Impact of COVID-19 lockdown on the atmospheric boundary layer and instability process over Indian region

The abrupt reduction in the human activities during the first lockdown of the COVID-19 pandemic created unprecedented changes in the background atmospheric conditions. Several studies reported the anthropogenic and air quality changes observed during the lockdown. However, no attempts are made to investigate the lockdown effects on the Atmospheric Boundary Layer (ABL) and background instability processes. In this study, we assess the lockdown impacts on the ABL altitude and instability parameters (Convective Available Potential Energy (CAPE) and Convective Inhibition Energy (CINE)) using WRF model simulations. Results showed a unique footprint of COVID-19 lockdown in all these parameters. Increase in the visibility, surface temperature and wind speed and decrease in relative humidity during the lockdown is noticed. However, these responses are not uniform throughout India and are significant in the inland compared to the coastal regions. The spatial variation of temperature (wind speed) and relative humidity shows an increase and decrease over the Indo Gangetic Plain (IGP) and central parts of India by 20% (100%) and 40%, respectively. Increase (80%) in the ABL altitude is larger over the IGP and central parts of India during lockdown of 2020 compared to similar time period in 2015-2019. This increase is attributed to the stronger insolation due to absence of anthropogenic activity and other background conditions. At the same time, CAPE decreased by 98% in the IGP and central parts of India, where it shows an increase in other parts of India. A prominent strengthening of CINE in the IGP and a weakening elsewhere is also noticed. These changes in CAPE and CINE are mainly attributed to the dearth of saturation in lower troposphere levels, which prevented the development of strong adiabatic ascent during the lockdown. These results provide a comprehensive observation and model-based insight for lockdown induced changes in the meteorological and thermo-dynamical parameters.

The structure-function analysis of Obg-like GTPase proteins along the evolutionary tree from bacteria to humans

Obg proteins belong to P-loop guanine triphosphatase (GTPase) that are conserved from bacteria to humans. Like other GTPases, Obg cycles between guanine triphosphate (GTP) bound "on" state and guanine diphosphate (GDP)-bound "off" state, thereby controlling various cellular processes. Different members of this group have unique structural characteristics; a conserved glycine-rich N-terminal domain known as obg fold, a central conserved nucleotide binding domain, and a less conserved C-terminal domain of other functions. Obg is a ribosome dependent GTPase helps in ribosome maturation by interacting with several proteins of the 50S subunit of the ribosome. Obg proteins have been widely considered as a regulator of cellular functions, helping in DNA replication, cell division. Apart from that, this protein also takes part in various stress adaptation pathways like a stringent response, sporulation, and general stress response. In this particular review, the structural features of ObgE have been highlighted and how the structure plays important role in interacting with regulators like GTP, ppGpp that are crucial for executing biological function has been orchestrated. In particular, we believe that Obg-like proteins can provide a link between different global pathways that are necessary for fine-tuning cellular processes to maintain the cellular energy status.

Effect of external volume expansion on the survival of fat grafts

Introduction:

External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear.

Aims and Objectives:

This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat.

Materials and Methods:

Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat.

Results:

All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention.

Conclusions:

A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.

First two bilateral hand transplantations in India (Part 2): Technical details

Introduction:

This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream.

Materials and Methods:

The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient.

Results:

The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines.

Conclusions:

Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring

Introduction:

Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'.

Materials and Methods:

Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy.

Results:

Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately.

Discussion:

Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well.

Conclusion:

A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

First two bilateral hand transplantations in India (Part 1): From vision to reality

Introduction

Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015.

Materials and Methods

The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services.

Results

Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines.

Conclusions

The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome

Introduction

This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India.

Materials and Methods

The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year.

Results

Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand.

Conclusion

Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.

Historical and Projected Surface Temperature over India during the 20th and 21st century

Surface Temperature (ST) over India has increased by ~0.055 K/decade during 1860-2005 and follows the global warming trend. Here, the natural and external forcings (e.g., natural and anthropogenic) responsible for ST variability are studied from Coupled Model Inter-comparison phase 5 (CMIP5) models during the 20th century and projections during the 21st century along with seasonal variability. Greenhouse Gases (GHG) and Land Use (LU) are the major factors that gave rise to warming during the 20th century. Anthropogenic Aerosols (AA) have slowed down the warming rate. The CMIP5 projection over India shows a sharp increase in ST under Representative Concentration Pathways (RCP) 8.5 where it reaches a maximum of 5 K by the end of the 21st century. Under RCP2.6 emission scenarios, ST increases up to the year 2050 and decreases afterwards. The seasonal variability of ST during the 21st century shows significant increase during summer. Analysis of rare heat and cold events for 2080-2099 relative to a base period of 1986-2006 under RCP8.5 scenarios reveals that both are likely to increase substantially. However, by controlling the regional AA and LU change in India, a reduction in further warming over India region might be achieved.

Elevated NEFA levels impair glucose effectiveness by increasing net hepatic glycogenolysis

AIMS/HYPOTHESIS

Acute hyperglycaemia rapidly suppresses endogenous glucose production (EGP) in non-diabetic individuals, mainly by inhibiting glycogenolysis. Loss of this 'glucose effectiveness' contributes to fasting hyperglycaemia in type 2 diabetes. Elevated NEFA levels characteristic of type 2 diabetes impair glucose effectiveness, although the mechanism is not fully understood. Therefore we examined the impact of increasing NEFA levels on the ability of hyperglycaemia to regulate pathways of EGP.

METHODS

We performed 4 h 'pancreatic clamp' studies (somatostatin; basal glucagon/growth hormone/insulin) in seven non-diabetic individuals. Glucose fluxes (D-[6,6-(2)H(2)]glucose) and hepatic glycogen concentrations ((13)C magnetic resonance spectroscopy) were quantified under three conditions: euglycaemia, hyperglycaemia and hyperglycaemia with elevated NEFA (HY-NEFA).

RESULTS

EGP was suppressed by hyperglycaemia, but not by HY-NEFA. Hepatic glycogen concentration decreased ~14% with prolonged fasting during euglycaemia and increased by ~12% with hyperglycaemia. In contrast, raising NEFA levels in HY-NEFA caused a substantial ~23% reduction in hepatic glycogen concentration. Moreover, rates of gluconeogenesis were decreased with hyperglycaemia, but increased with HY-NEFA.

CONCLUSIONS/INTERPRETATION

Increased NEFA appear to profoundly blunt the ability of hyperglycaemia to inhibit net glycogenolysis under basal hormonal conditions.

Xylitol prevents NEFA-induced insulin resistance in rats

AIMS/HYPOTHESIS

Increased NEFA levels, characteristic of type 2 diabetes mellitus, contribute to skeletal muscle insulin resistance. While NEFA-induced insulin resistance was formerly attributed to decreased glycolysis, it is likely that glucose transport is the rate-limiting defect. Recently, the plant-derived sugar alcohol xylitol has been shown to have favourable metabolic effects in various animal models. Furthermore, its derivative xylulose 5-phosphate may prevent NEFA-induced suppression of glycolysis. We therefore examined whether and how xylitol might prevent NEFA-induced insulin resistance.

METHODS

We examined the ability of xylitol to prevent NEFA-induced insulin resistance. Sustained ~1.5-fold elevations in NEFA levels were induced with Intralipid/heparin infusions during 5 h euglycaemic-hyperinsulinaemic clamp studies in 24 conscious non-diabetic Sprague-Dawley rats, with or without infusion of xylitol.

RESULTS

Intralipid infusion reduced peripheral glucose uptake by ~25%, predominantly through suppression of glycogen synthesis. Co-infusion of xylitol prevented the NEFA-induced decreases in both glucose uptake and glycogen synthesis. Although glycolysis was increased by xylitol infusion alone, there was minimal NEFA-induced suppression of glycolysis, which was not affected by co-infusion of xylitol.

CONCLUSIONS/INTERPRETATION

We conclude that xylitol prevented NEFA-induced insulin resistance, with favourable effects on glycogen synthesis accompanying the improved insulin-mediated glucose uptake. This suggests that this pentose sweetener has beneficial insulin-sensitising effects.

Cross-chest liposuction in gynaecomastia

Background: Gynaecomastia is usually treated with liposuction or liposuction with excision of the glandular tissue. The type of surgery chosen depends on the grade of the condition. Objective: Because gynaecomastia is treated primarily as a cosmetic procedure, we aimed at reducing the invasiveness of the surgery. Materials and Methods: The technique complies with all recommended protocols for different grades of gynaecomastia. It uses liposuction, gland excision, or both, leaving only minimal post-operative scars. The use of cross-chest liposuction through incisions on the edge of the areola helps to get rid of all the fat under the areola without an additional scar as in the conventional method. Results: This is a short series of 20 patients, all with bilateral gynaecomastia (i.e., 40 breasts), belonging to Simon's Stage 1 and 2, studied over a period of 2 years. The average period of follow-up was 15 months. Post-operative complications were reported in only two cases, with none showing long-term complications or issues specifically due to the procedure. Conclusions : Cross-chest liposuction for gynaecomastia is a simple yet effective surgical tool in bilateral gynaecomastia treatment to decrease the post-operative scars. The use of techniques like incision line drain placement and post-drain removal suturing of wounds aid in decreasing the scar.

Cross-chest liposuction in gynaecomastia

BACKGROUND

Gynaecomastia is usually treated with liposuction or liposuction with excision of the glandular tissue. The type of surgery chosen depends on the grade of the condition.

OBJECTIVE

Because gynaecomastia is treated primarily as a cosmetic procedure, we aimed at reducing the invasiveness of the surgery.

MATERIALS AND METHODS

The technique complies with all recommended protocols for different grades of gynaecomastia. It uses liposuction, gland excision, or both, leaving only minimal post-operative scars. The use of cross-chest liposuction through incisions on the edge of the areola helps to get rid of all the fat under the areola without an additional scar as in the conventional method.

RESULTS

This is a short series of 20 patients, all with bilateral gynaecomastia (i.e., 40 breasts), belonging to Simon's Stage 1 and 2, studied over a period of 2 years. The average period of follow-up was 15 months. Post-operative complications were reported in only two cases, with none showing long-term complications or issues specifically due to the procedure.

CONCLUSIONS

Cross-chest liposuction for gynaecomastia is a simple yet effective surgical tool in bilateral gynaecomastia treatment to decrease the post-operative scars. The use of techniques like incision line drain placement and post-drain removal suturing of wounds aid in decreasing the scar.

A clinicoepidemiological study of 50 cases of cutaneous tuberculosis in a tertiary care teaching hospital in pokhara, Nepal

BACKGROUND

Cutaneous tuberculosis (TB) is essentially an invasion of the skin by Mycobacterium tuberculosis, the same bacteria that causes pulmonary tuberculosis.

AIM

This study was conducted to study the common types of cutaneous TB and to find the management pattern in a tertiary teaching hospital in Pokhara, Nepal.

MATERIALS AND METHODS

All the cases of cutaneous TB were biopsied and furthermore investigated by performing Mantoux test, sputum examination, fine needle aspiration cytology, chest X-ray and ELISA.

RESULTS

In this study, we found that tuberculosis verrucous cutis (48%) had a higher incidence than other types of cutaneous TB. More males were affected than were females (1.2:1). Commonly affected sites were the limb and the buttock (48%). The most commonly affected age group was 16-25 years (40%). All cases (except two) were more than 15 mm in size in the Mantoux test. The histopathological picture was typical in all except three cases. All patients were treated with antitubercular treatment as per the national guidelines.

CONCLUSION

The most common type of cutaneous TB was tuberculosis verrucous cutis and the most commonly affected sites were the limb and the buttock. As cutaneous TB sometimes reflects the presence of pulmonary tuberculosis, its incidence should not be ignored.

HPLC determination of valproic acid in human serum

A HPLC method for the determination of valproic acid (VA) in human serum using diazepam as internal standard (I.S.) is described. The eluates were separated with a C18 250 x 4.6 mm internal diameter reversed phase column maintained at a temperature of 50 degrees C. A mobile phase consisting of acetonitrile and 0.05 M phosphate buffer (pH 3.0) 45:55 v/v was used at a flow rate of 1.2 ml/min. Wavelength was switched from 360 nm to 210 nm during valproic acid retention. The method was linear over a concentration range of 20 to 160 microg/ml for valproic acid. Recovery was greater than 94% over a concentration range of 20 to 120 microg/ml and the limit of quantitation was 1 microg/ml. The intra day and inter day relative standard deviation (R.S.D.) measured at 20, 60, 80 and 120 microg/ml ranged from 1.46 to 5.34% and 0.83 to 5.03% respectively. The method is simple, rapid, accurate and sensitive and it was used for Therapeutic Drug Monitoring (TDM) in Indian epileptic patient population. The results obtained with this method correlated well with clinical practice.

Validated HPLC method for determination of chlorzoxazone in human serum and its application in a clinical pharmacokinetic study

A high performance liquid chromatographic (HPLC) method for the determination of chloroxazone in human serum using phenacetin as internal standard (IS) is described. Protein precipitation is used for preparation of the sample. A mobile phase consisting of acetonitrile and 0.5% acetic acid in water mixture (40:60 v/v) was used at a flow rate of 1 ml/min on a C18 column. The eluate was monitored using an UV/VIS detector set at 287 nm. Ratio of peak area of analyte to IS was used for quantification of serum samples. The absolute recovery was greater than 96% over a concentration range of 1 to 100 micrograms/ml and the limit of quantitation was 0.05 microgram/ml. The intra-day relative standard deviation (RSD) measured at 1, 10, 50, and 100 micrograms/ml ranged from 0.9 to 5.1%. The inter-day RSD ranged from 0.6 to 3.0%. The method is simple, sensitive and has been successfully used in pharmacokinetic study conducted in healthy human volunteers.

Characterization of beta-thalassaemia mutations in 57 beta-thalassaemia families seen at Lucknow

As an initial step towards establishing prenatal diagnostic service for beta-thalassaemia in the state of Uttar Pradesh, we have investigated the prevalence of five common mutations reported from India in 57 families, each with an index patient of thalassaemia major, by amplification refractory mutation system (ARMS). Thirtyone of the 57 families (54.3%) hailed from Uttar Pradesh; 11 (19.3%) from Sindh in Pakistan, 6 (10.5%) from Punjab, 6 (10.5%) from North-West Pakistan and one each (1.8%) from Bengal, Madhya Pradesh and Bihar. In the 31 families from Uttar Pradesh, 29 were of beta-thalassaemia and 2 of HbE/beta-thalassaemia. IVS-1 nt 5 (G-C) mutation was the most common mutation in families native to Uttar Pradesh. This mutation was identified in 60 per cent (33 out of 55) of the obligate heterozygotes. Amongst the 43 obligate heterozygote carriers originating from Western India, the prevalence of IVS-1 nt 5 (G-C) mutation was 46.5 per cent; 619 bp deletion 23.3 per cent; Co 8/9 (+G) mutation 11.6 per cent and Co 41/42 (-CTTT) mutation 4.6 per cent. In 23.6 per cent of carriers from Uttar Pradesh and 7.0 per cent of carriers from Western India, none of the 5 mutations tested were detected. IVS-1 nt 1 (G-T) mutation was found in one family native to Sindh.

Effective audit: reporting to the National Confidential Enquiry into Perioperative Deaths

OBJECTIVE

To investigate the effectiveness of computer based and manual district and unit information systems for identifying hospital deaths eligible for reporting to the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

DESIGN

Prospective six to 10 week study of hospital (death register, immediate coding of medical records) and district information systems followed by six month assessment after modification to entry of data.

SETTING

Acute units within Lewisham and North Southwark Health District.

PATIENTS

All 290 patients dying in hospital during the six weeks, for whom the medical records were obtainable in 231.

MAIN OUTCOME MEASURES

Sensitivity and specificity of the information systems in ascertaining eligible surgical deaths (patients dying in hospital who had during 30 days previously had a surgical procedure while under the care of a consultant in a surgical specialty) tested against validated list of screened medical records.

RESULTS

Of 231 medical records, 30 (12 from Lewisham, 18 from North Southwark) met the national inquiry's criteria. The computer based systems of both units detected less than 60% of eligible deaths (sensitivity 53%, specificity 83%); the death register detected about 60% (sensitivity 61%, specificity 89%); manual systems detected all eligible deaths. Subsequent modification to ensure immediate coding of records into the computerised systems during follow up failed to show any improvement.

IMPLICATIONS

Routine hospital information systems may miss up to half the deaths eligible for NCEPOD.

Action of DL-alpha-difluoromethyl ornithine on Acanthamoeba culbertsoni

The multiplication of A. culbertsoni in the peptone medium was not inhibited by 10-20 mM concentration of alpha-difluoromethyl ornithine (DMFO) while a partial and transient inhibition of cell multiplication was observed by 10-20 mM DFMO in proteose peptone, yeast extract, glucose (PYG) medium. Ornithine decarboxylase (ODC) activity in the cells and cell free extracts was strongly inhibited by DFMO, excluding enzyme refractoriness and impermeability of cells for DFMO as the possible causes of DFMO resistance. The presence of polyamines in the peptone and PYG media as well as uptake of polyamines by the amoebae has been demonstrated. The growth and multiplication of A. culbertsoni in chemically defined medium was not affected by 1-5 mM DFMO while 10-20 mM DMFO yielded partial inhibition. A lowering of diaminopropane levels and enhancement of spermidine levels was observed in DFMO inhibited cells and level of ODC was drastically reduced in the inhibited cultures. Uptake of polyamines from the growth media may partly account for DFMO resistance of A. culbertsoni. Alternative mechanisms for DFMO resistance are indicated.

Action of methylglyoxal bis (guanyl hydrazone) and related antiprotozoals on Acanthamoeba culbertsoni

Methylglyoxal bis(guanyl hydrazone) (MGBG) and the related diamidine compounds berenil and pentamidine inhibited multiplication of A. culbertsoni. The growth inhibition by MGBG (2.5 mM) in the peptone medium was accompanied by the disappearance of spermidine and a marked reduction in the level of diaminopropane. MGBG and berenil completely inhibited growth in a chemically defined medium at 1 mM and 1-2 microM concentration, respectively. However, there was no decrease in the polyamine levels in the early stages of growth inhibition by these agents. Uptake of putrescine, spermidine and spermine by A. culbertsoni has been demonstrated but addition of exogenous polyamines did not reverse the growth inhibitory action of MGBG and berenil. Inhibition of S-adenosylmethionine decarboxylase and decrease in polyamine synthesis do not seem to be the primary targets for the antiamoebic action of MGBG and berenil.

Polyamine metabolism as a target for growth inhibition of Acanthamoeba culbertsoni

Alpha-difluoromethylornithine had no inhibitory effect on the growth of Acanthamoeba culbertsoni, while methylglyoxal bis(guanyl-hydrazone) and sinefungin completely blocked amebic growth at 2.5 mM and 5 micrograms/ml concentrations, respectively. Cyclohexylamine caused only partial inhibition of amebic growth at 50-200 microM concentrations. Methylglyoxal bis(guanyl-hydrazone) inhibited S-adenosylmethionine decarboxylase of A. culbertsoni indicating this enzyme to be the target for its antiamebic action. This enzyme was, however, not inhibited by sinefungin, suggesting an alternative target for growth inhibition by this compound.

2,3-butanediol: an unusual metabolite in the serum of severely alcoholic men during acute intoxication

In a controlled experiment 15 (79%) of 19 severely alcoholic men but only 1 of 22 controls had a serum concentration of greater than or equal to 5 mumol/l 2,3-butanediol after ingestion of distilled spirits. Another diol, 1,2-propanediol, was found in a concentration of greater than or equal to 5 mumol/l in all patients' specimens after drinking; but it was also present in lower concentrations in the reference specimens of most of the patients. These data are consistent with the experimental evidence that ethanol can be metabolised in rats to produce 2,3-butanediol and with the epidemiological hypothesis that severely alcoholic men metabolise ethanol by a different pathway than do control subjects.

Aneurysms of the petrous portion of the internal carotid artery

Aneurysms of the petrous portion of the internal carotid artery are rare lesions. One case is reported here and 18 others have been found in the literature. These lesions usually arise in young men who present with auditory dysfunction. The aneurysm is usually discovered as a pulsating purple mass in the middle ear and mistaken for a glomus jugulare tumor. A definitive diagnosis can be made by carotid angiography. Subtraction techniques are very helpful. Carotid ligation or trapping is the treatment of choice.

Gliomas (astrocytomas) of the brain-stem with spinal intra- and extradural metastases: report of three cases

Astrocytomas of the pons and medulla oblongata ('brain-stem gliomas') while often invasive locally, do not as a rule seed and metastasize along the spinal meninges. Three cases are here reported (two adults, one child) in whom astrocytoma of the brain-stem metastasized along the spinal cord. The dura mater itself and the spinal epidural space were invaded in two cases. The child and one adult had a pontine astrocytoma, the other adult's tumour originated in the medulla oblongata. In the two cases that came to necropsy the tumour of the brain-stem was much better differentiated than the meningeal deposits. These three cases suggest that the possibility of spinal spread of brain-stem gliomas should be considered when dealing with diagnostic and therapeutic problems of such patients.