Microplastics in environment: global concern, challenges, and controlling measures.

Plastic pollution in various forms has emerged as the most severe environmental threat. Small plastic chunks, such as microplastics and nanoplastics derived from primary and secondary sources, are a major concern worldwide due to their adverse effects on the environment and public health. Several years have been spent developing robust spectroscopic techniques that should be considered top-notch; however, researchers are still trying to find efficient and straightforward methods for the analysis of microplastics but have yet to develop a viable solution. Because of the small size of these degraded plastics, they have been found in various species, from human brains to blood and digestive systems. Several pollution-controlling methods have been tested in recent years, and these methods are prominent and need to be developed. Bacterial degradation, sunlight-driven photocatalyst, fuels, and biodegradable plastics could be game-changers in future research on plastic pollution control. However, recent fledgling steps in controlling methods appear insufficient due to widespread contamination. As a result, proper regulation of environmental microplastics is a significant challenge, and the most equitable way to manage plastic pollution. Therefore, this paper discusses the current state of microplastics, some novel and well-known identification techniques, strategies for overcoming microplastic effects, and needed solutions to mitigate this planetary pollution. This review article, we believe, will fill a void in the field of plastic identification and pollution mitigation research.

Chronic Spontaneous Urticaria: Clinical Profile, Autologous Serum Skin Test Positivity and Associated Impairment in Quality of Life in Nepalese Patients.

Background Chronic Spontaneous Urticaria is considered to be an autoimmune phenomenon in half of the total cases. Autologous serum skin test is a simple screening test for the presence of auto-antibodies in chronic urticaria. Significant impairment in quality of life have been observed in autologous serum skin test positive cases. There are limited literatures on chronic spontaneous urticaria, autologous serum skin test and associated Dermatology Life Quality Index in Nepal till date. Objective To find the proportion of autologous serum skin test positive cases in chronic urticaria and impairment in quality of life in such patients. Method This was a retrospective review of outpatient records of patients diagnosed with chronic spontaneous urticaria, from January 2018 to December 2019, from a tertiary care hospital in Kathmandu, Nepal. Details of the patients, autologous serum skin test and dermatology life quality index scores were analyzed and presented. Result Among the total 114 cases positive autologous serum skin test was seen in 48.2% of cases. The mean total Dermatology Life Quality Index score was 8.06±6.64. A significantly higher quality of life impairment was observed in in patients with positive autologous serum skin test as compared to the negative ones. The odds of finding a positive autologous serum skin test in patients with angioedema was 2.1, however the difference was not statistically significant. Conclusion Chronic spontaneous urticaria was more common in females as compared to males. A positive autologous serum skin test was present in half of the patients which was in turn associated with a greater impairment of quality of life.

Magnetic Resonance Imaging Evaluation of Musculoskeletal Diseases of Ankle and Foot.

Background Ankle and foot pain is a common clinical problem, that may be due to a variety of soft tissue and osseus abnormalities. Magnetic resonance imaging plays vital role for diagnosing internal derangement of the ankle joint, assessing soft tissue structures around the ankle such as tendons, ligaments, nerves and osseus structures. Method Retrospective magnetic resonance imaging evaluation of the ankle and foot was done in 100 patients using 0.3T and 1.5T magnetic resonance imaging. Clinical history included pain, swelling of the ankle and foot, trauma, twisting injury, palpable mass and difficulty in walking. Result Fifty two patients were male and 48 patients female aged 6 months to 70 years. Ligaments tear were the commonest and seen in 22% patients. Tenosynovitis found in 17%, Pigmented villonodular synovitis (PVNS) in 3%, Achilles tendon abnormality in 8%, stress fracture-9%, osteomyelitis-8%, soft tissue vascular malformation in 5%, soft tissue and bone tumor-4%, marrow edema-20%, osteoarthritis-10%, Osteochondral lesion of talus-8%, sinus tarsi syndrome-3%, posterior impingement-5%, plantar fasciitis-2%, Sever disease-2%, peroneus tendon split-2%. The commonest clinical presentation was pain and swelling of the ankle in 42 patients, twisting/inversion injury of the ankle in 23 patients followed by traumatic injury with difficulty in walking in 20 patients and palpable mass in 8 patients. Ligaments injury were mostly associated with inversion/twisting injury. Conclusion Magnetic resonance imaging is advantageous for assessing soft tissue structures around the ankle and foot, such as tendons, ligaments, nerves, masses and occult osseus lesions. It provides a quick, non-invasive tool for the diagnosis of related injuries and guide for the further treatment planning.

Cold Storage Exacerbates Renal and Mitochondrial Dysfunction Following Transplantation.

Long-term renal function is compromised in patients receiving deceased donor kidneys which require cold storage exposure prior to transplantation. It is well established that extended cold storage induces renal damage and several labs, including our own, have demonstrated renal mitochondrial damage after cold storage alone. However, to our knowledge, few studies have assessed renal and mitochondrial function after transplantation of rat kidneys exposed to short-term (4 hr) cold storage compared to transplant without cold storage (autotransplantation). Our data reveal that cold storage plus transplantation exacerbated renal and mitochondrial dysfunction when compared to autotransplantation alone.

Renal Mitochondrial Lipid Peroxidation during Sepsis.

Sepsis can provoke kidney injury, which increases mortality. Human and animal studies have documented increased renal oxidative injury and mitochondrial damage during sepsis. However, few studies have attempted to dissect specific renal targets and/or types of oxidative injury using the cecal ligation and puncture (CLP) murine model of sepsis. The purpose of this short communication is to examine the extent of lipid peroxidation within renal mitochondria using CLP and blue native gel electrophoresis which separates intact mitochondrial respiratory complexes. Our results show that CLP induced increased 4-hydroxy-nonenal protein adduction (marker of lipid peroxidation) in renal homogenates and mitochondrial fractions. Blue native gel electrophoresis revealed that respiratory complex III was selectively targeted within mitochondrial fractions. This supports our prior report showing renal complex III inactivation following CLP. Future studies will identify specific renal proteins within complex III that are modified during sepsis to provide mechanistic insight on how mitochondrial respiration is inhibited during sepsis.

Inadequate Empirical Antibiotic Therapy in Hospital Acquired Pneumonia.

INTRODUCTION: Inadequate empirical antibiotic therapy for HAP is a common phenomena and one of the indicators of the poor stewardship. This study intended to analyze the efficacy of empirical antibiotics in the light of microbiological data in HAP cases. METHODS: Suspected cases of HAP were followed for clinico-bacterial evidence, antimicrobial resistance and pre and post culture antibiotic use. The study was taken from February,2014 to July 2014 in department of Microbiology and department of Respiratory medicine prospectively. Data was analyzed by Microsoft Office Excel 2007. RESULTS: Out of 758 cases investigated, 77(10 %) cases were HAP, 65(84%) of them were culture positive and 48(74 %) were late in onset. In early onset cases, isolates were Acinetobacter 10(42%), Escherichia coli 5(21%), S.aureus 4(17%), Klebsiella 1(4%) and Pseudomonas 1(4%). From the late onset cases Acinetobacter 15(28%), Klebsiella 17(32%) and Pseudomonas 13(24%) were isolated. All Acinetobacter, 78% Klebsiella and 36% Pseudomonas isolates were multi drug resistant. Empirical therapies were inadequate in 12(70%) of early onset cases and 44(92%) of late onset type. Cephalosporins were used in 7(41%) of early onset infections but found to be adequate only in 2(12%) cases. Polymyxins were avoided empirically but after cultures were used in 9(19%) cases. CONCLUSIONS: Empirical antibiotics were vastly inadequate, more frequently so in late onset infections. Use of cephalosporins empirically in early onset infections and avoiding empirical use of polymyxin antibiotics in late onset infections contributed largely to the findings. Inadequate empirical regimen is a real time feedback for a practitioner to update his knowledge on the local microbiological trends.

Distally based sural faciocutaneous and fascial (adipofascial) flap for reconstruction of distal leg, ankle and foot defects.

BACKGROUND: Any soft tissue defect in distal leg, ankle and hind foot is still a challenging problem. There are various options for coverage of such defects, but the distally based sural neurocutaneous and neurofascial flap based on the sural nerve and superficial sural artery has been an important option. OBJECTIVE: To evaluate the efficacy of distally based sural flap in reconstruction of the distal leg, ankle and hind foot soft tissue defects. METHOD: Seventeen patients with soft tissue defects over distal leg, ankle and hind foot were included in this study. All patients were treated with distally based sural flap. Most of the cases were due to trauma (16 cases) which compromised tendon and bone. One case was of malignant melanoma of sole of hind foot which required wide excision and soft tissue reconstruction with sural flap. RESULT: In all cases defects were successfully covered. Three showed venous congestion and partial necrosis. One developed secondary infection. One flap failed completely. Mean follow up of patients was 20 months (6-36 months). CONCLUSION: Sural flap is a good option for reconstruction of distal leg, ankle and foot defects.

Epidemiological and outcome analysis of orthopedic implants removal in Kathmandu University Hospital.

BACKGROUND: Orthopedic Implant removal is one of the commonly performed elective orthopedic surgeries. Implants are generally removed after the purpose of keeping implant is solved by healing of the fracture, but there is no consensus whether routine implant removal should be a policy for all fractures that were fixed. OBJECTIVE: This study aims to analyze the epidemiology and outcome of implant removal surgery carried out in the past three years in Kathmandu University Hospital. METHODS: Patients who underwent implant removal between 2010 January to 2012 December constituted the study cohort. Demographic data, indications, types of hardware and location of fractures were recorded. Similarly, duration of surgery, type of anesthesia and duration of hospital stay were recorded. All the patients who had undergone implant removal in this three years period were called for follow up examination but those who were not able to come were interviewed on telephone. RESULTS: There were 275 implant removals constituting 7.8% of total orthopedic operations and 26.3% of fracture fixations. Male to Female ratio was 189: 86. Pediatric age group (34.5%) had the highest incidence of implant removal. Moderate sized implants were the commonest hardwares removed (63.2%). Femur (27.3%) followed by radius (26.9%) were the commonest bone for implant removal. Average operative time was 47.3 minutes with average hospital inpatient stay of 2.6 days. Commonest indication for the implant removal procedure was pain (45%). CONCLUSION: Implant removal procedures are one of the most commonly performed elective orthopedic surgeries. Though, after orthopedic implants removal, pain relief can be expected but it is not so predictive and hence patient should be well counseled before and the indications for implant removal has to be evaluated for better patient satisfaction and safety.

Medical abortion versus manual vacuum aspiration in a hilly district hospital of eastern Nepal: a comparative study.

BACKGROUND: Nepal government has approved medical abortion and manual vacuum aspiration for early first trimester pregnancy. Both the procedures have been approved by World Health Organization for use in early first trimester. OBJECTIVES: The study aims to compare efficacy and safety of medical abortion with surgical abortion in a district hospital of rural eastern Nepal. METHOD: An observational study conducted in district hospital, Dhankuta from July 2010 to January 2011. Clients for abortion services were counseled about methods of abortion and were allowed to make decision on their own and classified as medical abortion group (N=48) (receiving 200 milligram Mifepristone followed by 800 microgram misoprostol sublingually or vaginally on day two)and manual vacuum aspiration group (N=36). The two groups were compared for rate of complete abortion and other complications and contraception use after procedure. RESULTS: Rate of complete abortion was similar in both groups, 95.8% among medical abortion and 97.2% in manual vacuum aspiration. Moderate to severe expulsion bleeding was reported in 91.6% of cases after medical abortion but none required medical attention for hemorrhage. Condom was the most preferred contraceptive in medical abortion group and depo provera in manual vacuum aspiration group. CONCLUSION: Medical method of abortion using mifepristone and misoprostol is equally safe and effective as manual vacuum aspiration in rural setting district hospitals of Nepal.

A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu University Hospital and its outreach centers in rural area.

BACKGROUND: Physical trauma is one of the major cause of mortality and morbidity among young and active age group and its increasing trend is of main concern. There are only few studies concerning the spectrum of physical trauma in Nepal. OBJECTIVE: This study aims to evaluate the epidemiological spectrum, the extent, severity of the physical trauma and the outcome evaluation of patients with physical trauma over a period of one year in the emergency department of the Kathmandu University Hospital and compare the same parameters with those patients presenting to the various outreach centers of the hospital in the community. METHODS: Patient treatment files from the emergency department and the reports from various outreach centers were retrieved for a period of one year (May 2011 to April 2012). Epidemiological information, mode, type and anatomic location of injuries were recorded. Outcome evaluation was assessed by number of patients discharged from emergency department of the hospital or the outreach centers after the treatment, patients admitted for inpatient management and referred to other centers for further specialty management. RESULT: In a period of one year, total 2205 (20%) of physical trauma cases presented to the emergency department and 1994 (6.12%) in the outreach centres. Most commonly involved age group in physical trauma both in Hospital set up and in Community set up were the young adults (15 to 49 years). Fall from height was the commonest mode of injury followed by road traffic accidents among the patients coming to the hospital while significant number of trauma patients coming to outreach centers were due to fall from height. In the hospital set up, 1525 (69.2%) of the cases were discharged while 537 (24.4%) needed inpatient management and 85 (3.8%) needed referral to other centers for the specialty management. In case of outreaches, half of the patients were discharged after the primary treatment and almost another half were referred to the hospital, mainly for need of further investigations. CONCLUSION: Fall related injuries and road traffic accidents are the most common mode of trauma in the hospital set up and fall related injuries are the single most important mode of trauma seen in the outreaches. Mostly young adults in their active period of life are involved in physical trauma so appropriate preventive measures through public health approach should be included in comprehensive trauma management for reducing mortality and morbidity rates related to physical trauma.

Intramedullary nailing for paediatric diaphyseal forearm bone fracture.

BACKGROUND: Though most of the pediatric diaphyseal forearm bone fracture can be treated with closed reduction and cast application, indications for operative intervention in pediatric both-bone forearm fractures include open fractures, irreducible fractures, and unstable fractures. Controversy exists as to what amount of angulation, displacement, and rotation constitutes an acceptable reduction. OBJECTIVE: To review union time and functional outcome of pediatric diaphyseal forearm bone fracture managed with intramedullary rush pin by closed or open reduction. METHODS: Fifty patients with both bone fracture of forearm were treated with intramedullary rush pin by closed or open reduction were included in the study and followed up for minimum six months for radiological and functional outcome. RESULTS: Out of 50 patients, 31 underwent closed reduction and 19 underwent open reduction. All fractures maintained good alignment post operatively. Forty seven patients had excellent results with normal elbow range of motion and normal forearm rotation and three patients had good results. In all patients good radiological union was seen in three months time. Eight patients had minor complications including skin irritation over prominent hardware, backing out of ulnar pin, superficial skin break down with exposed hardware. Twenty-three (46%) patients had undergone implant removal at an average of 6 months (range 4-8 months) under regional or general anesthesia. CONCLUSION: Fixation with intramedullary rush pin for forearm fracture is an effective, simple, cheap, and convenient way for treatment in pediatric age group.

Ipsilateral supracondylar fracture and forearm bone injury in children: a retrospective review of thirty one cases.

BACKGROUND: Pediatric supracondylar fracture and forearm bone fracture is common in isolation but combined supracondylar fracture with ipsilateral forearm bone fracture, known as floating elbow is not common injury. The incidence of this association varies between 3% and 13%. Since the injury is rare and only limited literatures are available, choosing best management options for floating elbow is challenging. METHOD: In retrospective review of 759 consecutive supracondylar fracture managed in between July 2005 to June 2011, children with combined supracondylar fracture with forearm bone injuries were identified and their demographic profiles, mode of injury, fracture types, treatment procedures, outcome and complications were analyzed. RESULT: Thirty one patients (mean age 8.91 yrs, range 2-14 yrs; male 26; left side 18) had combined supracondylar fracture and ipsilateral forearm bone injury including four open fractures. There were 20 (64.51%) Gartland type III (13 type IIIA and 7 type III B), seven (22.58 %) type II, three (9.67 %) type I and one (3.22 %) flexion type supracondylar fracture. Nine patients had distal radius fracture, six had distal third both bone fracture, three had distal ulna fracture, two had mid shaft both bone injury and one with segmental ulna with distal radius fracture. There were Monteggia fracture dislocation, proximal ulna fracture, olecranon process fracture, undisplaced radial head fracture of one each and two undisplaced coronoid process fracture. Displaced forearm fracture required closed reduction and fixation with Kirschner wires or intramedullary nailing. Nineteen patients with Gartland type III fracture underwent operative intervention. Among them nine had closed reduction and K wire fixation for both supracondylar fracture and forearm bone injury. There were three radial nerve, one ulnar nerve and one median nerve injury and two postoperative ulnar nerve palsy. Three patients had pin tract related complications. Among type III, 16 (80%) patients had good to excellent, two had fair and one had poor result in terms of Flynn criteria in three months follow up. CONCLUSION: Displaced supracondylar fracture with ipsilateral displaced forearm bone injuries need early operative management in the form of closed reduction and percutaneous pinning which provides not only stable fixation but also allows close observation for early sign and symptom of development of any compartment syndrome.

Scaphoid fracture: functional outcome following fixation with Herbert Screw.

BACKGROUND: Most scaphoid fractures though heal uneventfully with cast treatment, immobilization with cast is associated with complication like wrist stiffness. Open reduction and fixation with Herbert Screw though technically demanding procedure can yield excellent results and prevents complication like nonunions and loss of wrist function. OBJECTIVES: To assess clinical outcome and radiological union of scaphoid fracture after operative management following Herbert screw fixation in patient attending Dhulikhel Hospital. METHODS: All scaphoid fracture, treated from Feb 2007 till Feb 2011, were retrospectively studied in Dhulikhel Hospital, Kathmandu University Hospital. Fifteen patients with scaphoid fractures were treated with Herbert screw. Fourteen were males and one was female. Serial radiographs were taken to assess radiographic union and functional outcome was assessed using Modified Mayo wrist score. RESULTS: Out of 15 patients, 13 scaphoid had waist fractures and two had proximal pole fractures. All scaphoid were treated with open reduction and Herbert screw fixation either by volar approach or by dorsal approach. All fractures maintained good alignment post operatively. Nine (60%) patients had excellent results with normal wrist range of motion, five (33.3%) patients had good results and one (6.7%) patient had poor outcome. In 14 (93.3%) patients good radiological union was seen at final follow up at six months time. CONCLUSION: Fixation with Herbert screw for scaphoid fracture is an effective and convenient way of treatment with satisfactory functional outcome and less complication.

Operative fixation of displaced middle third clavicle (Edinburg Type 2) fracture with superior reconstruction plate osteosynthesis.

BACKGROUND: Conservative management of middle third clavicle fracture has been recently reported with suboptimal outcomes. Despite higher nonunion rates in initial open reduction and internal fixation, understanding the problem better and taking in accounts of previous shortcomings, such fractures can be optimally treated by open reduction and internal fixation with reconstruction plate. OBJECTIVE: To study the outcome of middle third clavicle fracture treated with superior reconstruction plating in terms of function using Constant shoulder score, union time and rate, complications and patient satisfaction. METHODS: Twenty patients with displaced middle third clavicle fracture (Edinburg type 2) treated with open reduction and internal fixation with reconstruction plate implanted in superior surface were prospectively followed for at least one year after surgery. RESULTS: There were 20 patients, 16 males and 4 females. The mean age of the patients was 31.5 years with SD 11.5 years (range 15-60 years) and 5 patients (25%) had associated injuries. All fractures united in 16 weeks or less in near anatomic position with complication in 2 (5%) patients, one deep infection and one frozen shoulder which on subsequent management recovered well. There was no nonunion or implant failure. The average Constant score was 97.45 in one year follow up and the patients were relatively satisfied with the treatment.The most common indication (25%) for hardware removal was young age of the patient, hardware prominence and occasional discomfort. CONCLUSION: This small series shows that displaced midshaft clavicle fracture can be optimally treated with operative fixation implanting the reonstruction plate in superior surface with six cortical purchases on either side and supervised physiotherapy, although subsequent surgery for implant removal might be necessary.