Predictors of Stone Free Rate and Application of the Size, Topography, Obstruction, Number and Evaluation of Hounsfield Units (S.T.O.N.E) Scoring System in Predicting the Outcome in Patients Undergoing Semi-rigid Ureteroscopic Lithotripsy for Ureteric Calculi at a University Hospital of Nepal.

Background Ureteric colic is common urological emergency in patients with urinary stone disease. Semi rigid ureteroscopic lithotripsy is a widely acceptable treatment modality for ureteric calculi. Objective To evaluate the predicting factors of stone free rate (SFR) and application of the Size, Topography, Obstruction, Number and Evaluation of Hounsfield units (S.T.O.N.E) scoring system in predicting success rate of ureteroscopiclithotrisy (URSL) for ureteric calculi. Method This was a prospective hospital based observational study conducted at the Department of Surgery, Dhulikhel Hospital, Kathmandu University Hospital from October 2021 to September 2022. Patients undergoing ureteroscopiclithotripsy using laser and/or pneumatic lithotripsy for ureteric calculi were included in the study. Informed consent was taken from each patient and data collection was done by filling the proforma. Result A total of 82 patients were included in the study. Mean age of patients was 35.89 ± 11.51 years. Overall stone free rate was 80.5%. Stone free rate were 96.67% and 71.15% in moderate (6-9) and high (10-13) S.T.O.N.E score groups respectively. Stone size and S.T.N.O.E score were found to be significantly high in patients with retained stone following ureteroscopiclithotrisy (p value < 0.05). Duration of surgery was significantly high in high S.T.O.N.E score group (p< 0.05). However no significant correlation was found between patient characters like age, sex, Body mass index and Hounsfield units of stone with stone free rate in this study. The area under the curve of the receiver operating characteristic curve for the S.T.O.N.E score and stone size were 0.693 and 0.660 respectively in this study. Conclusion Stone size and S.T.O.N.E score can be used as predictors of success following semirigid ureteroscopic lithotripsy. The value of S.T.N.O.E score has good predictive value for SFR and duration of surgery. There was no significant impact of patient's age, sex, Body mass index and Hounsfield units of stone in stone free rate following ureteroscopic lithotrisyin this study.

Outcome of Endoscopic Myringoplasty Using Gelfoam Versus no Gelfoam in Tympanic Cavity and External Auditory Canal.

Background Absorbable gelatin sponge (gelfoam) is used routinely during myringoplasty as a scaffold that supports tympanic membrane grafts and ossicular chain and to promote hemostasis. However, gelfoam could cause fibrosis, adhesions, granulations, new bone formation within the middle ear cavity and could obstruct the tympanic ostium of the eustachian tube and affects inner ear function and also interferes with the healing process of neodrum and middle ear cavity. Objective To compare the outcome of endoscopic myringoplasty with and without use of gelfoam in external auditory canal and tympanic cavity. Method Fifty patients, with 25 patients in each group who underwent endoscopic myringoplasty with and without gelfoam packing in middle ear cavity and external auditory canal were enrolled in the study. The hearing outcome was assessed by comparing pre-operative ABG (Air bone gap) with post-operative air bone gap and air bone gap closure in speech frequencies (0.5kHz,1kHz, 2kHz,4kHz). The status of graft and hearing results was evaluated on 3months of follow-up in both the groups. Result Out of total 25 patients enrolled for study in both non gelfoam packing group (NGFPG) and gelfoam packing group (GFPG), 24(96%) had graft uptake in each group. The audiological gain in non gelfoam packing group was 11.15±2.4dB whereas in gelfoam packing group it was 12.45±0.81dB. The audiological gain between the two groups did not show any statistically significant (p= 0.190). However, the pre and postoperative hearing difference was statistically significant(p=0.001) in both non gelfoam packing group and gelfoam packing group. Conclusion This study concluded that non gelfoam packing group has similar graft uptake and hearing gain when compared with gelfoam packing group in endoscopic myringoplasty. Hence, myringoplasty can be performed safely without using any gelfoam in the middle ear cavity.

Plexiform Schwannoma Clinically Masquerading as Thrombosed Vein.

Plexiform schwannoma is a rare benign nerve sheath tumor usually located in trunk, head, neck, upper extremities and occasionally in lower extremities. It is usually less than 2 cm in size and generally affects young adults. The tumour is composed of schwann cells and exhibit a plexiform growth pattern both in gross or histologic examination and is frequently accompanied by multinodularity causing serpentine distortion. Plexiform neurofibroma commonly mimics plexiform schwannoma and it is important to differentiate between them, as recurrence and malignant potential are more common with plexiform neurofibroma. We present the case of a 14-year-old female with history of a nodular soft tissue mass over his right foot measuring 11 cm in length. A Doppler scan of the foot was suggestive of thrombosed superficial vein in right foot. The histological evaluation of the mass revealed Plexiform schwannoma. S-100 immunostaining is diffuse and strong confirming the diagnosis of Plexiform schwannoma.

The Evolving Role of Biologics in Otorhinolaryngology:Innovations, Applications, and Future Perspectives.

The introduction of biologics into otorhinolaryngology has marked a significant shift in the management of complex and chronic ENT (Ear, Nose and Throat) conditions. This review delves into the mechanisms, clinical applications, and evidence supporting the use of biologics in treating disorders such as chronic rhinosinusitis, allergic rhinitis, head and neck cancer, and autoimmune inner ear disease. By examining current research and clinical trials, this article provides an in-depth analysis of the transformative impact of biologics and discusses future directions in this rapidly advancing field.

Mirror Ear: A Rare Case of Polyotia.

Polyotia is an anomaly of the external auricle in which the accessory auricle is large enough to closely resemble an additional pinna rather than a skin remnant and cartilage. Polyotia, also known as mirror ear or accessory ear, is a type of ear anomaly in the tragus area, but the term refers to substantial anomalies which resemble an accessory ear, unlike a pre-auricular tag. It is an extremely rare condition and to date, less than 30 cases of polyotia have been reported according to a review of the literature. A variety of theories has been proposed for development of such abnormal external auricle. We report two cases of polyotia which presented to Dhulikhel Hospital ENT OPD that was successfully corrected surgically. An 8-year-old boy and a 14-year-old boy presented with a large accessory anomalous auricle on left and right ear respectively. The accessory auricle was composed of an elastic cartilaginous component covered with skin and was positioned anteriorly to the original auricle in both the cases. The anomaly was not as large as the patient's external auricle, rather it mirrored the external auricle. On the opposite ear both the cases presented with preauricular skin tag. Surgical correction was done by dissecting the skin free from the duplicated cartilage via an incision along the free edge of the helix the duplicated cartilage was contoured to fill the pre-tragal hollow and the tragus reconstructed with a free cartilage graft.

Is Ba3In2O6a high-Tcsuperconductor?

It has been suggested that Ba3In2O6might be a high-Tcsuperconductor. Experimental investigation of the properties of Ba3In2O6was long inhibited by its instability in air. Recently epitaxial Ba3In2O6with a protective capping layer was demonstrated, which finally allows its electronic characterization. The optical bandgap of Ba3In2O6is determined to be 2.99 eV in-the (001) plane and 2.83 eV along thec-axis direction by spectroscopic ellipsometry. First-principles calculations were carried out, yielding a result in good agreement with the experimental value. Various dopants were explored to induce (super-)conductivity in this otherwise insulating material. NeitherA- norB-site doping proved successful. The underlying reason is predominately the formation of oxygen interstitials as revealed by scanning transmission electron microscopy and first-principles calculations. Additional efforts to induce superconductivity were investigated, including surface alkali doping, optical pumping, and hydrogen reduction. To probe liquid-ion gating, Ba3In2O6was successfully grown epitaxially on an epitaxial SrRuO3bottom electrode. So far none of these efforts induced superconductivity in Ba3In2O6,leaving the answer to the initial question of whether Ba3In2O6is a high-Tcsuperconductor to be 'no' thus far.

An investigation into the potential for upward range expansion in high-montane species on the roof of the world.

Climate warming is occurring in high-mountain areas at a faster rate than the global average. To escape the increasing temperatures, alpine species may shift in distribution upwards, threatening cold-adapted nival plant specialists. However, little is known about the success of seedling emergence and establishment at high altitudes outside the current range, particularly in the highest mountain areas of the Himalayas. We selected four native alpine species occurring around 4000 m a.s.l. and sowed seeds at the natural growing site (GS), at a high elevation site (HS; 5000 m a.s.l.) and at high elevation with soil from the growing site (HS-S) in the Khumbu Valley, north-eastern Nepal. We monitored seedling emergence and establishment for two consecutive years. Seedling emergence and establishment varied between species. Emergence was similar between GS and HS and improved at HS-S. Establishment was low at high elevations with all but one species having high mortality after winter. Seedling emergence of low elevation plants is possible at high elevations in the Everest region, indicating species may be able to shift their distribution range upwards. However, successful establishment may be limited by the soil and high winter mortality at high elevations, although not in all species. Climate warming will potentially lead to upward migration of some Himalayan plant species, leading to altered community composition in high-mountain areas.

Alarm Fatigue among Nurses Working in Critical Care Setting in a Tertiary Hospital, Nepal.

Background Alarm fatigue is a well-recognized patient safety concern in critical care settings. It occurs when nurses become overwhelmed by the total number of alarm signals which can result in alarm desensitization and eventually contributes to missing of serious and important changes in a patient's condition, thus failing to respond properly. Objective To find out alarm fatigue and its associated factors among nurses working in critical care setting. Method A cross-sectional study design with convenient sampling technique was used to select 56 nurses working at different critical care settings in Dhulikhel Hospital. A selfconstructed semi structured questionnaire and nurses alarm fatigue questionnaire was used for the survey. Frequency, percentage, mean and standard deviation were used for descriptive statistics whereas Independent t-test and One-way ANOVA were used for inferential statistics. Result The result shows that more than half of the nurses were less than 25 years, single and more than two-third of the participants worked in Adult Intensive Care Unit. Out of total obtainable score 44, the overall mean score of the Alarm Fatigue was 28.03±12.813. The result showed that there was no significant difference between alarm fatigue and selected socio-demographic and work related characteristics. Conclusion The alarm fatigue among nurses working in critical care settings was found to be higher in this study. Since alarm fatigue is directly related to patients' safety, the effective management of medical device alarms can reduce alarm fatigue and prevent potentially dangerous outcomes.

Huge Lipoma of Left Parotid Region with Intra-Parotid Extension.

Lipoma is a benign mesenchymal tumor originating from adipose tissue. The occurrence of this tumor in head and neck is less frequent and it rarely involves parotid gland. These are asymptomatic and occur both in the deep and the superficial lobe of the parotid. The most favored age group is from the fifth to sixth decade of life and is 10 times more common in the males. A 66-year-old male patient, with left parotid region lipoma is reported in this article. A fine-needle aspiration biopsy and ultrasonography were performed to establish the preoperative diagnosis and to plan the correct surgical approach. It was managed by surgical excision of lipoma with removal of cuff of superficial parotid tissue on superior aspect with preserving facial nerve. Follow-up examinations were planned to assess any facial nerve injury complications.

Phenotypic and functional characterisation of synovial fluid-derived neutrophils in knee osteoarthritis and knee infection.

OBJECTIVE: An increase in the number of neutrophils (NEUs) has long been associated with infections in the knee joints; however, their impact on knee osteoarthritis (KOA) pathophysiology remains largely unexplored. DESIGN: This study compared the phenotypic and functional characteristics of synovial fluid (SF)-derived NEUs in KOA and knee infection (INF). RESULTS: KOA NEUs were characterised by a lower expression of CD11b, CD54, and CD64 and higher expression of CD62L, TLR2, and TLR4 compared with INF NEUs. Except for CCL2, lower levels of inflammatory mediators and proteases were detected in KOA SF than in INF SF. Functionally, KOA NEUs displayed increased reactive oxygen species production and phagocytic activity compared with INF NEUs. Moreover, KOA and INF NEUs differed in cell sizes, histological characteristics of the surrounding synovial tissues, and their effects on the endothelial cells assessed by human umbilical vein endothelial cells. When KOA patients were subdivided based on the SF NEU abundance, patients with high NEUs (10%-60%) were characterised by i) elevated SF protein levels of TNF-α, IL-1RA, MMP-9, sTREM-1, VILIP-1 and ii) lower CD54, CD64, TLR2 and TLR4 expression compared to patients with low NEUs (<10%). Analysis of paired SF samples suggests that low or high NEU percentages, respectively, persist throughout the course of disease. CONCLUSIONS: Our findings suggest that NEU may play a significant role in KOA pathophysiology. Further studies should explore the mechanisms that contribute to the increased number of NEUs in SF and the clinical consequences of neutrophilic phenotype in KOA.

In search of lost ergots: phylogenetic re-evaluation of Claviceps species in Japan and their biogeographic patterns revealed.

Claviceps (Clavicipitaceae, Hypocreales) was erected in 1853, although ergotism had been well-known for a much longer time. By 2000, about 70 taxa had been described in Claviceps, of which eight species and six varieties were based on Japanese type or authentic specimens. Most of these Japanese Claviceps taxa are based on lost specimens or have invalid names, which means many species practically exist only in the scientific literature. The ambiguous identities of these species have hindered taxonomic resolution of the genus Claviceps. Consequently, we sought and collected more than 300 fresh specimens in search of the lost Japanese ergots. Multilocus phylogenetic analyses based on DNA sequences from LSU, TEF-1α, TUB2, Mcm7, and RPB2 revealed the phylogenetic relationships between the Japanese specimens and known Claviceps spp., as well as the presence of biogeographic patterns. Based on the phylogenetic analysis, host range and morphology, we re-evaluated Japanese Claviceps and recognised at least 21 species in Japan. Here we characterised 14 previously described taxa and designated neo-, lecto- and epi-types for C. bothriochloae, C. imperatae, C. litoralis, C. microspora, C. panicoidearum and C. yanagawaensis. Two varieties were elevated to species rank with designated neotypes, i.e. C. agropyri and C. kawatanii. Six new species, C. miscanthicola, C. oplismeni, C. palustris, C. phragmitis, C. sasae and C. tandae were proposed and described. Taxonomic novelties: New species: Claviceps miscanthicola E. Tanaka, Claviceps oplismeni E. Tanaka, Claviceps palustris E. Tanaka, Claviceps phragmitis E. Tanaka, Claviceps sasae E. Tanaka, Claviceps tandae E. Tanaka; New status and combination: Claviceps agropyri (Tanda) E. Tanaka, Claviceps kawatanii (Tanda) E. Tanaka; Typifications (basionyms): Lecto- and epitypification: Claviceps yanagawaensis Togashi; Neotypifications: Claviceps purpurea var. agropyri Tanda, Claviceps bothriochloae Tanda & Y. Muray, Claviceps imperatae Tanda & Kawat., Claviceps microspora var. kawatanii Tanda, Claviceps litoralis Kawat., Claviceps microspora Tanda, Claviceps panicoidearum Tanda & Y. Harada; Resurrection: Claviceps queenslandica Langdon. Citation: Tanaka E, Tanada K, Hosoe T, Shrestha B, Kolarík M, Liu M (2023). In search of lost ergots: phylogenetic re-evaluation of Claviceps species in Japan and their biogeographic patterns revealed. Studies in Mycology 106: 1-39. doi: 10.3114/sim.2022.106.01.

Outcomes of Laparoscopic Cholecystectomy in a Tertiary Hospital in Nepal.

Background Laparoscopic Cholecystectomy (LC) is the gold-standard surgery for symptomatic cholelithiasis with low mortality and morbidity. Objective The main objective of this study is to study the outcomes of laparoscopic cholecystectomy in Dhulikhel Hospital over the period of seven years. Method The records of all the patients who underwent laparoscopic cholecystectomy in Dhulikhel Hospital from January 1, 2015, to December 31, 2021 were reviewed. Patient demographics, indication of surgery, hospital stay, and number of conversions to open cholecystectomy were collected. The percentage, mean and median were calculated for socio-demographic information and Chi-square test was performed to measure the association between socio-demographic characteristics, duration of hospital stay, and operative procedure. Result Out of 2106 patients who underwent laparoscopic cholecystectomy from January 1, 2015, to December 31, 2021, 584 (27.73%) were male, and 1522 (72.27%) were female. The female-to-male ratio was 2.6:1. The median age of the patients was 40 years (IQR=52-30). Most common indications for surgery were symptomatic cholelithiasis in 1740 (82.62%) patients along with chronic cholecystitis in 268 (12.73%) patients, and Post ERCP Cholecystectomy in 92 (4.37%) patients. Median hospital stay was three days. Out of 2106 cases, 24 cases were converted to open cholecystectomy. Conclusion Laparoscopic cholecystectomy is the gold standard treatment for benign diseases of the gallbladder and can be performed safely as day care surgery to reduce the cost, length of hospital stay, and long waiting list in low and middle-income countries.

Medical Students' Perception towards Online Education at Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.

Background Online education has gained popularity in various fields, including medicine, owing to its flexibility and time-saving advantages. The COVID-19 pandemic has further accelerated its adoption as an alternative to traditional in-person learning. Medical students appreciate the ability to study at their own pace, access resources remotely, and engage in virtual collaboration and networking. Objective The objective of this study was to determine the perception of online education among medical students. Method A cross-sectional descriptive study was conducted at Kathmandu University School of Medical Sciences (KUSMS), Nepal, comprising 332 participants. A Google Form questionnaire was used to assess their perceptions and responses deliberated on a three-point Likert scale. Descriptive analysis was used to determine the respondents' views. Result The results showed that a significant majority (64.8%) of the respondents agreed that accessing the internet for online education was easy. However, only 35.5% felt comfortable attending online lectures at home. Regarding the effectiveness of online learning, the majority (66.3%) disagreed that it was similar to traditional classroom lectures. More than half (51.5%) of the respondents agreed that online classes were time-consuming and (71%) required breaks during sessions. Surprisingly, only 27% expressed a preference for online education. Additionally, a notable proportion (87%) disagreed that online education could provide similar real-world skills. Moreover, the majority (85%) disagreed that conducting exams for theoretical and practical/clinical courses virtually was possible. Conclusion Despite the availability of internet access for the majority of students, a significant proportion expressed discomfort with online education. Only a quarter preferred it, and many disagreed that it could replicate the traditional classroom experience or provide comparable skills. Training all faculties, providing high-speed internet, improving student interaction, and giving online demonstrations can enhance student preferences and online quality.

Endoscopic Transcanal Atticoplasty: How we do it?

Endoscopic otological surgery has revolutionized ear surgery. Endoscopes are frequently used in myringoplasty and tympanoplasty, and their use in attic reconstruction (atticoplasty) is gaining popularity. While microscopic surgery for limited attic cholesteatoma and attic retraction (grade III and IV) is difficult especially anterior area, the endoscope has emerged as a new treatment option, offering a 360-degree view of the attic and facilitating the complete removal of diseased tissue.1 We had performed atticoplasty with rigid nasal endoscopes (Karl Storz) of 4 mm diameter and 18-cm length. Our preliminary results showed that transcanal endoscopic atticoplasty is a reliable and safe technique for the surgical management either attic retraction pocket (grade III or IV) or limited attic cholesteatoma.

Inverted Papilloma: A Practical Approach to Diagnosis, Management, and Current Controversies.

Inverted papilloma (IP) is an uncommon sinonasal malignancy primarily affecting middle-aged adults. It is characterized by locally aggressive behavior, a high recurrence rate, and a concerning potential for malignant transformation. The etiology of inverted papilloma remains unclear, although human papillomavirus (HPV) infection has been implicated in up to 40% of cases. Surgical intervention is the mainstay of treatment, with the approach (endoscopic versus external) dictated by the extent and characteristics of the tumor. Rigorous follow-up is mandatory to ensure early detection of local recurrence, which can manifest early or with a delayed presentation.

Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis.

Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton's duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton's duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton's duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy.

Comparison of Surgical Outcome of Bipolar Scissors with Conventional Cold Dissection Tonsillectomy.

Background The tonsillectomy is the most common Ear, Nose, and Throat (ENT) surgical procedure. Different methods have been used to improve the outcome of the surgery. One such method is tonsillectomy performed with bipolar scissors. In our scenario, the comparison of bipolar scissors tonsillectomy with conventional cold dissection has not been done. Objective To compare the surgical outcomes of bipolar scissors tonsillectomy and conventional cold dissection tonsillectomy. Method A prospective randomized study was conducted in 40 patients who underwent tonsillectomy on one side using bipolar scissors and on the other side using conventional cold dissection. Intraoperative blood loss, operation time, postoperative pain, and postoperative hemorrhage were all analyzed in both surgical techniques. Result The median operative time was 10 minutes for bipolar scissors compared with 12 minutes for conventional cold dissection, with a p-value of 0.390 which was not statistically significant. The median blood loss was 48 mL on the bipolar scissors side and 60 mL on the conventional cold dissection side, with a p-value of 0.232 which was also not statistically significant. The overall postoperative hemorrhage rate was 12.5%. Of these, 4 (10%) occurred on the bipolar scissors side (left side mainly) and 1 (2.5%) on the conventional cold dissection side (also left side), with a p-value of 0.002 which was statistically significant. There was no statistically significant difference in the pain scores between the two methods in both rest and swallowing (p > 0.05). Conclusion The bipolar scissors did not show any benefit over conventional cold dissection in terms of surgical time, intraoperative blood loss, or postoperative pain. However, postoperative hemorrhage was more common with bipolar scissors. Therefore, conventional cold dissection remains a safe technique for tonsillectomy in adult patients.

Laryngeal Paraganglioma - A Rare Entity.

Laryngeal paragangliomas are neural crest derived rare neuroendocrine tumors which originates from either superior or inferior laryngeal paraganglia. It arises most commonly in supraglottis with mean age of 44 years and it is three times more common in females. This is a case of 39 years female who underwent endoscopic debulking and excision of tumor for histopathological examination which proved to be poorly differentiated squamous cell carcinoma and received a cycle of chemotherapy that probably resulted in complete resolution of initial mass which was confirmed in subsequent follow up. Futher immunohistochemistry examination diagnosed the case as Laryngeal paraganglioma. With this consideration, how effective is the role of chemotherapy in the management of proven case of Laryngeal paragangliomas?