Spine revisited: principles and parlance redefined

A revised appreciation of the evolution and the nature of bone in general and of vertebrae in particular, allows revisiting the human spine to usher in some new principles and more rational parlance, that embody spine's phylogeny, ontogeny, anatomy and physiology. Such an approach accords primacy to spine's soft-tissues, and relegates to its bones a secondary place.

Ocular side effects of antitubercular drugs - a focus on prevention, early detection and management

Given the increasing prevalence of tuberculosis, antitubercular drugs frequently used are also associated with ocular toxicity. Ethambutol is the most commonly implicated drug. It is generally well tolerated, but known to cause optic neuritis, more specifically retro bulbar neuritis causing blurred vision, decreased visual acuity, central scotomas, and loss of red-green color vision. The exact mechanism of toxicity is not understood. Though optic neuritis due to ethmabutol is generally considered to be reversible upon prompt discontinuation of the drug, there are reports of reversible toxicity, particularly in the elderly population. Isoniazid can rarely cause retro bulbar neuritis. Dose relationship is usually not seen. Streptomycin is known to cause pseudo tumorcerebri. Thiacetazone can produce severe cutaneous reactions including Steven Johnson Syndrome affecting the skin and mucosa including conjunctiva. Educating the patients for early detection of the ocular manifestations and regular follow-ups are very essential.

Hemicraniectomy for large middle cerebral artery territory infarction: outcome in 19 patients

BACKGROUND

Large space-occupying middle cerebral artery infarction accounts for 10-15% of all supratentorial infarctions and carries a mortality of 50% to 80%. Hemicraniectomy may be useful when optimal medical management has failed.

METHODS

Between June 1997 and June 2000, 19 patients who fulfilled the clinical and imaging criteria for large middle cerebral artery infarction underwent hemicraniectomy because of impending herniation despite best medical therapy. The National Institute of Health Stroke Scale (NIHSS) assessed neurological status on admission and at one week after surgery. At 3 month follow up, The Barthel Index (BI) and Rankin Scale (RS) were used to assess the functional outcome among survivors.

RESULTS

There were 15 males and 4 females with a mean age of 46.5 years (range 27-76 years). Ten patients (53%) had dominant hemisphere stroke. The mean interval between stroke onset and surgery was 60.3 hours (range 20-103 hours). The mean NIHSS score before surgery was 20.5 (range 17-26) and 10.5 (range 6-22) after surgery. One patient (5.2%) died due to post-operative meningitis. At follow up, mean BI was 56.4 (range 25-90) and RS revealed severe handicap in 4 patients (21%). Patients under 50 years of age had a significantly better outcome with mean BI of 60.7 as compared to only 41.3 (p=<0.048) in older patients. Speech function, especially comprehension improved in all patients with dominant hemisphere infarction.

CONCLUSION

These findings add to previous studies suggesting hemicraniectomy may be a useful procedure in patients with large middle cerebral artery territory infarction. The functional outcome is good in younger patients. A randomised controlled trial is required to substantiate these findings.

Proximal femoral reconstruction with custom mega prosthesis

Seventy-seven patients with proximal femoral tumours underwent limb salvage surgery with custom mega prostheses between July 1989 and January 2002. We describe 44 cases with a mean follow-up of 57.8 months. Forty-one patients presented with malignant neoplasms of which 11 were malignant giant cell tumours, eight were chondrosarcoma and five were metastases. Wide margins were achieved for all malignant tumours, and marginal resection was done for all benign and metastatic lesions. Six patients died of disease and two were lost to follow-up. Mechanical complications were observed in six cases, fracture being the most common. Oncological complications occurred in five patients. Functional activity was satisfactory in 79% of patients.

Protection against oxidative protein damage induced by metal-catalyzed reaction or alkylperoxyl radicals: comparative effects of melatonin and other antioxidants

Melatonin is a well-known hydroxyl radical (*OH) scavenger that protects DNA and lipids from free radical attack. In this paper, we studied the ability of melatonin to prevent oxidative damage to bovine serum albumin (BSA) induced by two different paradigms: the metal-catalyzed oxidation (MCO) induced by Cu(2+)/H(2)O(2) and the alkoxyl and alkylperoxyl radicals formed by the azo initiator 2,2'-azobis(2-amidinopropane) hydrochloride (AAPH, 40 mM). The protective effects of melatonin were compared with 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (trolox), glutathione (GSH), ascorbate, 3,4',5-trihydroxy-trans-stilbene (resveratrol, 0.1 microM-4 mM) and mannitol (50 microM-100 mM). Melatonin efficiently prevented protein modification induced by both models, as assayed by polyacrylamide gel electrophoresis and carbonyl content. Both trolox and ascorbate had an obvious pro-oxidant effect in the Cu(2+)/H(2)O(2) model, whereas both prevented BSA damage induced by AAPH. In the MCO model, the efficacy of GSH in terms of protein protection was higher than melatonin at relatively high concentrations (250 microM-4 mM); however, at lower concentrations (50-250 microM), the efficacy of melatonin was superior to GSH. D-Mannitol (50 microM-100 mM) and resveratrol did not protect BSA from the site-specific damage induced by Cu(2+)/H(2)O(2). On the other hand, the relative protective efficiency in the AAPH model was melatonin approximately trolox>GSH>ascorbate.

Non-Hodgkin's lymphoma of the brainstem with atrial septal mass

Simultaneous occurrence of cardiac and central nervous system tumors have been rarely reported. A 23 years male presented to us with right cerebello-pontine (CP) angle symptoms and signs. Cranial imaging showed a mass lesion in the right pons infiltrating into the right and middle cerebellar peduncles. There was also a cardiac-atrial septal mass. The brainstem lesion was found to be a non-Hodgkin's lymphoma where as the cardiac lesion was not accessible. Central nervous system lymphomas are reported rarely and the prognosis is poor. The chances of the cardiac lesion in this patient also being a lymphoma are high, as it was a infiltrative cardiac mass, infiltrating the atrial septum.

Major ion correlation in groundwater of Kancheepuram Region, South India

Groundwater samples were collected from both dugwells and borewells in an intensively irrigated area of Kancheepuram Taluk, Tamil Nadu. pH, EC and TDS of groundwater samples were measured in the site. The collected samples were analysed in the laboratory for Ca, Mg, Na, K, Cl, HCO3, CO3, SO4, NO3, P-PO4 and Si-SiO2. The results are used for inter elemental correlation analysis which indicates that most of the elements having good correlation. Piper Trilinear diagram is used to find out the hydrochemical type of groundwater which shows that most of them are CaHCO3 and the remaining are CaMgCl type. Hydrochemical characteristics of groundwater indicate that silicate weathering reaction is a probable source for high concentration of major ions.

Low levels of p53 mutations in Indian patients with osteosarcoma and the correlation with fluoride levels in bone

The pathogenesis of osteogenic sarcoma is not known. Recently, chronic fluoride exposure has been incriminated as having a possible etiologic role by causing a nonspecific osteoblast proliferation. We were interested in exploring the possible relationship between fluoride bone content and p53 mutations. We analyzed p53 mutations in various exons in tissue of osteosarcoma, and correlated the findings with the bone fluoride levels in Indian patients. We analyzed tissue samples from 20 osteosarcoma patients for possible genetic alterations including mutations, and we assessed the extent of fluoride accumulation in bone. Fragments displaying an altered electrophoretic mobility were confirmed as having mutated sequences. Mutation was observed in samples of two cases (10% incidence). Eighteen samples showed bone fluoride levels between 1000 and 27,000 ppm, whereas the 2 mutated samples showed fluoride levels of 64,000 and 89,000 ppm, respectively. The high levels of bone fluoride levels and the similarity of the mechanisms of action between fluoride-induced DNA damage and chemically-induced p53 mutations lead us to propose that high fluoride bone content might have been one of the major factors causing osteosarcoma.

Effect of melatonin on cell growth, metabolic activity, and cell cycle distribution

We have recently demonstrated that the pineal secretory product melatonin inhibits the key transcriptional regulator nuclear factor-kappa B (NF-kappa B). As the activation of NF-kappa B is known to regulate the expression of cellular genes associated with cell cycle progression, cell growth, and differentiation, we investigated the effect of melatonin treatment on several cellular processes. These include cell viability, metabolic activity, and cell cycle phase distribution. Human embryonic kidney (293S) cells were treated with melatonin at concentrations of 0.02, 0.2, or 2 mM. When cell viability was measured 24, 48, and 72 hr after continuous exposure to melatonin using the trypan blue dye exclusion method, no significant cell death was observed. Even after exposure to 2 mM melatonin for 72 hr, cell viability remained at 98%. In contrast, another antioxidant compound, pyrrolidine dithiocarbomate (PDTC), at a 2 mM concentration reduced cell viability to 80.7+/-2.1% as early as 24 hr compared with untreated controls (P<0.05). When the metabolic activity was determined at 24, 48, and 72 hr using the colorimetric MTT assay, no significant changes in metabolic activity were observed. Even if the cells were treated with 10 mM melatonin for 72 hr, the metabolic activity was similar to that of the control cells. When cell cycle analysis was performed by flow cytometry, no marked difference in cell cycle distribution was observed. Melatonin at a concentration of 2 mM, however, did slightly alter the cell cycle (percentage of S phase cells) at 48 hr. This study revealed that when 293S cells are treated with concentrations of melatonin up to 2 mM, no significant alterations in three important cellular functions occurred. Exogenously added melatonin appeared to have a limited influence on the normal functioning of the cells even when the exposure continued for 72 hr.

Antioxidant compounds interfere with the 3

Antioxidants are often added to culture media as cytoprotective agents. We examined the effects of antioxidants on the results and interpretation of the 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay for cell viability. Without cells, the thiol-containing antioxidant compounds beta-mercaptoethanol, dithiothreitol, pyrrolidine-dithiocarbamate, and N-acetyl-L-cysteine (acetylcysteine) reduced MTT tetrazolium salts to a blue formazan product in a dose-dependent manner. Addition of the compounds L-ascorbic acid and (+)-alpha-tocopherol acid succinate had different effects. In contrast, addition of the antioxidants N-acetyl-5-methoxytryptamine and (-)-2-oxo-4-thiazolidine carboxylic acid, which do not contain reactive thiol groups, did not result in the development of blue formazan product. These results showed that antioxidants, and potentially other chemotherapeutic compounds that contain free thiol groups or other reducing equivalents, readily reduce MTT to produce the blue formazan, irrespective of the viability of the cells present. This undescribed reaction can, therefore, significantly influence the results and interpretation of cell-viability experiments.

Circulating nucleic acids of Chlamydia pneumoniae and cytomegalovirus in patients undergoing coronary angiography

Peripheral blood mononuclear cells from 208 consecutive patients undergoing elective coronary angiography or angioplasty were collected before, immediately after, and 4 h after the procedure. Nucleic acids of Chlamydia pneumoniae and of cytomegalovirus (CMV) were detected by PCR and confirmed by hybridization. Circulating C. pneumoniae DNA was identified in 24 patients (11.5%) and was associated with current smoking (odds ratio [OR] = 4.5, 95% confidence interval [CI] = 1.6 to 12.2, P = 0.004) but not with arterial narrowing on coronary angiogram or with serological results positive for C. pneumoniae. Circulating CMV DNA was identified in 36 patients (17.3%) and was associated with anti-CMV immunoglobulin G (OR = 2.7, 95% CI = 1.2 to 6.3, P = 0.02) but not with angiographic arterial narrowing or with the need for revascularization. Neither C. pneumoniae nor CMV DNA detection increased after angioplasty, a procedure in which endothelium is disrupted. Larger prospective studies are needed to determine the prognostic significance of DNA detection.

Percutaneous trigeminal ganglion balloon compression: experience in 40 patients

Forty patients of trigeminal neuralgia were treated with percutaneous trigeminal ganglion balloon compression. Symptoms had been present since six months to twenty years. The age ranged between 23 years and 73 years. All the patients had immediate relief from pain. Two had already undergone trigeminal cistern rhizolysis. One patient had foramen ovale stenosis. After the procedure, all the patients had mild to moderate degree of ipsilateral facial sensory loss which included buccal mucosa and anterior 2/3rd of the tongue. Facial dysaesthesia (anaesthesia dolorosa) was seen in only one case, who had mild involvement lasting one week. Thirty patients had altered taste sensation, probably due to general somatic sensory loss. Five patients had herpes perioralis. In this study group, two patients had already undergone microvascular decompression. All the patients were followed for a period ranging from one to eighteen months. Balloon compression technique seems to be better than injection of alcohol, glycerol or radio frequency lesion. Recurrence of pain was noted in 3 patients after one year.

Sympathoexcitatory CVLM neurons mediate responses to caudal pressor area stimulation

Neurons in the caudal pressor area (CPA) are a source of tonic sympathoexcitation that is dependent on activation of cardiovascular sympathetic premotor neurons in the rostral ventrolateral medulla (RVLM). In the present study, we sought to clarify the mechanism through which CPA neurons elicit increases in RVLM neuronal discharge, vasoconstrictor sympathetic tone, and arterial pressure. In urethan-chloralose-anesthetized, paralyzed, and artificially ventilated rats, bilateral disinhibition of CPA with bicuculline (Bic) after bilateral disinhibition of caudal ventrolateral medulla (CVLM) caused increases in splanchnic sympathetic nerve activity (+277% control) and arterial pressure (+54 mmHg). Inhibition of CVLM neurons with muscimol abolished the pressor response to activation of CPA neurons, suggesting that neurons within CVLM mediate the excitatory responses from CPA. Disinhibition of CVLM and CPA with Bic enhanced the sympathoexcitatory responses to stimulation of CPA with DL-homocysteic acid, which were blocked by microinjections of kynurenic acid into CVLM. We conclude that the pathway from CPA to RVLM involves an obligatory glutamatergic activation of sympathoexcitatory neurons in the vicinity of CVLM.

Chemotherapy trial in paucibacillary leprosy using clofazimine

In a double blind study, 300 PB patients (smear negative, indeterminate, tuberculoid and borderline tuberculoid) were randomly allotted to two regimens, the control subjects (150 patients) receiving the standard WHO multidrug regimen of six doses of once a month rifampicin with daily dapsone therapy for six months, while the study group (150 patients) receiving 50 mg of clofazimine daily for six months in addition to the WHO regimen. After stoppage of therapy all the patients were followed up on placebo. The regimens were well tolerated. In 7.5% of patients on clofazimine containing regimen, the lesions showed persisting activity at the time of stoppage of therapy, compared with 16% on the control regimen. This activity subsided spontaneously, more rapidly, in the study group (80% compared with 30% in the control group) in six months. Two patients in the control group and one patient in the study group developed late reaction. There were no relapses in the study group, whereas, two patients have relapsed in the control group during a follow-up of 2.5 to 3.5 years.

Nocturnal and daytime panic attacks--comparison of sleep architecture, heart rate variability, and response to sodium lactate challenge

BACKGROUND

The purpose of this study was to determine if nocturnal panic patients have greater autonomic dysregulation than patients with daytime panic.

METHODS

Three groups were studied: patients who suffer from panic attacks during sleep (n = 12), those who suffer from daytime panic attacks only (n = 12), and control subjects (n = 12). Each subject underwent 24-hour holter monitoring for heart rate variability (HRV), an overnight sleep recording, and sodium lactate challenge during wakefulness.

RESULTS

There was a marked subjective response to the sodium lactate challenge in the panic disorder (PD) patients but not in control subjects. Each group showed changes in HRV in response to sodium lactate challenge. The decrease in HRV measures was more marked in PD patients as a whole than in control subjects. During non-rapid eye movement (REM) sleep the value for total power (TP) was significantly higher in the nocturnal panic patients. The PD patients as a whole had higher values for TP and low-frequency (LF) power during REM sleep than control subjects. There were no significant differences between the two PD groups in sleep architecture. The PD patients as a whole had lower sleep efficiency and less stage 4 sleep than control subjects.

CONCLUSIONS

These findings indicate that there are substantial differences between PD and control subjects in autonomic regulation and that there are small differences between patients with daytime panic attacks and those with sleep-related panic attacks.

Adrenal epinephrine secretion is not regulated by sympathoinhibitory neurons in the caudal ventrolateral medulla

By providing the principal inhibitory regulation of the discharge of sympathetic premotor neurons in the rostral ventrolateral medulla (RVLM), neurons in the caudal ventrolateral medulla (CVLM) play a major role in regulating the level of sympathetic nerve activity (SNA) to cardiovascular targets. To determine whether adrenal medullary secretion of epinephrine (EPI) is also regulated by sympathoinhibitory inputs from the CVLM to the RVLM, we compared levels of plasma EPI obtained after disinhibition of RVLM neurons with levels obtained after inhibition of CVLM neurons, both of which result in sustained elevations in arterial blood pressure (AP), SNA, and heart rate (HR). Plasma norepinephrine (NE) concentrations were significantly elevated following bilateral microinjection either of bicuculline (BIC) into the RVLM or of muscimol into the CVLM of urethane/chloralose-anesthetized, artificially-ventilated rats. In sharp contrast, although plasma EPI concentrations were significantly elevated following disinhibition of neurons in the RVLM, they were unchanged by inhibition of neurons in the CVLM. These results demonstrate that the discharge of sympathetic premotor neurons in the RVLM regulating adrenal secretion of EPI is modulated by a tonic, GABA-ergic inhibition that arises from a source that is different from the sympathoinhibitory neurons in the CVLM that project to RVLM sympathetic premotor neurons controlling vasoconstrictor and cardiac targets.

Viability determination of M.leprae: comparison of normal mouse foot pad and bacillary ATP bioluminescence assay

Correlation between viability assessment by mouse foot pad and ATP bioluminescence was studied in biopsy specimens from multibacillary leprosy cases. Biopsies were processed for inoculation into mouse foot pad and estimation of bacillary ATP levels by bioluminescent assay by earlier established procedures. ATP content as pg/million bacilli was estimated and correlation was assessed with growth in the mouse foot pad. It was observed that when the ATP content was > 36 pg/million bacterial cells, (> 1% probable viables) there was growth in the mouse foot pad from all the specimens. Similar results were observed when the ATP content was in the range of 3.6 to 35.99 pg/million cells (0.1 to 1% probable viables). The positivity rates in the mouse foot pad decreased when the ATP content decreased further. No positive growth in the specimens below 0.04 pg/million bacilli (< 0.001% viable organisms) was observed. These findings show an overall correlation between viability assessed by mouse foot pad and ATP bioluminescence. These observations validate the concept of ATP content of viable unit of M.leprae being in the order of 10(-15) g/live cell which is in the same order of magnitude as a colony forming unit of cultivable mycobacteria.