Stereotactic Radiosurgery and Radiotherapy for Vestibular Schwannoma in NF2-Related Schwannomatosis

OBJECTIVES

To determine the long-term control rates and hearing outcomes for growing vestibular schwannoma in NF2-related schwannomatosis (NF2) treated with stereotactic radiosurgery (SRS) and fractionated radiotherapy (FRT).

METHODS

Retrospective review of all patients treated with SRS/FRT between 1986 and2021 from a tertiary NF2 unit. Overall tumor control was defined as: (1) growth control (growth failure was defined as growth in any dimension of 3 millimetres or more from baseline post-SRS/FRT), and (2) treatment control (no need for further intervention). Loss of serviceable hearing was defined as a drop in speech discrimination score below 50% after SRS/FRT.

RESULTS

There were 81 cases, with a mean duration of follow-up of 125 months. Overall control rate was 72% (58/81), with 80% (65/81) growth control and 74% (60/81) treatment control. There was a 5-year actuarial survival of 77% and 10-year survival of 71%. Forty-three percent (30/69) of cases did not have serviceable hearing at baseline. Of those remaining, 49% (19/39) preserved serviceable hearing during follow-up at a mean of 106 months. Actuarial survival for preservation of serviceable hearing at 5 and 10 years was 69% and 53%. There were poorer outcomes with increasing genetic severity, and with baseline tumor size >3 cm. No cases of SRS/FRT-related malignancy were identified at a mean follow-up of 10 years.

CONCLUSION

Stereotactic radiosurgery/fractionated radiotherapy are an effective option to treat growing vestibular schwannoma in patients with NF2 with the potential for hearing preservation in a proportion of patients.

LEVEL OF EVIDENCE

4-Case Series Laryngoscope, 134:2364-2371, 2024.

Assessing the risk of magnetic interaction between auditory implants and programmable ventriculoperitoneal shunts

PURPOSE

This study investigated whether the magnetic field of the internal magnet of cochlear implants and bone-anchored hearing aids (BAHA) would be sufficient to affect a programmable ventriculoperitoneal (VP) shunt. Current guidelines suggest against implanting these hearing devices ipsilateral to a programmable VP shunt, but the exact nature of the interaction has not been quantified.

METHODS

The magnetic field strength (mT) was measured at 0 and 10 mm from the edge of both the Cochlear Implant CI512 (Cochlear Corporation) magnet and BAHA Attract magnet. Next, the hearing devices were placed into their anatomical positions in a 3-D clay model, along with three different types of programmable VP shunts. The valve setting was measured before and after exposure.

RESULTS

At 10 mm, neither device generated a magnetic field sufficient to adjust the VP shunt valve. In the clay model, the valve settings were not affected by the presence of any device.

CONCLUSION

Neither the cochlear implant nor the BAHA subcutaneous internal magnets generated sufficient magnetic field to reprogramme the valves of commonly used programmable VP shunts. The magnetic field from each device decreases dramatically at 10 mm. Further clinical studies to help mitigate the current restrictive guidance should consider involvement of VP shunt manufacturers to inform future shunt development and design.

Snapping Sartorius tendon due to a medial knee ganglion: an unusual cause of medial knee pain

Snapping of knee could be due to plethora of causes. We describe a case of snapping of Sartorius over a medial knee ganglion that was treated successfully by ultrasound guided aspiration with complete resolution of symptoms.

357 Improving Surgical Consent – A Quality Improvement Project to Enhance the Consenting Process

Introduction

RCS guidelines on consent, recently updated, encourage a dialogue where all risks material to that patient are discussed and are clear. An audit was performed to assess whether practice at Oxford Hospitals is compliant with these guidelines – that all patients for elective surgery are consented prior to admission.

Method

Thirty-two undergoing elective Functional Endoscopic Sinus Surgery (FESS), Tonsillectomy and Septoplasty were interviewed in May-June 2019. Baseline data were presented at a local educational meeting, along with education on the recent changes to the RCS guidelines. Repeat audit took place in August-September 2020.

Results

All 32 patients were consented as per RCS guidelines and understood the reason for their surgery, but only 31% could explain the risks, and 56% could explain alternative options. Twenty (63%) consent forms were easily legible on randomised heuristic assessment. After education and change in department practice, understanding of the operation was much improved (80-100%). One outcome was to create pre-filled consent forms for common ENT operations.

Conclusions

Whilst RCS policy on completing consent prior to admission is being achieved, patient interviews suggest a lack of understanding of the operation. Standardised consent forms have the potential to enhance this understanding, as well as saving time.

P64 Improving surgical consent – a quality improvement project to enhance the consenting process

Introduction

RCS guidelines on consent, recently updated, encourage a dialogue where all risks material to that patient are discussed and are clear. An audit was performed to assess whether practice at Oxford Hospitals is compliant with these guidelines – that all patients for elective surgery are consented prior to admission.

Method

Thirty-two undergoing elective Functional Endoscopic Sinus Surgery (FESS), Tonsillectomy and Septoplasty were interviewed in May-June 2019. Baseline data were presented at a local educational meeting, along with education on the recent changes to the RCS guidelines. Repeat audit took place in August-September 2020.

Results

All 32 patients were consented as per RCS guidelines and understood the reason for their surgery, but only 31% could explain the risks, and 56% could explain alternative options. Twenty (63%) consent forms were easily legible on randomised heuristic assessment. After education and change in department practice, understanding of the operation was much improved (80-100%). One outcome was to create pre-filled consent forms for common ENT operations.

Conclusions

Whilst RCS policy on completing consent prior to admission is being achieved, patient interviews suggest a lack of understanding of the operation. Standardised consent forms have the potential to enhance this understanding, as well as saving time.

Identification of methylation changes associated with positive and negative growth deviance in Gambian infants using a targeted methyl sequencing approach of genomic DNA

Low birthweight and reduced height gain during infancy (stunting) may arise at least in part from adverse early life environments that trigger epigenetic reprogramming that may favor survival. We examined differential DNA methylation patterns using targeted methyl sequencing of regions regulating gene activity in groups of rural Gambian infants: (a) low and high birthweight (DNA from cord blood (n = 16 and n = 20, respectively), from placental trophoblast tissue (n = 21 and n = 20, respectively), and DNA from peripheral blood collected from infants at 12 months of age (n = 23 and n = 17, respectively)), and, (b) the top 10% showing rapid postnatal length gain (high, n = 20) and the bottom 10% showing slow postnatal length gain (low, n = 20) based on z score change between birth and 12 months of age (LAZ) (DNA from peripheral blood collected from infants at 12 months of age). Using BiSeq analysis to identify significant methylation marks, for birthweight, four differentially methylated regions (DMRs) were identified in trophoblast DNA, compared to 68 DMRs in cord blood DNA, and 54 DMRs in 12‐month peripheral blood DNA. Twenty‐five DMRs were observed to be associated with high and low length for age (LAZ) at 12 months. With the exception of five loci (associated with two different genes), there was no overlap between these groups of methylation marks. Of the 194 CpG methylation marks contained within DMRs, 106 were located to defined gene regulatory elements (promoters, CTCF‐binding sites, transcription factor‐binding sites, and enhancers), 58 to gene bodies (introns or exons), and 30 to intergenic DNA. Distinct methylation patterns associated with birthweight between comparison groups were observed in DNA collected at birth (at the end of intrauterine growth window) compared to those established by 12 months (near the infancy/childhood growth transition). The longitudinal differences in methylation patterns may arise from methylation adjustments, changes in cellular composition of blood or both that continue during the critical postnatal growth period, and in response to early nutritional and infectious environmental exposures with impacts on growth and longer‐term health outcomes.

Intrasynovial spindle cell lipoma of the deep flexor of the middle finger causing intermittent carpal tunnel syndrome-case report and review of the literature

Carpal tunnel syndrome (CTS) represents the most common entrapment neuropathy of the upper extremity. Intermittent CTS has been reported in the surgical literature and usually, related to masses associated to flexor tendons. We describe a patient with an intrasynovial lipoma involving the deep flexor of the middle finger causing intermittent CTS and snapping on flexion-extension.

Posterior Fossa Hypervascular Tumour Embolisation

Hemangioblastomas are histologically benign tumours that comprise 7–12% of all posterior fossa lesions. Treatment of these lesions is often complicated by the significant vascularity of the tumour and the difficult surgical resection in the sensitive neural tissue. In such situations, preoperative embolisation facilitates surgery by not only decreasing the intraoperative blood loss, but also by decreasing the total operative time and allowing a near complete resection of the tumour. Though infrequent, fatal complications can occur during preoperative embolisation procedures. We report two such cases in which the tumour bled during the procedure. In both cases, this was effectively managed by arterial pedicle occlusion with NBCA (N-Butyl Cyano acrylate). The early detection, immediate control and the possible causes of this complication is presented.

Awareness and knowledge of cervical cancer and its prevention among the nursing staff of a tertiary health institute in Ahmedabad, Gujarat, India

BACKGROUND

Carcinoma of the cervix is the second most common cancer in women worldwide, while it is the commonest cancer among Indian women. Awareness regarding cervical cancer and its prevention is quite low amongst Indian women. The Pap test is a simple and cost effective technique for early diagnosis of cervical cancer. It is necessary to make nursing staff aware of cervical cancer, so that they can impart knowledge regarding cervical cancer and its prevention to the general public.

AIMS AND OBJECTIVES

(1) To assess the knowledge level regarding symptoms, risk factors, prevention and screening of cervical carcinoma among nursing staff. (2) To find out the behaviour of respondents regarding prevention and screening of cervical carcinoma.

MATERIALS AND METHODS

A cross-sectional interview-based survey regarding knowledge levels about cervical carcinoma was conducted among the nursing staff from one of the tertiary health institutes of Ahmedabad, India. A structured questionnaire with multiple choices was used for data collection. Provision for open-ended responses was also made in the questionnaire. Department-wise stratification was carried out, and thereafter 15% of the total nursing staff from all departments were selected randomly so as to include a total of 100 nurses in the current study. Data entry was done in Microsoft Excel. SPSS statistical software was used to generate statistical parameters like proportion, mean, standard deviation, etc. The Z test was used as a test of significance, and a P value of <0.05 was considered as the level of significance.

Effects of co-exposure of benzene, toluene and xylene to Drosophila melanogaster: alteration in hsp70, hsp60, hsp83, hsp26, ROS generation and oxidative stress markers

Benzene, toluene and xylene are monocyclic aromatic hydrocarbon compounds, used both as individual compound and as mixtures, in industry as well as household. Previous studies involving exposures to these compounds, individually, have shown that benzene was more toxic compared to toluene or xylene. Here, we tested a working hypothesis that toluene and/or xylene in a mixture containing benzene affect benzene induced toxicity in a non-target organism, Drosophila melanogaster. We exposed D. melanogaster larvae transgenic for hsp70, hsp83 or hsp26 and wild type (Oregon R strain) larvae to 25.0-100.0mM benzene, 25.0-100.0mM toluene and 25.0-100mM xylene, individually or in mixtures. Subsequently, we examined the expression of stress genes (encoding heat shock proteins, hsps), generation of reactive oxygen species (ROS), induction of anti-oxidant stress markers and emergence of flies under treatment as well as control conditions. We observed that all these endpoints were significantly altered in all the treatment groups compared to their respective controls. However, the magnitude of toxicity of a benzene-toluene (BT) or benzene-xylene (BX) or benzene-toluene-xylene (BTX) mixture was significantly lower in the organism than that of individual chemical. Our results also show the modulation of toluene toxicity by xylene. Present study suggests antagonistic effect of xylene and toluene on benzene toxicity and additive/synergistic effect of xylene on toluene induced toxicity. Thus, expression of stress genes may be used as an assay for detection of early cellular toxicity. Further, our study supports the use of Drosophila as an alternative animal model for first tier screening of adverse effects of chemical mixtures.

Poly I:C induced microglial activation impairs motor activity in adult rats

Polyinosinic:polycytidic acid (poly I:C) is a synthetic double stranded RNA, which mimics with viral genome and mediates immune activation response similar to double stranded RNA virus infection into the brain. Microglial cells are the immune competent cells of the central nervous system having Toll like receptors-3 on their surface. Upon establishing that poly I:C infusion into the brain causes microgliosis by creating a viral infection model, the present study was designed to evaluate the effects of microglial activation following poly I:C infusion on motor activity. We infused 100 microl of 1% solution of Poly I:C in TBE buffer directly into the lateral ventricle and TBE buffer as vehicle to controls. A significantly higher microglial cell count as compared to control on 2, 3 and 7 days post infusion was recorded. Motor activity and microglial cell count was assessed in both controls and poly I:C infused rats on 1, 2, 3, 7, 14, 21 and 28 days post infusion. A significant decrease in motor activity and motor coordination occurred with respect to control. The results clearly demonstrate that microglial activation has a direct relevance with decreased motor activity. Findings could also have their importance in understanding the role of microglial cells on behavioral aspects in viral diseases.

Internal iliac artery ligation for arresting postpartum haemorrhage

OBJECTIVE

To study the role of internal iliac artery ligation (IIAL) in arresting and preventing postpartum haemorrhage (PPH).

DESIGN

Retrospective chart review of women undergoing therapeutic IIAL for PPH or prophylactic IIAL for risk of PPH.

SETTING

Tertiary care hospital in Pune, India.

SAMPLE

Women admitted to King Edward Memorial (KEM) Hospital, Pune, India, who underwent IIAL to control or prevent PPH.

METHODS

Bilateral IIAL was performed in all women.

MAIN OUTCOME MEASURES

Need for re-laparotomy or hysterectomy to control haemorrhage, complications of the procedure.

RESULTS

Out of 110 women who underwent IIAL, 88 had therapeutic IIAL for PPH from atony (36), genital tract injury (23), placenta praevia (21), placental abruption (4), uterine inversion (3) or coagulopathy (1). Hysterectomy was performed after IIAL failed to arrest haemorrhage in 33 (39.3%) of 84 women (excluding 4 with vaginal lacerations). Hysterectomy was more likely with uterine rupture (79%) than with nontraumatic PPH (up to 27%). Failure to control haemorrhage by IIAL was evident immediately, and bleeding arrested by IIAL did not recur to require later laparotomy in any woman. Out of 22 women at high risk for PPH undergoing prophylactic IIAL at caesarean section, none had subsequent haemorrhage. One woman had an iliac vein injury that was repaired with no further morbidity. There were no ischaemic complications either during inpatient stay or up to 6 weeks.

CONCLUSIONS

IIAL is useful in the treatment and prevention of PPH from any cause. Early resort to IIAL effectively prevents hysterectomy in women with atonic PPH. In traumatic PPH, IIAL facilitates hysterectomy or repair as indicated and prevents reactionary haemorrhage.

Heparin or local thrombolysis in the management of cerebral venous sinus thrombosis?

SUMMARY

Patients with acute cerebral venous sinus thrombosis treated with Heparin or in situ thrombolysis in our department were evaluated in an attempt to rationalize treatment with heparin or thrombolysis. 279 patients with angiographically proven acute cerebral venous sinus thrombosis were included in the study. Patients were classified into mild and severe clinical grade. The study was divided into three phases. Phase I included 27 patients treated with systemic heparin. Phase II included 72 patients, 30 in severe grade and 42 in mild. 26 were thrombolysed with 14 in severe and 12 in mild grade. Phase III included 180 patients treated according to a defined protocol. 133 were in mild grade and 47 in severe. 67 patients were thrombolysed. In the thrombolysed group 27 patients were in mild grade and 40 in severe. 113 patients were treated with systemic heparin. Following acute management all were anticoagulated for six months. The baseline characteristics were found to be same in all three phases. On comparison of outcome in Phase III with Phase 1 the likelihood ratio was found to be statistically significant in favor of Phase III (p<0.0001). The likelihood ratio was found to be statistically significant in mild and severe clinical grade in favor of thrombolysis in Phase III (p 0.039 in mild and p 0.00001 in Severe clinical grade). This ratio was insignificant (p=0.716) for intracranial bleed; however, local puncture site bleeding was found to be significant in the thrombolysed group (0.00005).

Inferior petrosal sinus sampling in the diagnostic evaluation of Cushing's syndrome: K.E.M. experience

INTRODUCTION

An overlap in the clinical and biochemical features of the more common pituitary Cushing's disease and the rare ectopic ACTH secreting tumors often leads to a diagnostic dilemma. High quality computed imaging modalities have a poor sensitivity and do not always help in localising the tumor. Inferior petrosal sinus sampling (IPSS) with measurement of ACTH levels localizes the source of excess ACTH secretion and aids in the differential diagnosis of ACTH dependant Cushing's syndrome.

AIMS AND OBJECTIVES

To analyze the efficacy of inferior petrosal sinus sampling in the basal state and its role in the diagnostic evaluation in patients of Cushing's syndrome.

MATERIAL AND METHODS

Forty four patients of proven Cushing's syndrome underwent HDDS and pituitary imaging followed by IPSS (unstimulated). The data was analysed in 39 patients with definite histopathological diagnosis which included 34 patients with Cushing's disease, four with ectopic Cushing's syndrome and one with adrenal carcinoma. A centre:periphery ratio of plasma ACTH levels of > or =2 was considered diagnostic of Cushing's disease.

RESULTS

Cannulation rate was 100%. No neurological complications were encountered. IPSS could correctly localize the lesion in 23 of 34 patients of Cushing's disease (sensitivity: 67.6%). All patients of ectopic Cushing's syndrome and adrenal carcinoma had a ratio of <2 (specificity: 100%). IPSS helped in localization of the lesion and improved the diagnostic yield from 26.7% to 73.5%.

CONCLUSIONS

IPSS helps in localization in patients of Cushing's syndrome with a diagnostic dilemma and should be carried out only in centers with suitable expertise.

Pharmacokinetic study of 11-Keto beta-Boswellic acid

INTRODUCTION

Boswellia serrata has been used in traditional medicine for treatment of inflammatory diseases since antiquity. However human kinetic studies are lacking for this. Hence to better elucidate its effects in humans and determine its optimal dosing, this study was planned.

MATERIAL AND METHODS

Twelve healthy adult men volunteers were given capsule Wok Vel containing 333 mg of Boswellia Serrata Extract, orally, after a seven days washout period. Venous blood samples were drawn through indwelling canula from each volunteer prior to drug administration and at 30, 60, 120, 150, 180, 210, 240, 300, 360, 480, 600, 720, 840 minutes after drug administration. Plasma obtained after centrifuge was analyzed to measure concentration of 11-Keto beta-Boswellic Acid (KBA) by HPLC. Various kinetic parameters were then calculated from the plasma concentrations.

RESULTS

The results are expressed as mean +/- Standard Error of Mean. The peak plasma levels (2.72 x 10(-3) +/- 0.18 micromoles/ml) of BSE were reached at 4.5 +/- 0.55 h. The concentration declined with a mean elimination half life of 5.97 +/- 0.95 h. The apparent volume of distribution averaged 142.87 +/- 22.78 L and the plasma clearance was 296.10 +/- 24.09 ml/min. The AUC(0-infinity) was 27.33 x 10(-3) +/- 1.99 micromoles/ml h.

CONCLUSION

Elimination half life of nearly six hours suggests that the drug needs to be given orally at the interval of six hours. The plasma concentration will attain the steady state after approximately 30 hours. BSE is a safe drug and well tolerated on oral administration. No adverse effects were seen with this drug when administered as single dose in 333 mg.

Digestive enzymes in the gut and salivary gland of the larvae of Chilo auricilius Ddgn

Amylase, alpha- and beta-glucosidase, alpha- and beta-galactosidase, beta-fructosidase, trypsin, aminotripeptidase, leucine-aminopeptidase, prolinase, prolidase glycyl-L-leucine dipeptidase and glygylglycine dipeptidase are present in the 3rd instar larvae of Chilo auricilius.