Calvarial hyperpigmentation

Background

Osseous hyperpigmentation of the calvarium is an extremely rare finding with only few reported cases in literature.

Case Description

The case is of a 59-year-old Caucasian male who presented with an acute history of generalized tonic clonic seizures and progressive weakness of the right upper limb. He had a background history of a malignant melanoma which had been resected from his left external acoustic meatus 4 weeks prior. Neuroimaging of the brain showed an intra-axial space-occupying lesion in his left parietal lobe with no associated osseous changes. A left mini parietal craniotomy was performed which revealed black discoloration of the parietal bone. The lesion was successfully resected and the bone flap was secured back in place. The patient was discharged on the 4th day postoperatively with no complications. The unusual finding of black discoloration of the calvarium was found to be secondary to adolescent tetracycline use.

Conclusion

Calvarial hyperpigmentation is a phenomenon encountered incidentally and will often come as surprise for surgeons. Once encountered, thorough history taking and examination should be done to investigate the cause.

Single surgeon case series of myelomeningocele repairs in a developing world setting: Challenges and lessons

Purpose

Neural Tube Defects are the second most common group of birth malformations following congenital heart anomalies, with myelomeningoceles being the most severe manifestation (MMC). They require expedited surgical repair, preferably within 72 ​h of birth. In low- and middle-income countries (LMIC) where resources are limited, timing to MMC repair is not optimal and leads to undesirable outcomes. The purpose of this study was to determine whether a proactive approach in a setting from a LMIC could achieve repair within 72 ​h.

Methods

A concerted effort to expedite repair of all neonates referred with a MMC was undertaken from 01 January 2014 to 1 August 2015. A consensus was reached between neonatologists and neurosurgeons that neonates born or admitted with a MMC are referred immediately to surgeons and that repair will be performed within 72 ​h of birth. Hospital records of neonates who had MMC repaired during this period were reviewed for infant characteristics and hospital outcomes.

Results

24 patients with a MMC were operated upon by the senior author (CP) during the study period. Only 13 of these patients were born at the treating institution and 11 were referred from outside hospitals. Most MMCs were in the lumbosacral region and mean MMC surface area was 19.4 ​cm². Mean time to repair for the entire series was 13.6 days. Patients born at the treating institution has a mean time to repair of 10.5 days and patients referred from outside had a mean time to repair of 17.3 days. Series wide, only 21% of neonates were operated upon in less than 72 ​h.

Conclusion

Despite a pro-active commitment to repairing MMCs within 72 ​h for the duration of this series, satisfactory time to repair was not achieved. Late referral, referral from outside hospitals and operating theatre availability were the predominant factors leading to delay in MMC repair. Nevertheless, time to repair in our series was significantly shorter than that reported in MMC repair series based in similar environments. This suggests that even if the gold-standard of a 72-h window cannot be achieved, neonates benefit from much quicker repair when a concerted effort to minimise repair time is employed. This study also highlights the urgent need to address health care constraints in LMIC to improve outcomes for this vulnerable group.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Cytotoxicity and ultrastructural changes in H9c2(2-1) cells treated with pavetamine, a novel polyamine

Intake of pavetamine, a novel polyamine, synthesized by certain rubiaceous plants, is the cause of gousiekte ("Quick disease") in ruminants. The disease is characterized by a latent period of 4-8 weeks, followed by heart failure. The aim of this study was to firstly investigate the cytotoxicity in H9c2(2-1) cells using the MTT (3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide) and LDH (lactate dehydrogenase) release assays. Maximum cell death occurred after pavetamine exposure of cells for 72h at a concentration of 200muM (55%+/-9.84), as measured by the MTT assay. LDH release was only observed after 72h exposure to pavetamine. Secondly, the ultrastructural changes induced by pavetamine in H9c2(2-1) cells were investigated. Changes in the mitochondria and sarcoplasmic reticula were observed. The nucleus was not affected during the first 48h exposure of cells to pavetamine and no chromatin condensation occurred. However, after 72h exposure to pavetamine, the nucleus became fragmented and membrane blebbing occurred. It was concluded that the ultimate cell death of H9c2(2-1) cells treated with pavetamine, was through necrosis and not apoptosis. Thirdly, the effect of pavetamine on the mitochondrial membrane potential (DeltaPsi) was evaluated by using the JC-1 (5,5',6,6'-Tetrachloro-1,1',3,3'-tetraethyl-imidacarbocyanine iodide) and TMRM (tetramethylrhodamine methyl ester perchlorate) probes. Pavetamine treatment led to significant hyperpolarization of the mitochondrial membrane potential. Cyclosporin A (CsA), an inhibitor of the mitochondrial permeability transition pore, did not reduce the cytotoxicity of pavetamine significantly, indicating that the MPTP (mitochondrial permeability transition pore) plays no role in the cytotoxicity of pavetamine.

Some fungi, zearalenone and other mycotoxins in chicken rations, stock feedstuffs, lucerne and pasture grasses in the communal farming area of Rhenosterkop in South Africa

Mycotoxins may be present in feeds without any visible signs of mould contamination. There is a need for rapid and accurate measurement of mycotoxins for purposes of continual monitoring and identification of high risk commodities. Samples from commercial chicken feed (maize kernels), cattle feed (lucerne, grass and hay) and milk were analysed for the presence of certain mycotoxins and cultured for fungi. Results of fungal profiles showed that most samples were contaminated by moulds belonging to the genera, Alternaria, Aspergillus, Fusarium, Penicillium, Mucor, Phoma and Rhizopus. All the chicken feed samples tested contained mycotoxins either below the recommended safe levels for poultry or below the detection limits of the ELISA tests. However, samples of grass contained levels of zearalenone greater than the allowable concentration for dairy and beef cattle (250 ppm), which may be linked to the presence of Fusarium scirpi identified in the fungal profiles. The levels of AFM1 were below the detection limits of the ELISA tests, which may be attributed to the low levels of aflatoxins found in the feed (grass) samples. The presence of the fungus in samples analysed is not evidence for the presence of mycotoxins.

Establishment and validation of primary hepatocytes of the African sharptooth catfish (Clarias gariepinus)

In vitro systems such as primary cells and continuous cell lines are gaining momentum in ecotoxicological studies. Cytotoxicity tests with fish cells as well as tests using specific endpoints such as CYP1A induction are valuable in the toxicity assessment of environmental samples. The main objective of this study was to establish and validate the use of primary hepatocytes from the African sharptooth catfish (Clarias gariepinus) as an in vitro toxicity monitoring system. The successful isolation of primary hepatocytes from the sharptooth catfish was achieved using an in situ perfusion method. The primary hepatocytes responded to CYP1A induction, while a continuous Chinese hamster ovary (CHO-K1) cell line showed no activity when exposed to various concentrations of benzo[a]pyrene (B[a]P) (p<0.0001). Cytotoxicity, as measured by the methyl thiazol tetrazolium (MTT) assay, was not observed following a 72 h exposure of the primary hepatocytes and the CHO-K1 cell line to different B[a]P concentrations. However, the hepatocytes were damaged at higher B[a]P concentrations (>10(-6)M) as shown by transmission electron microscopy. This cytotoxicity effect was also confirmed by the trypan blue exclusion assay (TD(50) of 10(-6)M). Differences in the results between the MTT and trypan blue exclusion assays are probably due to mitochondria that are still metabolically active, causing the tetrazolium salt to be dehydrogenated. The internal architecture of normal primary hepatocytes included large quantities of rough endoplasmic reticulum (often in close proximity to the nucleus), mitochondria, aggregates and scattered glycogen, a few lipid droplets and spherical nuclei with distinct nucleoli. The primary catfish hepatocyte cell culture system, expressing CYP1A when exposed to B[a]P, could be used as a biomarker for aromatic hydrocarbon pollutants in aquatic ecosystems of southern and East Africa.