Combined supratentorial and infratentorial approach to large pineal-region meningioma

Our case report is used to describe a combined supratentorial and infratentorial approach to a giant pineal-region meningioma. The procedure involves section of the less dominent transverse sinus and the tentorium. After the cerebellum and the occipital lobe are retracted away from each other, the operative procedure is carried out. The brain stem and the large veins of this region are better exposed with minimal retraction of the cerebellum and occipital lobe. The transverse sinus is resutured at the end of the procedure to reestablish the blood circulation. The operative procedure is ideal for extensive lesions in the pineal region, providing wide and direct exposure.

Brain abscess caused by Cladosporium trichoides

Brain abscess caused by the fungus Cladosporium trichoides is rare. Only 20 cases of brain abscess caused by this fungus are reported in the literature. We report a case of brain abscess caused by Cladosporium trichoides in a healthy adult male. The relevant literature on this subject is reviewed.

Clinical implications of acute cerebrospinal fluid changes following iophendylate myelography

Clinical features and serial cerebrospinal fluid (CSF) samples of 50 patients who underwent myelography with iophendylate were studied. Forty two patients (84%) developed one or more features suggestive of meningism lasting for 2-4 days. There was significant rise in the average (mean) CSF counts from 9.81 in the premyelogram sample to 532.6 at the end of 24 hours (p less than 0.001). Both neutrophil and lymphocyte (p less than 000) count increased. At the end of one week, there was significant decrease of total cells in the CSF to 204 (p less than 0.001). Both, neutrophils and lymphocytes decreased. There was significant rise in total proteins in the 24 hours sample, but the fall at one week was not significant statistically. The sugar and chloride values did not change significantly. All CSF samples were negative for bacterial cultures. In conclusion, a significant proportion of the patients undergoing iophendylate myelography develop clinical features suggestive of meningeal irritation and change in the CSF fractions suggestive of meningitis: however these changes are transient and do not warrant institution of chemotherapy or steroids.

'Tenting' stitches for the scalp

A subgaleal collection of blood or cerebrospinal fluid (CSF) is commonly encountered after craniotomy. In spite of the placement of subgaleal drains by many neurosurgeons, a collection at this site is frequent and occasionally can result in complications. 'Tenting' scalp stitches are described. Three to four (or more) stitches are inserted between the galea and the pericranium or between the pericranium and the craniotomy flap at the end of the surgical procedure. This simple manoeuvre was seen significantly to reduce collections in these spaces. To our knowledge, this technique has not been reported in the neurosurgical literature, and we strongly advocate its use.

Role of corticosteroids in the management of chronic obstructive lung disease: factors predicting response

A double-blind crossover trial of prednisolone was conducted in 70 patients of chronic obstructive lung disease (COLD). Emphysema dominated the clinical picture in 38, rest being chronic bronchitis with varying degrees of air trapping. None of the patients had clinical asthma. All the patients had obtained maximal benefit from an optimal dose of bronchodilators prior to entering the study. Prednisolone in a dose of 0.8 mg/kg was prescribed in a double blind crossover manner with identical appearing placebo tablets. Patients were evaluated on a weekly basis for an objective as well as a subjective response and side effects of therapy. Thirty-four patients demonstrated a statistically significant improvement in pulmonary functions. In 20 others only subjective response was observed. A good objective response was predicted by a pre-study variability in FEV1, disease duration of less than 10 years and a history of smoking less than 50 pack years.

Anomalous subarcuate loop. Technical note

An anomalous subarcuate loop of the anterior inferior cerebellar artery is described in which the artery is adherent to or penetrates the posterior fossa dura in the subarcuate fossa. When encountered during acoustic neurilemoma surgery, the artery should be carefully mobilized along with a sleeve of dura to prevent its injury.

Intracranial haemorrhage and death after iohexol myelography

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Safety and efficacy of unguided trans thoracic fine needle aspiration biopsy (FNAB) in outdoor patients

We studied the safety and efficacy of unguided transthoracic fine needle aspiration biopsy (FNAB) in peripheral lung lesions in an outpatient setting in 62 patients. The diagnostic yield of unguided aspiration was 67.7 per cent. Smaller lesions usually required guided FNAB. Specific tissue diagnosis was obtained in all cases aspirated successfully. Complications were seen in 7 patients (pneumothorax in 4 and haemoptysis in 3 patients). With careful patient selection, unguided FNAB can be an effective out-patient procedure for diagnosing lung lesion beyond the reach of the fiberoptic bronchoscope.

Interleukin 6 response factor binds co-operatively at two adjacent sites in the promoter upstream region of the rat alpha 2-macroglobulin gene

Transcription of the alpha 2-macroglobulin gene (alpha 2M) in rat hepatocytes is strongly induced during acute inflammations by interleukin 6 (IL6). An IL6-response region has previously been mapped in the promoter upstream sequence of this gene. The region consists of two adjacent elements (IL6-REs), the IL6-RE core (CTGGGAA, -164 to -158 bp) and the core homology (CTGGAAA, -184 to -178 bp), elements, that are located 20 bp apart. Both elements bind nuclear factors with very similar protein-DNA contact patterns when they are contained in their original sequence context. A protein-DNA complex III was obtained in gel mobility shift experiments using a probe individually representing the core site. With probes containing both the core and core homology sites, a hormone inducible complex II of slower mobility was obtained. Complex II consisted of multiple copies of the same protein or proteins with very similar molecular masses bound at both sites. The core homology site was the weaker binding site. With a probe containing two tandem copies of the core site, binding at the second site occurred with 81 times greater affinity when the first site was occupied, than when it was free. Thus, the factor binding at the IL6-REs, the IL6-RE binding protein (IL6 RE-BP), was capable of co-operatively interacting with itself. Another factor, IL6-DBP/LAP, has recently been shown to be involved in the regulation of a major subgroup of acute phase genes by IL6. Using recombinant IL6-DBP/LAP and corresponding antisera, we demonstrated here that the IL6 RE-BP of the alpha 2M gene was distinct from IL6-DBP/LAP and from the related factor DBP. Thus, two major IL6-response elements can be distinguished: type 1 elements occurring in the human C-reactive protein, hemopexin and haptoglobin genes and utilizing IL6-DBP/LAP; and type 2 elements occurring in the rat alpha 2M, and alpha 1-acid glycoprotein genes, and utilizing a different IL6 RE-BP. The IL6 RE-BP of the alpha 2M gene was also shown to be distinct from the transcription factor NF kappa B. The IL6RE-BP had relative molecular mass of Mr = 46,000, distinct from IL6-DBP/LAP (Mr = 32,000) and NF kappa B (Mr = 50,000) and its overall DNA binding capacity was induced under acute phase conditions.

Role of serial pleural biopsies in the diagnosis of pleural effusions

One hundred fifty-five cases of pleural effusion underwent a percutaneous pleural biopsy by the Cope needle. In the face of an inconclusive result in the first attempt, biopsy was repeated for upto three times. Diagnostic yields of biopsy in tuberculous and malignant effusion were 93.5 per cent and 66.7 per cent, respectively. When combined with pleural fluid cytology, a definite diagnosis of malignancy could be established in 80.95 per cent cases. Serial pleural biopsies significantly increased the diagnostic yield.

Heterotopic bone formation after hip replacement. The influence of the type of osteoarthritis

The relationship between heterotopic bone formation and the morphological type of osteoarthritis was examined after 43 hip replacements. Of the 43 hips studied, nine were atrophic, 19 were normotrophic, and 15 were hypertrophic. The incidence of heterotopic bone formation in the atrophic type was 11%, in the normotrophic type 32%, and in the hypertrophic type 87%. The difference between each type was statistically significant (p less than 0.001).

Efficacy of adenosine deaminase in the diagnosis of pleural effusions

Adenosine deaminase (ADA) activity was studied in 53 patients with pleural effusions. Patients with tuberculous pleural effusion (36) had significantly higher ADA activity (77.68 IU/L; P less than 0.001) in comparison to malignant (14.47 IU/L) and parapneumonic (28.65 IU/L) effusions. When tested with a reference limit of over 50.75 IU/L, the specificity of ADA activity was found to be 94.1 per cent. With a sensitivity of 100 per cent, low cost and easy performance pleural fluid ADA activity is proposed as a routine investigation for etiological diagnosis in pleural effusion.

Whither short-course chemotherapy for tuberculous meningitis?

Short-course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease. We present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years. Short-term therapy was associated with recrudescence of tuberculous meningitis and, in some cases, with the development of deep cerebral infarcts and permanent neurological deficits. We think short-term chemotherapy for tuberculosis of the central nervous system is inadequate.

Cryptogenic hemoptysis: role of fiberoptic bronchoscopy

Fiberoptic bronchoscopy (FOB) was performed for recurrent hemoptysis in 79 patients with normal chest roentgenograms. Seventy per cent were females with a mean age of 31.93 years. Normal findings were obtained in 60 patients. In 19 patients with abnormal findings on bronchoscopy underlying malignant disease was discovered in 3 patients following bronchoscopy. All these patients were elderly male smokers. In three patients unexplained left recurrent laryngeal nerve palsy was discovered. Thus, FOB as a diagnostic aid for cryptogenic hemoptysis is useful only in elderly male smokers.

Clinical and roentgenological profiles and etiological correlations of encysted pleural effusions

One hundred and thirty-six cases of encysted pleural effusions were studied and investigated to reach an etiological diagnosis. The clinical profile of encysted pleural effusions differed little from that of free pleural effusions. Of the four sites of encystments seen (costoparietal, interlobar, subpulmonic, and mediastinal), costoparietal effusions were the commonest and resulted most often from infections. Interlobar encystments came next in frequency and most often resulted from congestive cardiac failure. Of the various causes of encysted pleural effusions, tuberculosis was the commonest, followed by pyogenic infection and congestive cardiac failure, in this order. Conventional radiographic techniques were adequate in diagnosing most cases of encysted pleural effusions.

Intracranial ectopic pituitary tumour

Pituitary tumours originating primarily from sites other than the sella turcica are rare. A case of an ectopic pituitary tumour in the region of the lesser wing of the sphenoid is reported. The patient presented with signs and symptoms of a progressive increase in intracranial pressure. CT scan appearances resembled those of a sphenoid wing meningioma. The vascular lesion was partially excised. Histology showed it to be a pituitary tumour.

Review of a liver transplantation programme

Liver transplantation is now a routine operation in specialist centres. The author reviews the programme of a pioneering unit in Pittsburgh, USA, which he observed during an elective.

Cerebellopontine angle epidermoid cysts: a report on 30 cases

Thirty cases of cerebellopontine angle epidermoid cysts treated over a period of 20 years are reviewed with regard to their clinical features, the pathophysiology of their symptoms and their management. The predominating symptoms were related to the 7th and 8th cranial nerves and headaches. The signs and symptoms were present for an average period of 4 months. It was not always possible to determine if the signs and symptoms were due to local involvement by the epidermoid, increased intracranial pressure, or both. Diagnostic procedures evolved from angiography and ventriculography to non-invasive computed tomography and MRI. The posterior cranial fossa approach was used in 27 cases. Total excision of the epidermoid was the aim and was carried out in five (18%) patients but concern regarding the preservation of nearby important neurovascular structures forced partial removal in 22 patients. To minimise reformation, the residual epidermoid was carefully coagulated with the aid of the operating microscope and bipolar cautery without damaging surrounding neurovascular structures.

Transposable element-mediated enhancement of gene expression in Saccharomyces cerevisiae involves sequence-specific binding of a trans-acting factor

In our studies on the regulation of adjacent-gene expression by Ty sequences, we demonstrated that a single-base-pair change (T-A----C-G) in the epsilon sequence of Ty917-derived elements is primarily responsible for enhancement of beta-galactosidase expression from lacZ fusion plasmids. Using an electrophoretic gel mobility assay, we showed that the same base pair transition is required for binding of a trans-acting factor, TyBF, from crude cell extracts in vitro. We identified the site of TyBF binding and determined the guanine nucleotide contact sites required for TyBF interaction. We propose that TyBF binding to cis-acting Ty2 sequences activates adjacent-gene transcription.

Bacteriocin (klebocin) typing of clinical isolates of Klebsiella pneumoniae

Three-hundred-forty-two clinical isolates of Klebsiella pneumoniae were subjected to bacteriocin (klebocin) typing using six standard klebocin-producer strains (153-158). The overall typability was 72.8 per cent. The predominant klebocin types found were 244 (14.3 per cent), 313 (13.7 per cent) and 113 (7.6 per cent). Klebocin types 314 and 111 each contributed 5.2 per cent to the total number of isolates. No significant correlation was observed between the source of isolation and the klebocin type.

D-penicillamine-induced acute hypersensitivity pneumonitis and cholestatic hepatitis in a patient with rheumatoid arthritis

Acute hypersensitivity pneumonitis is not a known side effect of D-penicillamine. Also, there are only a few reports of cholestatic hepatitis caused by this drug. The present report describes a case of rheumatoid arthritis where these manifestations appeared in the same patient ten days after the institution of D-penicillamine therapy. The etiological relationship with the drug was established, inadvertantly, by its accidental intake by the patient 5 months later with the reproduction of the same manifestations.

Variation in the relationship between serum and saliva lithium levels

This study has been carried out to find out the reasons for the wide variations observed in the correlation between serum and saliva lithium levels. Serum/saliva lithium levels were monitored in 10 individuals on 6 occasions. The correlation coefficient (r) varied within individuals from 0.19 to 0.91 (p less than 0.025) whereas when all the individuals were considered simultaneously, it was 0.59 (p less than 0.005). It was concluded that prediction of serum lithium levels from salivary lithium levels would only be possible in those individuals showing good correlation. The variability in this correlation could be mainly due to inter-individual variations in the particular sample of individuals studied.

Saliva lithium levels for monitoring lithium prophylaxis of manic depressive psychosis

The usefulness of salivary lithium values for monitoring long-term lithium prophylaxis was studied in 60 patients on lithium therapy. A total of 99 pairs of saliva and serum samples were obtained, and the correlation between serum and salivary lithium levels (r = 0.73) was found to be significant at the 1% level. The ratio of salivary serum levels to that of serum was found to range from 1.77 to 6.68. The ratio of 51% of the samples was between 3 and 3.99. It is therefore suggested that it is important to identify the subgroup of patients who show better correlation of salivary and serum lithium levels and use each individual's ratio to monitor only his lithium therapy.