Journal of Advances in Internal Medicine <p>Official journal of the Society of Internal Medicine of Nepal (SIMON). Full text articles available. Please submit manuscripts as email attachments to <a href=""></a>.&nbsp;The Ethics committee approval statement (IRC approval) is compulsory at the time of manuscript submission.</p> <p>The inaugural issue was published on February 10, 2012 with an initiative from Prof. Umid Kumar Shrestha, MD, PhD,&nbsp;Editor-in-Chief of Journal of Advances in Internal Medicine (J Adv Intern Med). The journal has since been publishing Original Articles, Review Articles, Case Reports, Medical Images, Editorials and others. The articles in the journal are&nbsp;licensed under a&nbsp;<a href="" rel="license">Creative Commons Attribution 4.0 International License</a>&nbsp;&nbsp;<a href="" rel="license"><img src="" alt="Creative Commons License">.</a></p> <p>Authors do not have to pay for the submission, processing or publication of articles in this journal.</p> en-US (Dr Umid Kumar Shrestha, MD, PhD) (Sioux Cumming) Fri, 14 May 2021 07:48:01 +0000 OJS 60 COVID-19: Vaccine and antimicrobial resistance what are the global implications? <p>Antimicrobial resistance is a worldwide and highly quantified risk to global health and is more prevalent than resistance developed in vaccines as both antimicrobial resistance and vaccine resistance develop in different settings and because of alternate mechanisms. Vaccines act as a preventative measure and allow the immune system to kill any pathogen in the initial phases when the load is relatively low. This circumvents the replication of the pathogen and thus prevents the formation of mutations and furthermore resistance which is attributed to those mutations. Mutations in the target and or binding sites of a said therapeutic regime confer resistance more often in antimicrobials than they do vaccines.</p> <p>The alteration of a vaccines binding site does not confer resistance as a vaccine produces a wide spectrum of antibodies due to multiple epitopes on the said antigen, the remaining antibodies are thus still protective. In antimicrobials however, the drug targets a specific site and is not dynamic and thus if a mutation of the site arises, the drug efficacy is reduced.</p> <p>Although vaccine resistance is less quantified it may also pose a substantial risk to Global health as currently evident with the COVID-19 pandemic. The current global pandemic caused by SARS-CoV-2 has developed a host of mutations which are displaying a degree of resistance and reduced efficacy to the vaccines. This reduced efficacy and resistance of the mutations to current vaccination programmes, poses a risk to global health. It is vital for new vaccines to be synthesized to specifically be active against the variants. It is likely that the synthesis and development of new vaccines to counter new variants as they arise will be an ongoing process. It is evident in future that new vaccines to the mutations in COVID-19 may have to be developed as they are for the seasonal influenzae virus.</p> Jared Robinson, Alexandra Leclézio, Indrajit Banerjee Copyright (c) 2021 Jared Robinson, Alexandra Leclézio, Indrajit Banerjee Fri, 14 May 2021 00:00:00 +0000 Ethics in Medical Practice and Research <p>Ethics is a moral guide that helps the treatment group to be treated with due respect and care following the standard of practice. It also helps the research to be conducted without or minimal harm to the population under study. Besides ethics, clinical practice and research are guided by some nationally and internationally accepted principles or codes of conduct. The human subject under treatment or study should be respected to the utmost level and should be performed by trained personnel. The importance of ethics starts before studies so should be kept in medical curricula starting from basic sciences so that medical practitioners become acquainted from the beginning of the study.</p> Pramod Kattel Copyright (c) 2021 Pramod Kattel Fri, 14 May 2021 00:00:00 +0000 SARS-CoV-2 vaccines and their challenges against the variants <p>The coronavirus disease 2019 (COVID-19) pandemic has lead to the several researches for the development of the new severe acute respiratory syndrome corona virus 2 (SARS-CoV- 2) vaccines, namely mRNA vaccine, viral vector vaccine, recombinant protein vaccine and inactivated vaccine, with an objective to achieve the response which include production of neutralizing antibodies, generation of a T-cell response, and avoidance of immune-enhanced disease. Over a course of time, the SARS-CoV-2 virus has evolved and lead to mutations; the virus with one or more new mutations is referred to as a “variant” of the original virus. All new strains (P.1 from Brazil, B.1.351 from South Africa, B.1.1.7 from the UK and B.1.617 from India) have mutations in the spike protein, resulting in the threat to the effectiveness of the current available first generation vaccines. Hence, there might be the need of the development of the modified next generation of vaccines, which take care of all those variants. Nevertheless, the current first generation vaccines may still provide satisfying immunity against SARS-CoV-2 variants. Most vaccines are expected to provide protection against hospitalizations/deaths from these variants and a booster vaccine against these variants is likely to be effective. Hence, the current vaccination must proceed. As we are aware that the more the virus spreads, the more variants are likely to appear. In order to stop the spread of SARS-CoV-2 variants, it is important to get the vaccines once it is available and not to forget about the need to wash hands frequently, keep at least 1m distance from others and wear a mask. With the development of the effective SARS-CoV-2 vaccines and implementation of public health measures, we can surely defeat SARS-CoV-2 virus in COVID-19 battle and end this pandemic.</p> Umid Kumar Shrestha Copyright (c) 2021 Umid Kumar Shrestha Fri, 14 May 2021 00:00:00 +0000 46, XY Disorder of Sexual Development with Ambiguous Female External Genitalia: A Case Report <p>Disorder of Sexual Development (DSD) is a group of congenital conditions with atypical development of sex at chromosomal, gonadal or anatomic level. Genetic males with DSD (46 XY DSD) can present with female external genital phenotype, ambiguous, or a micropenis. It is caused by incomplete intrauterine masculinization with or without the presence of Müllerian structures. It results either from decreased synthesis of testosterone or DHT or from impairment of androgen action. Herein, we report a case of a 13-year child raised as female with hoarseness of voice and gradual enlargement of clitoris with hormonal assessment not suggestive of either 5 Alfa Reductase deficiency, Congenital Adrenal Insufficiency Syndrome or 17β-Hydroxysteroid Dehydrogenase deficiency</p> Anil Kumar Sah, Bipin Maharjan, Mahesh Bahadur Adhikari, Suman Baral, Mimi Giri Copyright (c) 2021 Anil Kumar Shah, Bipin Maharjan, Mahesh Bahadur Adhikari, Suman Baral, Mimi Giri Fri, 14 May 2021 00:00:00 +0000 Acute flaccid Paralysis as first presentation of Primary Sjogren’s Syndrome: A case report from Nepal <p>Sjögren’s syndrome is an autoimmune disease with glandular and extra-glandular involvement. The common neurological manifestation of Sjögren’s syndrome are peripheral neuropathy, anterior horn cell disease, transverse myelitis and aseptic meningitis. However, Sjögren’s syndrome presenting with acute flaccid paralysis is rare phenomenon. We report a case of a 35-year-old woman who presented with acute flaccid paralysis with respiratory failure who was later diagnosed as Primary Sjogren’s syndrome.</p> Abhishek Thapaliya, Bhupendra Shah, Roshan Chhetri, Auraj Uprety, Deepak Dhakal, Sanjib Kr Sharma Copyright (c) 2021 Abhishek Thapaliya, Bhupendra Shah, Roshan Chhetri, Auraj Uprety, Deepak Dhakal, Sanjib Kr Sharma Fri, 14 May 2021 00:00:00 +0000 Clinical and laboratory differences and role of gene xpert in tuberculous pleural effusion <p><strong>Background:</strong> The diagnosis of pleural effusion and its cause are essential for pleural fluid analysis. We have evaluated clinical and laboratory differences among the tubercular pleural effusion.</p> <p><strong>Methods:</strong> The cross-sectional, observational hospital based study was conducted in Bir hospital, Nepal. All patients were evaluated by clinically and laboratory investigations. Patients enrolled for study have pleural effusion and pleural fluid analysis indicative of an exudative pleural effusion using lights criteria. The criteria of enrollment of the patients were pleural fluid for Adenosine deaminizes value more than 40 IU/L, positive for gene xpert test and pleural effusion of any cases with sputum positive pulmonary tuberculosis. Patients were divided into two groups lymphocytic and neutrophilic predominant pleural effusion.</p> <p><strong>Results:</strong> Among 100 patients with diagnosis of exudative tubercular pleural effusion, the most common symptom was pleuritic chest pain in 85%, followed by fever in 84% and cough in 82%. Among the tubercular pleural effusion, 21% had neutrophils predominant and 79% had Lymphocytes predominant. The patients with neutrophil predominant Tubercular pleural effusion had higher fever rates (90.5vs.82.5%) than those with lymphocyte-predominant Tubercular pleural effusion. The mean value of Neutrophil predominant pleural fluid for lactate dehydrogenase (LDH) level was 1657.5 IU/L and protein was 5.3gm/dl and in lymphocyte predominant pleural fluid for LDH value was 610.2 IU/L and protein was 4.6 gm/dl; the difference was statistically significant with P value of &lt;0.001. Only 15% of patients had sputum positive for Acid fast bacilli. Among the sputum positive patients, 47% had positive for pleural fluid for gene xpert test with all patients had rifampicin sensitive. The sensitivity of pleural fluid for gene xpert test was 46.6%, and specificity was 90%.</p> <p><strong>Conclusion:</strong> In pleural effusion, the positivity of gene xpert for pleural fluid was higher among the sputum positive patients. The prevalence of Neutrophil-predominant pleural effusion was common in tubercular pleural effusion.</p> Manoj Kumar Shah, Sushil Baral, Tulsi Bhattarai Copyright (c) 2021 Manoj Kumar Shah, Sushil Baral, Tulsi Bhattarai Fri, 14 May 2021 00:00:00 +0000 Outcome of Pneumatic Balloon Dilatation in Achalasia Cardia <p><strong>Background:</strong> Achalasia Cardia is a rare esophageal motility disorder. Among various treatment options, Pneumatic Dilatation (PD) is the most widely used and cost effective modality till date. This is the first observational study aiming to evaluate the short term response and complications of PD for Achalasia Cardia in Nepal.</p> <p><strong>Methods:</strong> This prospective observational study was conducted between 28th Jan 2020 to 27th Jan 2021. It included 39 patients with Achalasia Cardia diagnosed by clinical presentation, esophagoscopy, barium esophagogram and high resolution manometry. Two patients of Type III achalasia were excluded from study. Thirty seven patients underwent pneumatic dilatation with 30 mm Rigiflex balloon (Boston Scientific, USA) for a duration of 1 minute. Response was assessed by Eckardts score at 3 and 6 months.</p> <p><strong>Result:</strong> Among 39 cases (mean age= 39.03±15.017 years, 59% men), commonest was Type II Achalasia (71.8%) followed by Type I (23.1%) and Type III (5.1%). Dysphagia was present in all patients (100%), followed by weight loss (84.6%), regurgitation (79.5%) and chest pain (35.9%). Mean basal Eckardts score and Lower Esophageal Sphincter pressure of the study population was 7.81±1.24 and 24.40±6.83 respectively. Response to pneumatic dilatation was 89.2%. Eckardts score changed significantly from7.81±1.24 to 1.03±1.82 at 6 months (p&lt;0.001). None of the patients had major complications. Younger age (23±6.377 years) had poor response to treatment, while predilatation Lower Esophageal Sphincter pressure, gender and type of achalasia did not affect the treatment outcome.</p> <p><strong>Conclusion:</strong> PD is safe and effective treatment modality for Achalasia. Younger patients have poor response to treatment with Pneumatic Dilatation. &nbsp;</p> Shankar Baral, Bidhan Nidhi Paudel, Ajit Khanal, Jiwan Thapa, Bhuwneshwer Yadhav, Ramila Shrestha, Bhupendra Kumar Basnet, Mukesh Sharma Paudel, Suresh Thapa, Dibas Khadka, Manoj Kumar Shah, Umid Kumar Shrestha Copyright (c) 2021 Shankar Baral, Bidhan NIdhi Paudel, Ajit Khanal, Jiwan Thapa, Bhuwneshwer Yadhav, Ramila Shrestha, Bhupendra Kumar Basnet, Mukesh Sharma Paudel, Suresh Thapa, Dibas Khadka, Manoj Kuar Shah, Umid Kumar Shrestha Fri, 14 May 2021 00:00:00 +0000 Study of Endoscopic Findings in First Episode of Upper Gastrointestinal Bleeding <p><strong>Background and Aims:</strong> Upper gastrointestinal bleeding (UGIB) is one of the most common and grave emergencies encountered in Emergency department in Tertiary health care centre in our country. Upper endoscopy has a crucial role in the diagnosis and treatment of upper gastrointestinal bleeding. The aim of this study is to assess the endoscopic findings in patients presenting with first episode of UGIB.</p> <p><strong>Methods: </strong>This was a hospital based cross sectional study of patients with haematemesis, melena or both who underwent UGI endoscopy at Bir Hospital during January 2019 to January 2020. Patient demographics, site and nature of lesions and risk factors for bleeding were analyzed.</p> <p><strong>Results:</strong> Among 72 enrolled patients 48 (66.67 %) were male and 24 (33.3 %) were female. Haematemesis 27% was the most common presenting complain followed by melena 25.5% and fainting/ dizziness 22.5%. Endoscopy was done in all cases and gastric ulcer disease 27.8% was the commonest cause of first episode of UGI bleeding followed by variceal bleeding, gastric erosion and duodenal ulcer, 25%, 16.7%, 12.5% respectively.</p> <p><strong>Conclusions: </strong>Peptic ulcer disease was the most common cause of first episode of UGI bleeding in our context. Among peptic ulcer diseases gastric ulcer was more common than duodenal ulcer. Haematemesis and melena were the commonest clinical presentation of UGI bleeding. &nbsp;</p> Krishna Raj Adhikari, Rajesh Kumar Mandal Copyright (c) 2021 Krishna Raj Adhikari, Rajesh Kumar Mandal Fri, 14 May 2021 00:00:00 +0000 Diagnostic accuracy of monofilament test to detect diabetic neuropathy <p><strong>Background</strong> Diabetic peripheral neuropathy (DPN) is a significant independent risk factor for diabetic foot, and an effective screening instrument is required to diagnose DPN early to prevent future ulceration and amputation. This study aims to determine the diagnostic accuracy of monofilament test to detect diabetic peripheral neuropathy.</p> <p><strong>Methods</strong> This cross-sectional study was conducted in National Academy of Medical Sciences, Bir hospital, Mahabouddha, Kathmandu from February 2016 to January 2017. A total of 96 diabetic patients attending inpatient and outpatient Department were selected. Diabetic peripheral neuropathy was assessed by measurement of loss of protective sensation (LOPS) by monofilament test and compared with vibration perception threshold by standard biothesiometer. The sensitivity, specificity, positive predictive value and negative predictive value of monofilament test were calculated.</p> <p><strong>Results</strong> The prevalence of diabetic peripheral neuropathy was 26%. The sensitivity, specificity, positive predictive value and negative predictive value of monofilament test were found to be 92.0%, 95.8%, 88.5% and 97.1% respectively. There was strong association between LOPS by monofilament and vibration perception threshold by biothesiometer.</p> <p><strong>Conclusion</strong> This study showed a strong diagnostic accuracy of monofilament test to detect DPN when compared with biothesiometer. As monofilament test is a cheap, easily available, and portable, it can be used in the periphery where biothesiometer is not available. &nbsp;</p> Sujan Shrestha, Mamen Prasad Gorhaly, Manil Ratna Bajracharya Copyright (c) 2021 Sujan Shrestha, Mamen Prasad Gorhaly, Manil Ratna Bajracharya Fri, 14 May 2021 00:00:00 +0000 Awareness regarding organ transplantation among visitors of the ICU patients in three tertiary care centres in Kathmandu, a cross-sectional study <p><strong>Background and aims:</strong> Organ transplant is often the only viable treatment option for various end stage organ failures. Inadequacy of organ procurement from living as well as cadaveric donors is common, more so in developing countries. The aim of this study was to find out the knowledge and attitude regarding organ transplantation.</p> <p><strong>Methods: </strong>A questionnaire-based survey was carried out among 150 respondents, who were the visitors of patients admitted to ICU of three tertiary care centres in Kathmandu.</p> <p><strong>Results:</strong> Majority of the respondents were male 105 (70%) and 132 (88%) were aware about organ transplant. Likewise, 111 respondents (84.1%) hold the belief that organ transplant save lives. Ninety-four of the responses (34.8%) believe that media was the source of knowledge and 121 (91.7 %) of the respondents stated that organ transplant should be promoted. Majority of them, 80 of the total respondents (60.6%) believed that organ can be donated by both living and deceased donors and 111 (84.1%) of them believed that organ transplant save lives. While 88 of the respondents (66.7%) have heard about brain death, 60 of them (45.4%) believe that there is an organ transplant act in Nepal. Out of all respondents who are aware about transplantation, 91 of them (68.9%) have opinion that they are willing to donate the organ of their beloved ones should there be a situation of brain death.</p> <p><strong>Conclusions:</strong> The study concludes that respondents have adequate knowledge regarding organ transplantation. Respondents have overall positive attitude towards organ donation and transplantation. &nbsp;</p> Gentle S. Shrestha, Amit S Bhattarai, Tseten Yonjen, Ramesh S Bhandari, Paleswan J Lakhey, Subhash P Acharya, Shreejana Singh, Moda N Marhatta Copyright (c) 2021 Gentle S. Shrestha, Amit S Bhattarai, Tseten Yonjen, Ramesh S Bhandari, Paleswan J Lakhey, Subhash P Acharya, Shreejana Singh, Moda N Marhatta Fri, 14 May 2021 00:00:00 +0000 Microalbuminuria and its associations with clinical profile and complications of type 2 Diabetes Mellitus <p><strong>Background and Aims:</strong> Microalbuminuria is an early marker of diabetic nephropathy, which accounts for a significant reduction in life expectancy of diabetic patients. Timely detection of microalbuminuria facilitates appropriate preventive and therapeutic approaches to minimize risks. The aim of this study is to determine the prevalence and association of microalbuminuria with clinical profile and complications of type 2 diabetes mellitus.</p> <p><strong>Methods:</strong> This study was a descriptive, cross sectional study involving 100 diabetic subjects between July 2018 to January 2019 at Bir Hospital. Microalbuminuria (mg/dl) was defined as spot urine albumin to creatinine ratio of 30-300 mg/g (Kidney Disease Improving Global Outcomes guidelines) in a single spot urine sample. Statistical analysis was done using Statistical package for the social sciences version 20.</p> <p><strong>Results:</strong> Microalbuminuria was found in 35% of the sample and the rate was significantly higher among males (P =0.027). Microalbuminuria was significantly related to Body mass index (P = 0.018), duration of diabetes (P =0.000), retinopathy (P = 0.000) and stroke (P = 0.043). No statistically significant relation was found between microalbuminuria and age (P = 0.366), hypertension (P = 0.208), HbA1c (P = 0.098), dyslipidemia (P = 0.171) and ischemic heart disease (P = 0.651).</p> <p><strong>Conclusions:</strong> This study shows high prevalence of microalbuminuria in Nepalese Type 2 diabetes mellitus. Screening for microalbuminuria should be done for all the type 2 diabetes mellitus patients for early detection and management of complications of diabetes mellitus. &nbsp;</p> Sanjay Shrestha, Rajesh Kumar Mandal, Kijan Maharjan Copyright (c) 2021 Sanjay Shrestha, Rajesh Kumar Mandal, Kijan Maharjan Fri, 14 May 2021 00:00:00 +0000 Comparing four standard Sleep Questionnaires to Polysomnography to predict possibility of Obstructive Sleep Apnea and its severity <p><strong>Background and Aims:</strong> Obstructed Sleep Apnea (OSA) is emerging as a significant problem in South East Asia with the rise of Obesity. Polysomnography (PSG) being expensive in Nepal, is usually deferred. The commonly used screening tools are cornerstone to evaluate clinical possibility and effects of OSA without having to rely on the PSG at the onset in Nepal. In this study, we proposed the use of four sleep related questionnaires separate as well as in combination to clinically predict OSA and its severity. And to do that we have compared these scores with Apnea Hypo-apnea Index (AHI) derived from the gold standard level one PSG.</p> <p><strong>Method</strong> This was a prospective randomized trial comparing level one polysomnography with individual scores from Epworth Sleepiness Score, STOP BANG score, Pittsburg Sleep Quality Index and Functional Outcome of Sleep Quality-10 and the composite sleep score derived from all the four.</p> <p><strong>Results </strong>120 patients with clinical suspicion of OSA underwent PSG after filling all four questionnaires. The mean AHI of the study population was 37.65 ± 23.66. STOP BANG had the highest sensitivity for all three groups of AHI (≥5, ≥15 and ≥30), at 92.5%, 93.4%, and 95.2% respectively when compared with ESS, PSQI and FOSQ-10. PSQI showed negative correlation with AHI. The proposed composite score showed no correlation with AHI.</p> <p><strong>Conclusion</strong> STOP BANG score and AHI showed good correlation. STOP BANG score had the highest sensitivity for all levels of AHI. ESS showed good PPV and NPV to predict OSA. PSQI had the highest NPV to predict AHI. And FOSQ-10 had the highest specificity, good PPV and good NPV. &nbsp;</p> Sanjeet Krishna Shrestha, Sanjeev Shrestha, Ruja Rajkarnikar, Jonas Malla, Sulav Rayamajhi, Sanjeet Bhattarai, Lucky Sharma, Yuvaraj Bhusal Copyright (c) 2021 Sanjeet Krishna Shrestha, Sanjeev Shrestha, Ruja Rajkarnikar, Jonas Malla, Sulav Rayamajhi, Sanjeet Bhattarai, Lucky Sharma, Yuvaraj Bhusal Fri, 14 May 2021 00:00:00 +0000 Association between lipid indices and 10-year cardiovascular risk of a cohort of black Africans living with type 2 diabetes mellitus <p><strong>Introduction</strong> Diabetes mellitus is an established cardiovascular risk factor. Diabetes mellitus impairs lipid metabolism and enhances atherosclerosis development. Absolute lipid parameter are inadequate in predicting cardiovascular risk and some lipid indices have been reported to circumvent this deficiency. The objective of the study was to determine the association between these lipid indices and 10-year cardiovascular risk among black Africans with diabetes.</p> <p><strong>Methods</strong> Seventy individuals (35 males and 35 females) living with diabetes who attended the diabetes clinic of a referral hospital in South-western Nigeria were recruited to the study. Ethical approval and participants’ informed consent were duly obtained. Fasting plasma glucose, fasting lipid profile and glycated haemoglobin were done using appropriate laboratory techniques. Atherogenic index of plasma, atherogenic coefficient, Castelli’s risk index I, Castelli’s risk index II and CHOLindex were calculated using appropriate formulae. QRISK 3 score was obtained using a validated calculator. The association between QRISK 3 and the lipid indices was determined using Pearson’s correlation.</p> <p><strong>Results</strong> The mean age of the participants was 53.34 ± 9.57 years. The mean duration of diabetes mellitus among the participants was 6.29 ± 2.78 years. The mean HbA1c and FPG were 6.98±0.72% and 6.32±0.87 mmol/L respectively. The mean QRISK 3 score was 7.58±4.80. There was a statistically significant and positive correlation between QRISK 3 score and AIP, AC, CR I and CR II. CHOLindex did not significantly correlate with QRISK 3 score.</p> <p><strong>Conclusion</strong> Among black Africans with diabetes, lipid indices (AIP, AC, CR I and CR II) significantly correlated with QRISK 3 score and therefore may be used as cheap markers of 10-year cardiovascular risk in these individuals. &nbsp;</p> Taoreed Adegoke Azeez Copyright (c) 2021 Taoreed Adegoke Azeez Fri, 14 May 2021 00:00:00 +0000 Post COVID-19 pulmonary fibrosis <p>No abstract available.</p> Gentle S Shrestha, Pooja Agrawal Copyright (c) 2021 Gentle S Shrestha, Pooja Agrawal Fri, 14 May 2021 00:00:00 +0000