Navigated Hybrid Open/Muscle-sparing Approach to 2-level Cement Augmentation of the UIV and UIV+1 for Prevention of Proximal Junctional Failure: Supplemental Manuscript to Operative Video

STUDY DESIGN

Operative video and supplemental manuscript.

OBJECTIVE

To present a cement augmentation technique of the upper instrumented vertebra (UIV) and UIV+1 for prevention of proximal junctional fractures (PJFs) in multi-level thoracolumbar posterior instrumented fusions.

SUMMARY OF BACKGROUND DATA

PJFs are unfortunately a common occurrence after multi-level thoracolumbar instrumented fusions to the pelvis for adult spinal deformity that can result in significant functional disability and often require costly revision operations. As such, their prevention is key.

METHODS

A surgical video illustrates the nuances of a 2-level cement augmentation technique, consisting of an open vertebroplasty of the UIV through fenestrated screws and a muscle-sparing kyphoplasty of the UIV+1.

RESULTS

Utility of performing an open vertebroplasty of the UIV through fenestrated screws and muscle-sparing kyphoplasty of the UIV+1 lies in its ability to minimize soft-tissue disruption at the adjacent segment while providing additional structural support to the anterior column at this high-risk zone.

CONCLUSIONS

Cement augmentation of the UIV and UIV+1 consisting of a hybrid open vertebroplasty and muscle-sparing kyphoplasty can be an effective strategy to decrease the incidence of PJF after multi-level posterior thoracolumbar instrumented fusions to the pelvis for adult spinal deformity.

Single Lung Transplantation for Pulmonary Fibrosis Secondary to COVID-19

Introduction

Case Report

Summary

Systematic review of single and combined treatments for different types of striae: a comparison of striae treatments

Striae distensae (SD) or stretch marks are among the most common forms of atrophic scarring and cosmetic problems, especially in women, that negatively affect quality of life. The main causes of SD vary widely, but the most significant ones include obesity, pregnancy, high corticosteroid levels, weight changes, endocrine disorders and genetic predispositions. Various modalities are available for the treatment of SD; however, there is still no gold standard therapy for this condition. Given the many questions concerning the preferred therapeutic modalities for SD or their overall cost-effectiveness, this comprehensive systematic review discusses the most prevalent, recent and promising therapies for SD in three main categories, including single therapy, therapeutic comparisons and combination therapy. A systematic search was carried out in Medline, Scopus, Web of Science and Google Scholar for original articles published on the treatment of SD by 20 May 2019. One hundred articles were reviewed and divided into three categories. In the single therapy category, we found that laser and other light-based devices and topical treatments are the most commonly applied interventions. In the therapeutic comparison category, we found that most of the common therapeutic modalities are equally effective and there is no significant difference between them in side-effects and treatment duration. In the combination therapy category, we found that the combination of two or more modalities is usually better than using each one alone.

The effect of Tempo and MitoTEMPO on oocyte maturation and subsequent embryo development in bovine model

Reactive oxygen species (ROS) are one of the factors which reduces oocyte quality and viability of the in vitro produced embryos. Oocyte mitochondria are the major source of ROS production, hence, and the addition of mitochondrion-specific antioxidants could be suggested to minimize the damage caused by ROS during culture. MitoTEMPO, a targeted mitochondrial antioxidant, is formed by conjugating TEMPO to triphenylphosphonium and has an activity like that of superoxide dismutase. It can pass through lipid bilayers easily and accumulate selectively in mitochondria. The goal of this study was to investigate the effects of MitoTEMPO and its non-targeted form, TEMPO, on the developmental competence of bovine oocytes. Accordingly, oocytes were cultured in maturation medium supplemented with either five mM TEMPO (T5) or one μM MitoTEMPO (M1), or T5 + M1 (MT15), or without the antioxidants (C). Nuclear maturation to metaphase II (MII) stage, intracellular glutathione (GSH) content and ROS levels in matured oocytes were analyzed. In addition, cleavage after in vitro fertilization, and blastocyst rates, total cell number in blastocysts as well as the relative abundance of apoptosis-related genes (BAX and BCL2) in blastocysts were determined. Results revealed that the proportion of oocytes at the MII stage, embryos at the blastocyst stage and total cell number in blastocysts increased significantly in the M1 group compared to the C and T5 groups. The levels of intracellular GSH and ROS in oocytes decreased in the M1 group than in the C group (P < 0.05). The expression level of the pro-apoptotic gene (BAX) reduced in blastocysts from the M1 group in comparison to the C and T5 groups (P < 0.05). On the other hand, the expression level of anti-apoptotic gene (BCL2) in obtained blastocysts was not affected by TEMPO and MitoTEMPO. However, the ratio of BAX/BCL2 in blastocysts from the M1 and MT15 groups decreased significantly compared to the C group. These findings suggest that MitoTEMPO can mitigate the adverse effects of oxidative stress on the developmental competence of bovine oocytes.

Probiotic as an adjuvant therapy in chronic urticaria: a blinded randomized controlled clinical trial

Summary

Background. Chronic spontaneous urticaria (CSU) is a common and treatment challenging disorder which may involve about 2% of normal population and in 50% do not respond properly even to the second line therapies. We aimed to evaluate the efficacy and safety of a synbiotic (prebiotic + probiotic) named as LactoCare in treatment of CSU in the RCT for the first time. Methods. This blinded RCT conducted on 42 patients (21 patients in control antihistamine group and 21 in intervention antihistamine + probiotic group) with CSU during 8 weeks. The efficacy assessed by Urticaria Activity Score (UAS7) and quality of life measured by Persian validated Dermatology Life Quality Index (DLQI). Results. Before and after UAS7 score in control group was 35.33 ± 7.81 and 16.86 ± 13.54, respectively. There was 53% score reduction in control group. Before and after UAS7 score in intervention group was 32 ± 7.84 and 11 ± 11.41, respectively. There was 66% score reduction in intervention group. Improvement of DLQI in control and intervention group was 44% and 66%, respectively. At the end, UAS7 score reduction and DLQI improvement in both groups was statistically significant. Conclusions. Probiotics are effective, safe and satisfactory adjuvant therapy for CSU. Combination of probiotic and antihistamines had no statistically significant different efficacy than the antihistamine alone, based on UAS7 score. But Patients with combination therapy may experience higher reduction rate of itch, number of urticaria and total UAS7 score that is clinically of great value and is really practical by itself. Patients with combination therapy experienced more improvement of quality of life (DLQI).

Intradural Disc Herniation in the Setting of Congenital Lumbar Spinal Stenosis

INTRODUCTION

Accounting for an estimated 1.10-1.76% of all lumbar herniations, lumbar intradural disc herniation (IDH) occurs primarily in males during the fourth to fifth decades of life. While not validated, congenital lumbar spinal stenosis (CLSS) is implicated as one precipitating factor for IDH.

CASE REPORT

We report 28-year-old Hispanic female with CLSS, severe obesity, and degenerative disk disease, with a history of minimally invasive surgical (MIS) decompression for a large paracentral L4-5 disc herniation at 25. After three years, the patient developed sudden burning dysesthesias in the L4-5 dermatomes bilaterally and temporary leg weakness. Lumbar magnetic resonance imaging exhibited severe L4-5 spinal stenosis, and the patient underwent repeat MIS decompression, which again provided her with adequate symptom resolution. However, 20 days postoperatively she developed cauda equina syndrome with anal dysfunction, and bilateral leg and foot weakness. Upon open surgical exploration we discovered a tense L4-5 dural protrusion. After a dorsal durotomy, a large IDH with a ventral dural tear was identified. Subsequent to adequate debulking of the IDH, the ventral tear was repaired, and an expansile duraplasty was performed. Overall, the patient's bladder and bowel function, pain, hypoesthesia, and motor strength all improved. Two weeks after surgery she presented with a lumbar pseudomeningocele that was managed conservatively.

CONCLUSION

This report not only highlights an atypical presentation of IDH and is the first case of CLSS linked with IDH, lending support to the hypothesis that CLSS can lead to IDH, but also provides a comprehensive review of IDHs.

The Optimal Surgical Approach to Intradural Spinal Tumors: Laminectomy or Hemilaminectomy?

Objective Traditionally, laminectomy has been the preferred surgical approach for the resection of intradural spinal tumors. Recent trends towards minimally invasive techniques have generated interest in hemilaminectomy as an effective alternative surgical approach to resect spinal tumors. However, it remains unclear if the potential benefits of hemilaminectomies, used in other routine spinal procedures, apply to intradural spinal tumors. This report presents a six-year single institutional analysis of open resection of intradural tumors using laminectomies as compared to hemilaminectomies. Methods A single institution, multisurgeon, retrospective review of 52 patients undergoing resection of intradural spinal tumors over a six-year period was performed. Estimated blood loss, operative time, post-operative complications, length of stay, and post-operative clinical spinal instability were analyzed and compared between the two surgical techniques. Results The mean follow-up was 34 and 20 months for the laminectomy and hemilaminectomy groups, respectively. There was no statistically significant difference in operative times between the two groups (hemilaminectomy: 250.13±76.44 minutes, laminectomy: 244.49±92.85 minutes; p=0.43). Similarly, there was no difference in overall estimated blood loss (hemilaminectomy: 125±74 cc, laminectomy: 256.05±320.8 cc; p=0.27) or mean hospital length of stay (hemilaminectomy: 4.00±2.12 days, laminectomy: 5.26±3.0 days; p=0.60). No patient in either surgical group had post-operative evidence of clinical spinal instability. Conclusion Hemilaminectomy is a viable approach for the resection of intradural spinal tumors, with similar rates of post-operative complications to laminectomy when using an open surgical approach. The laminectomy allows for bilateral exposure of the entire spinal canal and neural foramina; and continues to be the preferred method for resection of large tumors with complex morphology.

Internal Acoustic Canal Stenosis Due to Hyperostosis

Background  Exostoses and osteomas are benign, insidious lesions of the bone involving the internal acoustic canal (IAC). We present two cases of IAC exostoses managed with surgical decompression and review the clinical outcomes of previously reported cases in the literature. Methods  A comprehensive search was conducted using PubMed Central, Web of Science Core Collection, and Google Scholar databases to identify previous reports of IAC exostoses and osteomas. A total of 26 reported cases were identified, and patient presenting symptoms, management strategies, and response to surgery was obtained when available. Results  Of the 13 patients who underwent surgical decompression, 8 patients had resolution of vertigo symptoms, 10 patients had improvement of tinnitus symptoms, and all patients maintained some level of serviceable hearing. Conclusion  IAC exostoses and osteomas are rare lesions that lead to insidious onset of debilitating symptoms from vestibulocochlear nerve dysfunction. Although the role of surgical decompression remains unclear, it appears that patients presenting with vertigo have more favorable response to surgical decompression as compared with those presenting with tinnitus and sensorineural hearing loss.

Glioblastoma Multiforme of the Conus Medullaris—Management Strategies and Complications

Primary spinal glioblastoma multiforme (GBM) of the conus medullaris is a rare and devastating pathologic entity. The presenting symptoms commonly include progressive neurologic deficits in the lower extremities, bowel and bladder dysfunction, and low back pain. Histologically, these tumors have high-grade features similar to their intracranial counterparts. However, recent advancements in the field of molecular oncology have been beginning to elucidate a unique molecular blueprint for these spinal gliomas. Given the lack of standardized treatment strategies, we have presented our institutional experience in treating a small series of patients with conus medullaris GBM and have reviewed the reported data on the relevant molecular markers, management strategies, and complication avoidance for this malignant pathologic entity.

Review of the Neural Oscillations Underlying Meditation

Objective: Meditation is one type of mental training that has been shown to produce many cognitive benefits. Meditation practice is associated with improvement in concentration and reduction of stress, depression, and anxiety symptoms. Furthermore, different forms of meditation training are now being used as interventions for a variety of psychological and somatic illnesses. These benefits are thought to occur as a result of neurophysiologic changes. The most commonly studied specific meditation practices are focused attention (FA), open-monitoring (OM), as well as transcendental meditation (TM), and loving-kindness (LK) meditation. In this review, we compare the neural oscillatory patterns during these forms of meditation.

Method: We performed a systematic review of neural oscillations during FA, OM, TM, and LK meditation practices, comparing meditators to meditation-naïve adults.

Results: FA, OM, TM, and LK meditation are associated with global increases in oscillatory activity in meditators compared to meditation-naïve adults, with larger changes occurring as the length of meditation training increases. While FA and OM are related to increases in anterior theta activity, only FA is associated with changes in posterior theta oscillations. Alpha activity increases in posterior brain regions during both FA and OM. In anterior regions, FA shows a bilateral increase in alpha power, while OM shows a decrease only in left-sided power. Gamma activity in these meditation practices is similar in frontal regions, but increases are variable in parietal and occipital regions.

Conclusions: The current literature suggests distinct differences in neural oscillatory activity among FA, OM, TM, and LK meditation practices. Further characterizing these oscillatory changes may better elucidate the cognitive and therapeutic effects of specific meditation practices, and potentially lead to the development of novel neuromodulation targets to take advantage of their benefits.

A Multilayered Technique for Repair of the Suboccipital Retrosigmoid Craniotomy

Objective  Our primary objective was to retrospectively review our single institution experience using an anatomic multilayered repair of the retrosigmoid suboccipital craniotomy. Our secondary objective was to review the existing body of literature on the repair of this craniotomy and compare our outcomes to previous results. Design  Retrospective review of 25 consecutive patients undergoing repair for the retrosigmoid craniotomy. Setting  University of California Davis Medical Center (2010-2016). Participants  A total of 25 consecutive patients who underwent retrosigmoid craniotomy and repair. Exclusion criteria included patients who were under the age of 18 years. Main Outcome Measures  Main outcomes included incidence of postoperative headache, cerebrospinal fluid leak, and wound infections. Results  Postoperative headache was reported in two patients in this series (8%). None of the patients in the series developed cerebrospinal fluid leak or wound infections. Mean follow-up period was 16 months. Conclusion  Our multilayered anatomic repair after retrosigmoid suboccipital craniotomy results in favorable clinical results and may help reduce the risks associated with this operation.

Toward a Neuroscience of Adult Cognitive Developmental Theory

Piaget's genetic epistemology has provided the constructivist approach upon which child developmental theories were founded, in that infants are thought to progress through distinct cognitive stages until they reach maturity in their early 20's. However, it is now well established that cognition continues to develop after early adulthood, and several “neo-Piagetian” theories have emerged in an attempt to better characterize adult cognitive development. For example, Kegan's Constructive Developmental Theory (CDT) argues that the thought processes used by adults to construct their reality change over time, and reaching higher stages of cognitive development entails becoming objectively aware of emotions and beliefs that were previously in the realm of the subconscious. In recent years, neuroscience has shown a growing interest in the biological substrates and neural mechanisms encompassing adult cognitive development, because psychological and psychiatric disorders can arise from deficiencies therein. In this article, we will use Kegan's CDT as a framework to discuss adult cognitive development in relation to closely correlated existing constructs underlying social processing, such as the perception of self and others. We will review the functional imaging and electrophysiologic evidence behind two key concepts relating to these posited developmental changes. These include self-related processing, a field that distinguishes between having conscious experiences (“being a self”) and being aware of oneself having conscious experiences (“being aware of being a self”); and theory of mind, which is the objective awareness of possessing mental states such as beliefs and desires (i.e., having a “mind”) and the understanding that others possess mental states that can be different from one's own. We shall see that cortical midline structures, including the medial prefrontal cortex and cingulate gyrus, as well as the temporal lobe, are associated with psychological tasks that test these models. In addition, we will review computational modeling approaches to cognitive development, and show how mathematical modeling can provide insights into how sometimes continuous changes in the neural processing substrate can give rise to relatively discrete developmental stages. Because deficiencies in adult cognitive development can result in disorders such as autism and depression, bridging the gaps between developmental psychology, neuroscience, and modeling has potential implications for clinical practice. As neuromodulation techniques such as deep brain and transcranial stimulation continue to advance, interfacing with these systems may lead to the emergence of novel investigational methods and therapeutic strategies in adults suffering from developmental disorders.

Cervical spine fractures in osteopetrosis: a case report and review of the literature

While management of appendicular fractures has been well described in the setting of osteopetrosis, there is limited information on managing fractures of the axial spine. Here we present an osteopetrotic patient with multiple traumatic multiple, comminuted, unstable cervical spinal fractures managed with non-operative stabilization, and provide a review of the pathophysiology, genetic characteristics, and special considerations that must be explored when determining operative versus non-operative management of spinal injury in osteopetrosis. A PubMed query was performed for English articles in the literature published up to June 2016, and used the following search terms alone and in combination: "osteopetrosis", "spine", "fractures", "osteoclasts", and "operative management". Within four months after initial injury, treatment with halo vest allowed for adequate healing. The patient was asymptomatic with cervical spine dynamic radiographs confirming stability at four months. On four-year follow up examination, the patient remained without neck pain, and CT scan demonstrated partially sclerotic fracture lines with appropriate anatomical alignment. In conclusion, external halo stabilization may be an effective option for treatment of multiple unstable acute traumatic cervical spine fractures in patients with osteopetrosis. Given the challenge of surgical stabilization in osteopetrosis, further research is necessary to elucidate the optimal form of treatment in this select patient population.

Bone mineral density is lower in male than female patients with plaque-type psoriasis in Iran

Background

There are many similarities with regard to contributing cytokines in patients with psoriasis and osteoporosis. A theory of probable relationship between these two entities has been proposed but there is no concordant consensus. The aim of this study was to evaluate bone mineral density (BMD) in patients with psoriasis.

Method and materials

This cross-sectional study of BMD was conducted with 64 eligible patients with psoriasis who were referred to the dermatology clinic of Razi hospital in Tehran, Iran in between 2011 and 2012.

Results

The mean T score of femoral neck was –1.17 and –0.49 in men and women, respectively, which was statistically significant (p = .047). The mean T score of the lumbar spine was –0.93 and –0.30 in men and women, respectively, but not statistically significant (p = .058). In total except with the exclusion of the study site (femur or lumbar), men and women did not have a statistically significant difference with regard to osteoporosis or osteopenia in BMD (p = .114). The Pearson correlation coefficient demonstrated a moderate inverse relationship between age and T score of the femoral neck and lumbar spine (r = –0.419 and –.406, respectively), which was statistically significant (p = .001). Although there was no statistically significant relationship between the Psoriasis Area and Severity Index (PASI) and T scores of the femoral neck (p = .596), a positive and weak correlation was observed between the PASI and T scores for the lumbar spine, which was statistically significant (r = 0.269; p = .03).

Conclusion

Patients with psoriasis had decreased bone density, which was more significant in men. Prevalence of osteoporosis showed no statistically significant difference when compared with the healthy population in Iran.

Intradural Chordoma of Cerebellopontine Angle: Case Report and Review

BACKGROUND

Chordomas are rare, notochord-derived neoplasms. Of these tumors, intradural chordomas are exceedingly rare. Most occur within the prepontine, parasellar, or other midline intradural locations. An intradural chordoma arising from the cerebellopontine angle has not been described previously.

CASE REPORT

We describe the first case of an intradural chordoma originating from the left cerebellopontine angle resected over the course of 2 operations.

CONCLUSIONS

Intradural chordomas are rare and can arise anywhere in the posterior fossa. Lack of bony involvement on computed tomography and magnetic resonance imaging are indicative of this pathology when there is also a lack of markers indicating the presence of more common cerebellopontine angle tumors. Treatment goals should include gross total resection and possible radiation therapy.

Mycobacterium Genavense Granuloma Mimicking a Brain Tumor: A Case Report

Mycobacterium genavense (M. genavense) is a rare, non-tuberculous organism that commonly leads to gastrointestinal infections in immunocompromised patients. Only two cases of intracranial M. genavense infection have been reported to date. We describe a third case of M. genavense granuloma mimicking a right parietal intracranial mass, and review the literature on this exceedingly rare pathology.

Effect of Stereoscopic Anaglyphic 3-Dimensional Video Didactics on Learning Neuroanatomy

BACKGROUND

The teaching of neuroanatomy in medical education has historically been based on didactic instruction, cadaveric dissections, and intraoperative experience for students. Multiple novel 3-dimensional (3D) modalities have recently emerged. Among these, stereoscopic anaglyphic video is easily accessible and affordable, however, its effects have not yet formally been investigated.

OBJECTIVE

This study aimed to investigate if 3D stereoscopic anaglyphic video instruction in neuroanatomy could improve learning for content-naive students, as compared with 2-dimensional (2D) video instruction.

METHODS

A single-site controlled prospective case control study was conducted at the School of Education. Content knowledge was assessed at baseline, followed by the presentation of an instructional neuroanatomy video. Participants viewed the video in either 2D or 3D format and then completed a written test of skull base neuroanatomy. Pretest and post-test performances were analyzed with independent Student's t-tests and analysis of covariance.

RESULTS

Our study was completed by 249 subjects. At baseline, the 2D (n = 124, F = 97) and 3D groups (n = 125, F = 96) were similar, although the 3D group was older by 1.7 years (P = 0.0355) and the curricula of participating classes differed (P < 0.0001). Average scores for the 3D group were higher for both pretest (2D, M = 19.9%, standard deviation [SD] = 12.5% vs. 3D, M = 23.9%, SD = 14.9%, P = 0.0234) and post-test performances (2D, M = 68.5%, SD = 18.6% vs. 3D, M = 77.3%, SD = 18.8%, P = 0.003), but the magnitude of improvement across groups did not reach statistical significance (2D, M = 48.7%, SD = 21.3%, vs. 3D, M = 53.5%, SD = 22.7%, P = 0.0855).

CONCLUSION

Incorporation of 3D video instruction into curricula without careful integration is insufficient to promote learning over 2D video.

Intracerebroventricular opiate infusion for refractory head and facial pain

AIM: To study the risks and benefits of intracerebroventricular (ICV) opiate pumps for the management of benign head and face pain.

METHODS: SSix patients with refractory trigeminal neuralgia and/or cluster headaches were evaluated for implantation of an ICV opiate infusion pump using either ICV injections through an Ommaya reservoir or external ventricular drain. Four patients received morphine ICV pumps and two patientS received a hydromorphone pump. Of the Four patients with morphine ICV pumps, one patient had the medication changed to hydromorphone. Preoperative and post-operative visual analog scores (VAS) were obtained. Patients were evaluated post-operatively for a minimum of 3 mo and the pump dosage was adjusted at each outpatient clinic visit according to the patient’s pain level.

RESULTS: All 6 patients had an intracerebroventricular opiate injection trial period, using either an Ommaya reservoir or an external ventricular drain. There was an average VAS improvement of 75.8%. During the trial period, no complications were observed. Pump implantation was performed an average of 3.7 wk (range 1-7) after the trial injections. After implantation, an average of 20.7 ± 8.3 dose adjustments were made over 3-56 mo after surgery to achieve maximal pain relief. At the most recent follow-up (26.2 mo, range 3-56), VAS scores significantly improved from an average of 7.8 ± 0.5 (range 6-10) to 2.8 ± 0.7 (range 0-5) at the final dose (mean improvement 5.0 ± 1.0, P < 0.001). All patients required a stepwise increase in opiate infusion rates to achieve maximal benefit. The most common complications were nausea and drowsiness, both of which resolved with pump adjustments. On average, infusion pumps were replaced every 4-5 years.

CONCLUSION: These results suggest that ICV delivery of opiates may potentially be a viable treatment option for patients with intractable pain from trigeminal neuralgia or cluster headache.

Pemphigus vulgaris-associated Kaposi's sarcoma: response to paclitaxel and review of the literature

Systemic corticosteroids have long been the mainstay of treatment for pemphigus patients. However, the necessity of their high-dose and long-term administration has brought about a number of complications, sometimes causing significant morbidities. Maintaining a balance between therapeutic and undesirable effects of medications is not always easily achievable. Therefore, additional treatment modalities are frequently needed to control side-effects. Kaposi's sarcoma (KS) is a rare, potentially life-threatening complication in this setting. Due to the rarity of data on pemphigus-associated KS treatment, the best therapeutic approach is still undecided. Here, we report two cases of pemphigus patients who had developed extensive KS as a result of severe immunosuppressive therapy and were successfully treated with paclitaxel. In addition, we performed a review of literature to assess the results of the previously employed treatment modalities in this setting.

Aqueous Ferrofluid of Citric Acid Coated Magnetite Particles

Magnetic nanoparticles have found application in medical diagnostics such as magnetic resonance imaging and therapies such as cancer treatment. In these applications, it is imperative to have a biocompatible solvent such as water at optimum pH for possible bio-ingestion. In the present work, a synthetic methodology has been developed to get a well-dispersed and homogeneous aqueous suspension of Fe3O4 nanoparticles in the size range of 8–10 nm. The surface functionalization of the particles is provided by citric acid. The particles have been characterized using transmission electron microscopy, magnetization measurements with a superconducting quantum interference device, FTIR spectroscopy (for surfactant binding sites), thermogravimetric studies (for strength of surfactant binding), and x-ray photoelectron spectroscopy and x-ray diffraction (for composition and phase information). The carboxylate functionality on the surface provides an avenue for further surface modification with fluorescent dyes, hormone linkers etc for possible cell-binding, bioimaging, tracking, and targeting.