Pediatric epidural tumors of the spine--experience of a decade from the Kashmir Valley

We present our experience after analyzing retrospectively the clinicopathological characteristics, surgical approaches, immediate and long-term postoperative complications and survival outcome of pediatric spinal epidural tumors treated over a period of 10 years from 2000 to 2009 in a tertiary-care hospital. Our study included benign and malignant tumors. The majority of our patients were boys (14:8). The duration of symptoms was longer in benign lesions. Non-Hodgkin's lymphoma was the commonest malignant tumor and aneurysmal bone cyst was the commonest benign tumor. The mean duration of follow-up was 19 months (range 3-48 months). Most of the patients improved in their neurological grade after surgery; however, the degree of excision had no bearing on the length of survival for malignant lesions.

Immunoglobulin G4-associated cholangitis mimicking cholangiocarcinoma in a young boy

Autoimmune pancreatitis is a rare form of chronic pancreatitis, which commonly mimics pancreatic carcinoma. Immunoglobulin G4-associated cholangitis (IAC) is a rare type of autoimmune pancreatitis associated with bile duct involvement, which can present with or without pancreatic involvement. Usually, the bile duct involvement is in the form of multiple intra-and extra-hepatic strictures mimicking primary sclerosing cholangitis. Rarely, there can be an isolated stricture which mimics cholangiocarcinoma. Differentiating these from cholangiocarcinoma, though extremely difficult, is of critical importance since it can be treated without surgical intervention. Most cases with rare presentation mimicking cholangiocarcinoma have been reported in elderly patients. We present one such rare presentation of autoimmune pancreatitis in a young 13-year-old patient in whom hepaticojejunostomy was done for a hilar stricture, which later turned out to be related to IAC. To our knowledge this is the first reported case of its kind from India.

Fermentor temperature as a tool for control of high-density perfusion cultures of mammalian cells

Temperature is a key environmental variable whose potential in animal cell fermentor optimization is not yet fully utilized. The scarce literature data suggests that reduced fermentor temperature results in an improved viability and shear resistance, higher cell density and titer in batch cultures, and reduction in glucose/lactate metabolism. Due to the arrest of the cells in the G1 phase, the specific growth rate was found to decrease at temperatures below 37.0 degrees C. The response of the specific production rate was cell line dependent: in some cases it increased 2-to-3-fold, but decreased in other cases. The controlable slowdown of cell metabolism at lower temperature can be used in optimization of perfusion mammalian cell cultures with several potential advantages, including higher cell density in oxygen limited reactors, lower perfusion rate, improved product quality, simplified pH control, and others. To evaluate this strategy, a series of long-term experiments in 15 L perfusion bioreactors culturing recombinant hamster cells at 20.0 x 10(6) cells/mL were conducted. The temperature was changed over a range of set points, and maintained at each of these for a long period of time. Steady state process data was collected and analyzed. The effect of temperature on the following characteristics of the perfusion process was studied: cell growth, glucose/lactate metabolism, glutamine/ammonia metabolism, cell respiration, cell density at constant oxygen transfer rate, proteolytic activity, and product quality (glycosylation and molecule fragmentation). The results suggest that temperature is a variable with a significant potential in optimization of perfusion cultures. Properly selected temperature set point will contribute to the overall improvement of process performance. (c) 1997 John Wiley & Sons, Inc. Biotechnol Bioeng 55: 328-338, 1997.

Twin to twin transfusion syndrome

Twin to twin transfusion syndrome (TTTS) is a specific condition complicating 10-15% of monochorionic multiple pregnancy. Intertwin vascular anastomoses and transfusion is a normal event. Syndrome develops when blood flow is unbalanced. Recent studies suggest a paucity of bi-directional superficial anastomoses failing to compensate for hemodynamic imbalance resulting from unidirectional transfusion along deeper arterio-venous anastomoses. TTTS is associated with high rates of perinatal mortality. Acute and chronic forms exist and severity varies. The donor twin is often smaller, hypovolemic, anemic and develops congestive heart failure. The recipient is usually heavier and polycythemic. Antenatally, second trimester ultrasound usually detects the condition. Serial amnioreduction is the recommended therapy. Postnatally, intertwin haemoglobin and birth weight differences along with pallor in one twin and plethora in the other are helpful in making a diagnosis. Medical care of twins after birth is directed towards problem related to anemia, polycythemia and hydrops. Review of the syndrome is presented with an illustrative case.

Outpatient continuous interscalene brachial plexus block in cancer-related pain

This case outlines the use of a continuous interscalene brachial plexus block to treat cancer-related pain. Using an elastomeric device, the patient's previously intractable pain was controlled and he was able to return home. Furthermore, the patient developed a pragmatic and effective method of balancing loss of power and sensation against pain control using the flow restrictor. This case illustrates the potential of an integrated approach to cancer pain management to obtain rapid pain relief in the acute hospital setting.

Pharmacotherapy for meconium aspiration

In this article we have attempted to review the current pharmacological treatment options for infants with meconium aspiration syndrome with or without persistent pulmonary hypertension. These treatments include ventilatory support, surfactant treatment and inhaled nitric oxide (INO), in addition to older and newer pharmacological treatments. These include sedatives, muscle relaxants, alkali infusion, antibiotics and the newer vasodilators. Many aspects of treatment, including ventilatory care, surfactant treatment and the use of INO, are reviewed in great detail in this issue. On the other hand, many newer pharmacological modalities of treatment described here have not been evaluated with randomized control trials. We have given an overview of these emerging therapies.

Stent graft exclusion of pseudo-aneurysm arising from PTFE hemodialysis graft after recurrence following ultrasound guided thrombin injection

There are various non-invasive or minimally invasive techniques for management of pseudoaneurysms including ultrasound guided compression, ultrasound guided thrombin injection and covered stent placement. We report a case where a covered stent graft was successfully used for the treatment of a pseudoaneurysm directly arising from a PTFE graft which recurred 3 months following treatment with ultrasound guided thrombin injection.

The typical appearance of the inferior accessory ossicle of the anterior arch of the atlas

The inferior accessory ossicle of the anterior arch of the atlas is quite rare and has been described in the literature by only few articles. However, these articles have only included plain radiographs in the description. In our case, the above ossicle is illustrated in two imaging modalities, plain radiography and CT imaging. The importance of this ossicle lies in its recognition as only an anatomical variant and not to be confused with other pathological conditions such as a fracture.

Endovascular repair of a ruptured mycotic aneurysm of the common iliac artery

This report describes the case of a ruptured mycotic aneurysm of the left common iliac artery, successfully treated with endovascular stent-grafting. A 64-year-old woman underwent diagnostic coronary angiography complicated by an infected hematoma of the left groin. Seven days later, she developed methicillin-resistant Staphylococcus aureus septicemia and CT scan evidence of perivascular inflammation around the left common iliac artery. This was followed by rupture of a mycotic aneurysm of the left common iliac artery. The lesion was successfully treated with a stent-graft and prolonged antibiotic therapy, and the patient remains free of infection 10 months later. Accumulating evidence suggests that endovascular repair can be used safely for the repair of ruptured infected aneurysms.

Effect of pioglitazone therapy in lean type 1 diabetes mellitus

OBJECTIVE

The beneficial effects of metformin in peripubertal adolescents and rosiglitazone in overweight type 1 diabetic subjects, though modest have been demonstrated. This study was designed to analyze the effect of pioglitazone as an adjunctive therapy in post-pubertal lean T1DM.

PATIENTS AND METHODS

Sixty type 1 diabetic subjects with duration of illness of a year or more with body mass index between 18 and 24.9 kg/m(2) were randomly assigned to receive either 30 mg pioglitazone or placebo once daily for 6 months. The study was double-blinded placebo controlled with 30 subjects in each group, matched for age, sex, anthropometric and metabolic parameters. At the end of the study period, plasma glucose levels, HbA(1c), lipids and insulin requirement were compared between the two groups.

RESULTS

A significant improvement in post-prandial plasma glucose (PPPG) levels (9.1+/-1.7 and 8.4+/-1.3 mmol/L, p=0.002) and HbA(1c) (7.08+/-0.48 and 6.86+/-0.45%, p=0.001) were observed in the pioglitazone treated group, but not in the placebo treated group (8.3+/-1.8 and 7.8+/-1.8 mmol/L, p=0.06 and HbA(1c) 7.3+/-0.37 and 7.24+/-0.33%, p=0.74, respectively). However, the mean decrease in PPPG and HbA(1c) levels between groups corrected for baseline values at the end of study was significant only for the later (HbA(1c) -0.22+/-0.29 and -0.06+/-0.49, p=0.03), while for the former, it got attenuated (PPPG -0.69+/-1.1 and -0.48+/-1.36, p=0.68). There was no alteration in body weight, body mass index, insulin requirement, blood pressure and lipid profile in both the groups at the end of the study.

CONCLUSION

Pioglitazone is modestly effective adjunct to insulin therapy in lean type 1 diabetic subjects. It improves post-prandial glucose levels and HbA(1c) without alterations in body weight and insulin requirement.

Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression

PURPOSE

To retrospectively evaluate the 10 year follow-up results in patients who had "kissing" self-expanding stent aortic bifurcation reconstruction.

METHODS

Forty-three patients were treated with "kissing" self-expanding stents for aortoiliac occlusive disease. Early follow-up with clinical and ankle brachial pressure indices (ABPI) was performed at 3, 6, 12, and 24 months and with intra-arterial digital subtraction angiography at 12-24 months; clinical and angiographic follow-up was performed for symptom recurrence up to 10 years after treatment. Retrospective record review was performed to assess mortality, clinical patency, angiographic patency, and secondary assisted patency of both stents and downstream peripheral vessels at 5 and 10 years follow-up.

RESULTS

The 2 year primary angiographic and secondary assisted stent patencies were 89% and 93%, respectively. At 10 years follow-up in 40 patients the mortality was 38% (due to myocardial infarction, stroke, chronic renal failure, malignancy, and liver failure). At 5 and 10 years follow-up the primary clinical stent patency was 82% and 68%, and the secondary assisted stent patency 93% and 86%, respectively. At 5 and 10 years, the distal vessel patency was 86% and 72%, and the secondary assisted distal vessel patency treated by surgical or endovascular techniques was 94% and 88%, respectively. At 10 years there was no limb loss.

CONCLUSION

The long-term (10 year) results of aortic bifurcation arterial self-expanding stent placement in patients with arterial occlusive disease show a 10 year primary stent patency rate of 68% but a secondary assisted patency rate of 86%. In addition there is a high overall mortality due to other cardiovascular causes and the rate of distal disease progression and loss of patency is similar to the loss of stent patency rate.

Accidental blood exposure: risk and prevention in interventional radiology

There is a growing concern about the transmission of bloodborne pathogens during medical procedures among health care workers and patients. Over the last three decades, radiological services have undergone many changes with the introduction of new modalities. One of these new disciplines is interventional radiology (IR) which deals with procedures such as arteriography, image-guided biopsies, intravascular catheter insertions, angioplasty and stent placements. Despite these developments, the potential for accidental blood exposure and exposure to other infectious material continues to exist. Therefore, it is important for all radiologists who perform invasive procedures to observe specific recommendations for infection control. In this review, we look at the different policies for protection and universal standards on infection control.

Precocious pseudopuberty with testicular enlargement

Gonadotropins independent precocious puberty (GIPP) in male is characterized by early appearance of sexual hairs and phallic growth but without testicular enlargement. We report a case of GIPP with testicular enlargement who was diagnosed to have testotoxicosis and successfully managed with spironolactone.

Ichthyosis follicularis, alopecia and photophobia (IFAP) syndrome treated with acitretin

We describe a 3-year-old male patient with the ichthyosis follicularis, alopecia and photophobia (IFAP) syndrome, who developed cutaneous and ocular involvement in infancy. In addition, he had growth retardation and borderline intelligence; no other systemic involvement was found on detailed investigation. A moderate response to acitretin therapy (1 mg/kg) administered for 6 months was observed, with improvement in cutaneous features and corneal erosions and no change in alopecia or photophobia.

Diminished lung function, RSV infection, and respiratory morbidity in prematurely born infants

BACKGROUND

Diminished lung function appears to be a risk factor for respiratory syncytial virus (RSV) infection/bronchiolitis in term born infants.

AIMS

To determine if diminished lung function prior to neonatal unit discharge was associated with subsequent symptomatic RSV lower respiratory tract infection (LRTI) and respiratory morbidity in prematurely born infants.

METHODS

Of 39 infants in a tertiary neonatal intensive care unit (median gestational age 28 weeks, range 23-31), 20 had bronchopulmonary dysplasia. Lung function (compliance and resistance of the respiratory system (C(rs) and R(rs)) and functional residual capacity (FRC)) was measured on the neonatal unit at 36 weeks postmenstrual age (PMA). Following neonatal unit discharge, nasopharyngeal aspirates were obtained on every occasion, at home or in hospital, an infant had an LRTI. RSV was identified by immunofluorescence and/or culture.

RESULTS

The 15 infants who suffered a symptomatic RSV LRTI had a higher mean R(rs) and suffered more wheeze at follow up than the rest of the cohort. Regression analysis showed that a high R(rs) was significantly associated with a symptomatic RSV LRTI; significant factors for cough were a high R(rs) and a symptomatic RSV LRTI, and for wheeze were a high R(rs).

CONCLUSION

Prematurely born infants, who had a symptomatic RSV LRTI and/or respiratory morbidity at follow up, had worse lung function prior to neonatal unit discharge.

Characterization of serine/cysteine protease inhibitor α1-antitripsin from meconium-instilled rabbit lungs

We have recently purified from meconium-instilled rabbit lungs a novel serine proteinase inhibitor, with an apparent molecular mass of 50 kDa, which we assign to be alpha1-antitripsin. We hypothesize that serpin may attenuate pulmonary inflammation and improve surfactant function after meconium aspiration. Alpha1-antitripsin is a member of the proteinase inhibitor (serpin) superfamily and inhibitor of neutrophil elastase, and it can be identified as a member of the family by its amino acid sequence due to the high degree of conserved residues. Alpha1-antitripsin is synthesized by epithelial cells, macrophages, monocytes, and neutrophils. Deficiency in alpha1-antitripsin leads to exposure of lungs to uncontrolled proteolytic attack from neutrophil elastase or other damaging factors culminating in lung destruction and cell apoptosis. We hypothesize that accumulation of alpha1-antitripsin in the lungs serves as a predisposed protection against meconium-induced lung injury. In this paper, we show how this knowledge can lead to the development of novel therapeutic approaches for treatment of MAS.

GSK-3beta inhibition reverses axonal transport defects and behavioural phenotypes in Drosophila

The tauopathies are a group of disorders characterised by aggregation of the microtubule-associated protein tau and include Alzheimer's disease (AD) and the fronto-temporal dementias (FTD). We have used Drosophila to analyse how tau abnormalities cause neurodegeneration. By selectively co-expressing wild-type human tau (0N3R isoform) and a GFP vesicle marker in motorneurons, we examined the consequences of tau overexpression on axonal transport in vivo. The results show that overexpression of tau disrupts axonal transport causing vesicle aggregation and this is associated with loss of locomotor function. All these effects occur without neuron death. Co-expression of constitutively active glycogen-synthase kinase-3beta (GSK-3beta) enhances and two GSK-3beta inhibitors, lithium and AR-A014418, reverse both the axon transport and locomotor phenotypes, suggesting that the pathological effects of tau are phosphorylation dependent. These data show that tau abnormalities significantly disrupt neuronal function, in a phosphorylation-dependent manner, before the classical pathological hallmarks are evident and also suggest that the inhibition of GSK-3beta might have potential therapeutic benefits in tauopathies.