegmj.com/index.php/1/article/view/24 <p>The year 2020 has largely been about COVID-19. The zoonotic virus found in bats causing respiratory disease that originated from Wuhan, China towards the end of 2019, has engulfed the whole world and many regions are still reeling from recurring waves. At the time of this writing, the Johns Hopkins University COVID-19 dashboard1shows that there has been over 79 million cases worldwide with north of 1.7 million deaths. Much of western Europe is in or bracing for strict lockdown during the end of year holiday season, including Sweden which had adopted an approach of attaining “herd immunity” before vaccines, which was bound to fail, and it did. For the context – when Wuhan, the COVID-19 ground zero, went into lockdown amid growing number of cases and fatalities, the action seemed excessive. The official death toll1in the most populous country in the world, China, as of this writing is less than 5000, whereas daily deaths in the US is topping 3000 consistently in the new wave seen since the start of December. Let those numbers sink in first. A pandemic is like fashion – ever evolving and ever revolving. The difference is, of course, in the frequency that great pandemics occur after every few generations. The Spanish flu from a century ago is regarded as the last true pandemic. How COVID-19 differs from the historical contexts of pandemic is how science has evolved - not just in terms of diagnosis and management, but how mass traveling and modern means of transportation has allowed an epidemic to turn pandemic in a relatively short duration. And our voracity in consuming news, and more importantly “views” not just from traditional media outlets but from any ‘fool with a tool’ in this age of social media and influencers has only amplified this paradox. The net worth of a news/ event is no longer in the content but is a function of social media reach, click baiting, and ever so improving artificial intelligence algorithms. The digital footprints we leave behind with each keystroke or click is determining what social media post, news or opinion pieces we are fed. As such, for the same news, there exists more than one “reality” – in the COVID-19 context, each of the subsets of pro and anti-masks, pro and anti-vaccines have their own reality bubbles.And the biggest lesson that this pandemic has taught us – without political will or action, science alone is a lame duck. The New England Journal of Medicine2with over 200 years of history wrote a scathing editorial, first of its kind in its history, to denounce science denying rhetoric, specifically summing up the Trump administration’s approach to COVID-19 as “they have taken a crisis and turned it into a tragedy.” The Lancet3went even further urging US voters to opt for a change in leadership. Many other traditional publications broke ranks to voice their genuine concerns regarding the denial of existence and mishandling of the pandemic. Unprecedented times called for unprecedented actions. These voices of Science had a job to do. Whether one believes or belittles the recommendations of masks, hand washing, and physical distancing to avoid contracting the virus, the world as we knew and lived in has changed so much during these troubled times. The shortcomings or otherwise of US policies/ healthcare system is not the point of contention here, but the actions of a government regarded by many as the most powerful in the world in terms of resources, and seen as benchmark by smaller and poorer countries. It is easy for those in authority in resource scarce countries like Nepal to point their finger at the US and proclaim “even the mighty USA has been so hapless, we are but a poor country”.Throughout evolution, animals have relied on their ‘senses’ of sight/ sound/ smell to stay ahead of their predators and survive. During this pandemic, us humans, are collectively in need of the rarest commodity of them all, “common sense” within ourselves and more importantly of those around us to survive. Amidst all the gloom and doom, a new dawn is nigh. Highly effective vaccines are being rolled out. With newer more virulent strains being reported from different parts of the world in regular intervals, the efficacy of these vaccines could be different than initially reported. The biggest challenge now for vaccines manufacturers, countries, and the WHO is to ensure the logistics of it all so that the vaccines’ coverage worldwide is enough to ensure herd immunity, and there remains no sizeable population pocket of endemicity. Let’s hope that common sense prevails and world leaders are more receptive of scientific reasonings and evidences and collectively work to quell the unrelenting march of this pandemic. It’s not over till it’s over.</p> Rupendra Bahadur Adhikari Prerana Kansakar Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-28 2020-12-28 2 1 i ii Diversity in imaging findings of head injury patients: Our experience in a tertiary level hospital http://thegmj.com/index.php/1/article/view/27 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>Background</p> </div> </div> <div class="layoutArea"> <div class="column"> <p>Head injury is a major cause of mortality and morbidity worldwide. It can occur in isolation or in association with multisystem injuries. Proper and prompt imaging evaluation in head trauma can help in the triage and management of the patients.</p> <p>Material &amp; methods</p> <p>A hospital-based study using a non-interventional study design was employed. A total of 219 patients with head trauma who underwent CT were evaluated for various possible injuries using different window settings and algorithms. Data was entered in a predesigned proforma, and analysis was done using IBM SPSS version 20.</p> <p>Results</p> <p>The most common age group involved in head trauma was 20 to 40 years of age. Male patients were more frequently involved than female patients. Most common finding associated with the head trauma was calvarial fracture followed by cerebral hematoma/ contusions. Diffuse axonal injury and intraventricular hemorrhage were the least common findings in patients with head trauma.</p> <p>Conclusions</p> <p>Road traffic accidents are the leading cause of head trauma in our part of the world. They commonly involve young males exposed to the vulnerable environment. Proper road safety measures, if undertaken cautiously, can help prevent significant mortality and morbidity associated with these kind of injuries.</p> <p>Key words: Head injury, skull fracture, epidural hematoma, subdural hematoma, pneumocephalus, cerebral contusion</p> </div> </div> </div> </div> Prakash Kayastha Nirmal Prasad Neupane Sharma Poudel Rupendra Bahadur Adhikari Chakra Raj Pandey Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-28 2020-12-28 2 1 1 4 Glandular density distribution in digital mammography http://thegmj.com/index.php/1/article/view/28 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>Objectives</p> </div> </div> <div class="layoutArea"> <div class="column"> <p>The aim of this study was to evaluate the breast density distribution in digital mammography of patients.</p> <p>Materials and Methods</p> <p>This prospective study was performed in the Department of Radiology and Imaging of Tribhuvan University Teaching Hospital (TUTH). Data was collected over a period of 4 months from July to October 2019 and included one hundred and seventy patients who came for diagnostic or screening mammography, which was recorded as indication for the test. Appropriate statistical methods were used for analysis.</p> <p>Results</p> <p>The mean age of women included in this study was 48.09 ± 9.13 years. Nearly 43% of the patients had dense breasts. According to Breast Imaging, Reporting and Data System (BIRADS) classification of lesions, maximum mammograms i.e.,77.7% were normal or benign while 4.7% were BIRADS category 0 and 17.7% were of BIRADS category 3, 4 or 5. A negative correlation was observed between age and breast density category. The relationship between breast density and BIRADS category or indication for the test was insignificant while a weak correlation was observed between it and mammographic findings.</p> <p>Conclusion</p> <p>Our study showed an inverse linear relationship between age and mammographic density which is consistent with the fact that mammography has higher sensitivity in older age group usually with lesser density. No or weak correlation was present between breast density and BIRADS category, indication or findings on mammography. All patients in BIRADS 0 category had dense breasts.</p> <p>Key words: BIRADS, glandular density, mammogram.</p> </div> </div> </div> </div> Anamika Jha Ritu Panta Shanta Lall Shrestha Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-28 2020-12-28 2 1 5 9 Clinical, electrophysiological and MRI profile of Hirayama disease: A case series http://thegmj.com/index.php/1/article/view/29 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>Introduction:</p> </div> </div> <div class="layoutArea"> <div class="column"> <p>Hirayama disease (HD) is focal amyotrophy in young adults, and commonly involves distal upper limbs, often misdiagnosed as motor neuron disease and writer’s cramp. This often leads to delay in the diagnosis and results in disease progression. In this study, we have analyzed clinical, radiological and electrophysiological profile of patients presenting with hand wasting and weakness.</p> <p>Materials and Methods:</p> <p>Patients presenting with insidious onset of hand wasting (January 2014 to February 2017) were evaluated clinically and electro physiologically. Cervical MRI in neutral and flexion position was done.</p> <p>Results:</p> <p>All 16 patients were male, were less than 25 years of age, with median age of 22 years. Duration of illness was 3 months to 7 years. All patients presented with insidious onset of progressive weakness and lower motor neuron type of wasting of hands. Nine (56.25%) patients presented with right sided, five (31.25%) with left sided and another two (12.5%) presented with bilateral asymmetric weakness and wasting. None of the patients had neck pain or radicular symptoms. Twelve (75%) had cold paresis, eight (50%) had minipolymyoclonus and five (31.25%) had fasciculations. Electromyography (EMG) showed chronic denervation in the C7T1 myotomes. In MRI, localized lower cervical cord atrophy was seen in 13 (81.25%) cases. Asymmetric cord flattening was noted in 14 (87.5%) cases. Loss of dural attachment in 13 (81.25%), anterior displacement of dorsal dura on flexion in 14 (87.5%) and epidural flow voids were seen in 14 (87.5%) cases. Enhancing epidural crescent in flexion was seen in all 12/16(75.0%) cases. Intramedullary hyper intensity was seen in 2 (12.5%) patients.</p> <p>Conclusions:</p> <p>Clinical features of HD corroborated well with electrophysiological diagnosis of anterior horn cell disease of lower cervical cord. While dynamic contrast MRI is characteristic, routine studies have a high predictive value for diagnosis. Prompt diagnosis is important to differentiate it from other progressive conditions and to institute early therapy.</p> <p>Key words: Electrophysiology; flexion magnetic resonance imaging; hand wasting; Hirayama disease.</p> </div> </div> </div> </div> Javed Ahmad Khan Raju Poudel Nirmal Prasad Neupane Piyush Niraula Binod Bijukachhe Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-28 2020-12-28 2 1 10 18 Oxygen saturation at different altitudes in Nepal among adults http://thegmj.com/index.php/1/article/view/30 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>Introduction:</p> </div> </div> <div class="layoutArea"> <div class="column"> <p>The partial pressure of oxygen in the atmosphere decreases proportionately with an increase in the altitude. The study was done to compare the oxygen saturation of non- acclimatized adults going to different altitudes in Nepal.</p> <p>Materials and Methods:</p> <p>It was a descriptive observational study conducted on ten individuals of a medical team traveling to Humla district of Nepal for a multi-disciplinary medical camp. Oxygen saturation was measured at different altitudes i.e. in Kathmandu, Nepalgunj, in the flight at an altitude of 3360 meters and in Bargaun village of Humla district located at an altitude of 3300 meters. Mean pulse oximetry reading was calculated and compared.</p> <p>Results:</p> <p>Among the participants, age ranged from 24-57 years. Male to female ratio was 1.5:1. The mean SPO2 at Nepalgunj, Kathmandu, Bargaun of Humla and in the flight (at an altitude of 3360 meters) were 99.67 %, 97%, 91% and 87.4% respectively among the study participants. However, the difference in Oxygen saturation values at different altitudes among different gender and different age was not statistically significant.</p> <p>Conclusions:</p> <p>Oxygen saturation decreased linearly with the rise in altitude among all the study participants irrespective of age and gender.</p> <p>Key words: Adults, high altitude, oxygen saturation</p> </div> </div> </div> </div> Sabina Shrestha Aparajita Manoranjan Sushan Man Shrestha Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2021-01-21 2021-01-21 2 1 19 21 Knowledge and perception about anesthesia and anesthesiologist in patients undergoing surgery in Nepal http://thegmj.com/index.php/1/article/view/43 <p><strong>Background:</strong> Anesthesia as a distinct specialty has evolved much beyond the boundaries of operation theater but the services are yet under-recognized. This may be partly because of the lack of knowledge about anesthesia and anesthesiologist in general public and also due to lack of effort to raise awareness among the general public. This study was done to assess the knowledge and perception about anesthesia and anesthesiologist in patients undergoing surgery in Nepal.<br><strong>Material and Methods:</strong> A total of 719 patients scheduled for elective or emergency surgery in eight hospitals of Nepal were consecutively recruited and interviewed using questionnaire at pre-operative period before evaluation by anesthesiologist or anesthesiology resident. Individual response to each question was graded using three point scale.<br><strong>Results:</strong> The age of the patients ranged from 16 to 87 with a mean of 39.5±15.7 years. Only 31.6% and 28.2% had previous surgery and anesthetic exposure respectively. The majority (69.4% and 49.8% respectively) had good knowledge about health care workers present in operation theater and the ones delivering anesthesia. However, knowledge about anesthesia types and anesthetic agents was poor in 48.4% and 51.9% respectively. The knowledge was poor about person responsible for monitoring and maintaining homeostasis (49%), person responsible for resuscitation (46.5%) and management of anesthesia related complications (49.5%). Remarkably, 48.3% of the respondents had average knowledge about who manages post-operative pain. The mean knowledge score<br>for individual patient was calculated and, 11.1%, 83.4% and 5.4% had poor, average and good knowledge respectively.<br><strong>Conclusion:</strong> Majority of patients undergoing surgery had average knowledge and perception about anesthesia and anesthesiologist.</p> Anil Shrestha Gentle Sunder Shrestha Binita Acharya Pankaj Joshi Amit Sharma Bhattarai Binayak Upadhyay Ram Pukar Sah Ritu Pradhan Ashish Ghimire Archan Adhikari Rajesh Yadav Birendra Bahadur Singh Bal Krishna Bhattarai Moda Nath Marhatta Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2021-02-21 2021-02-21 2 1 37 42 Persistent pain after vertebroplasty: Not to miss facet joint pain http://thegmj.com/index.php/1/article/view/31 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>A patient can present with persistent pain even after vertebral compression fracture augmentation procedures. We report a case of a patient of carcinoma breast with L1 vertebral metastasis and fracture for which vertebroplasty was performed abroad. The patient had severe pain even after the procedure and multiple therapies. The patient’s pain was finally relieved with radiofrequency ablation of target medial branch, which highlights the importance of facet joint as source of pain generator in such group of patients.</p> <p>Key words : Compression fracture, facet joint</p> </div> </div> </div> </div> Bigen Man Shakya Renu Gurung Anl Shrestha Binita Acharya Ninadini Shrestha Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2021-01-01 2021-01-01 2 1 22 24 An uncommon cause of unilateral nasal bleeding http://thegmj.com/index.php/1/article/view/32 <div class="page" title="Page 1"> <div class="section"> <div class="layoutArea"> <div class="column"> <p>Leeches are segmented worms that belongs to phylum Annelida and Hirudinea subclass. They are commonly found in stream water, land and sea. Leech infestation is seen in people swimming or drinking water inhabited by leech. The most common symptom of nasal leech is unilateral nasal bleeding. In this case report, a ten-year-old Chinese boy went swimming in the river in countryside prior to the incident. On examination, he was found to have a leech in his left nostril. The leech self- extruded after irrigation with 5ml of normal saline. Health workers must be aware of the possibility of a leech as the differential diagnosis for unilateral nasal bleeding, especially in a rural area where leeches are prevalent.</p> <p>Keywords: Leech, unilateral nasal bleeding</p> </div> </div> </div> </div> Satish Yadav Bingqiang Zhang Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-28 2020-12-28 2 1 25 27 Incidental carcinoma of gallbladder following laparoscopic cholecystectomy: A single center study http://thegmj.com/index.php/1/article/view/37 <p><strong>Background</strong></p> <p>Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. Most of gall bladder cancers are detected incidentally only after pathological examination of the excised surgical specimens. In this study we investigated the characteristics of incidental gallbladder cancers in our center. </p> <p><strong>Material &amp; methods</strong></p> <p>We retrospectively reviewed all of the cholecystectomy specimens in sent for histopathology following laparoscopic cholecystectomy in the study period from January 2015 to October 2019. Clinicopathological characteristics were extracted from the patients' clinical charts, which included symptoms, radiological findings, laboratory data, and surgical procedures as well as outcome.</p> <p><strong>Results</strong></p> <p>We identified 6 cases of incidental gall bladder cancer, consisting of 4 women and 2 men ranging in age from 28 to 77 years (mean age 60.5 after pathological study of 1530 resected gall bladders. Out of the 6 cases, 1 case was carcinoma in situ of gall bladder, 1 was T1b and other 4 cases were T2 carcinoma.</p> <p><strong>Conclusions</strong></p> <p>The rate of incidental gallbladder carcinoma in our study was 0.39%. This lower incidence could in part be due to increasing use of routine laparoscopic cholecystectomy for symptomatic gallbladder. This strategy of increased early intervention further adds to the advantage of higher chances of gallbladder cancer detection in early stages, and thus better prognosis.</p> <p>Key words: <strong>Gall bladder,</strong> <strong>carcinoma</strong><strong>, </strong><strong>laparoscopic cholecystectomy</strong></p> Santosh Shrestha Deepak Sharma Roshan Ghimire Dhiresh Kumar Maharjan Prabin Bikram Thapa Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2020-12-31 2020-12-31 2 1 28 31 A descriptive study of seasonal influenza cases in a single season in a tertiary center in Kathmandu http://thegmj.com/index.php/1/article/view/42 <p><strong>Introduction:</strong></p> <p>This is a clinic-epidemiological study of the total cases of polymerase chain reaction (PCR) confirmed influenza cases. We aim to characterize the disease, its morbidities and mortality.</p> <p><strong>Materials and Methods:</strong></p> <p>The details of all PCR confirmed influenza (H1N1) cases were obtained from the hospital records and descriptive statistical analysis tools were used to report the findings.</p> <p><strong>Results:</strong></p> <p>A total of 35 cases were confirmed as influenza from January to March 2019. The most common presenting complaints were fever (91%), cough (85%) and shortness of breath (65%). The most frequent diagnosis made was pneumonia (88%). Septic shock was present in 29% while 14% had acute kidney injury (AKI). Oxygen therapy was required in 71% with 17% requiring mechanical ventilation and another 11% requiring non-invasive ventilation. Fourteen percent had developed severe acute respiratory distress syndrome (ARDS) requiring proning. A total of 77% patients were successfully discharged home, 8% were transferred to other centers on request for various reasons and 11% were withdrawn from all active treatment leading to death. One patient was taken home against advice whose outcome could not be traced. During treatment, two patients had developed ischemic stroke, two required haemodialysis for acute renal failure and other two had scrub typhus co-infection.</p> <p><strong>&nbsp;</strong><strong>Conclusions:</strong></p> <p>A total of 85% of the patient survived while the rest lost their lives. The most important factor recognized was the financial burden associated with the treatment. Diagnostic delays and limited supply of Oseltamivir might be the other barriers in the treatment of the disease.</p> Ninadini Shrestha Bipin Karki Pramesh Sunder Shrestha Santosh Acharya Sangita Tamang Sachit Regmi Subodh Sagar Dhakal Bishwanath Koiral Copyright (c) 2020 Grande Medical Journal https://creativecommons.org/licenses/by/4.0 2021-01-21 2021-01-21 2 1 32 36