Factors influencing postnatal liver function tests

OBJECTIVE

To investigate liver function tests (LFTs) changes in the puerperium and the influence of specific obstetric events on these changes.

DESIGN

A longitudinal observational study.

SETTING

West Middlesex University Hospital, Twickenham.

POPULATION

Ninety-four women with uncomplicated pregnancy who delivered at term.

METHODS

Aspartate transaminase (AST), alanine transaminase (ALT), gamma glutamyl transferase (GGT), total bilirubin (Bilirubin) and alkaline phosphatase (ALP) were measured in early labour and on day 1, day 2, day 5 and day 10 postnatal.

MAIN OUTCOME MEASURES

Peak enzyme concentration, time of peak enzyme concentration, the area under the curve for each enzyme and the rate of change of enzyme level from predelivery to peak concentration.

RESULTS

All LFTs were affected by delivery (P < 0.001), increasing by 88% (0-500%) on day 2 or day 5 for AST, 147% (0-1140%) on day 5 for ALT and 63% (0-450%) on day 5 or day 10 for GGT. Multiple linear regression showed that caesarean section and opioid administration was associated with a faster rise in AST (P = 0.001, P = 0.033 respectively). The mean peak GGT concentration was 39% higher in women having caesarean section compared with vaginal delivery (P = 0.015). Univariate analysis showed that perineal trauma, use of Entonox, maternal age at delivery and breastfeeding also influenced LFT concentration significantly.

CONCLUSION

Liver enzyme levels change significantly in the puerperium and are affected by common obstetric events, particularly caesarean section. This study aids clinical interpretation of postnatal LFTs in women recovering from liver-related illnesses, by facilitating the differentiation of physiological and pathological processes.

Immunity against both polyomavirus VP1 and a transgene product induced following intranasal delivery of VP1 pseudocapsid-DNA complexes

Murine polyomavirus VP1 virus-like particles (VLPs) can bind plasmid DNA and transport it into cells both in vitro and in vivo. Long-term expression of the transgene can be observed, suggesting that VP1 VLPs may be used as DNA delivery vehicles for gene therapy. In this study we have analysed the in vitro efficiency of transfection using different DNA/VLP molar ratios and the immune response induced following intranasal administration of these complexes to mice. Our results indicate that in short-term in vitro culture VP1 VLP-DNA complexes appear to be as efficient as DNA alone at transfecting cell monolayers. They also show that VP1 VLPs are very immunogenic, inducing high proliferative cell responses and both serum and mucosal antibodies. Moreover, VP1 VLP-DNA complexes appear to be capable of inducing a stronger immune response to the transgene product (beta-galactosidase) than immunization with DNA only. The results suggest that polyomavirus VP1 VLPs derived from the wild-type sequence may be too immunogenic for repeated use as gene delivery vehicles in gene therapy. However, due to their high immunogenicity and apparent adjuvant properties, they could be modified and used as vaccines either on their own or complexed with DNA.

Abnormal Migration and Extrusion of Abdominal End of Ventriculoperitoneal Shunt: An Experience of Eight Cases

Background:

Ventriculoperitoneal (VP) shunt is commonly used in the treatment of hydrocephalus. Migration and extrusion of the distal end of the VP shunt are relatively rarely occurring complications.

Aim:

To retrospectively analyze patients with extrusion of the abdominal end of ventriculoperitoneal shunts and evaluate the possible etiology and outcome.

Settings and Design:

All patients presenting with extrusion of lower end of the shunt were included. The variables collected were age, sex, site of extrusion, time duration of extrusion, presence of local infection, meningitis, shunt dependency, and treatment received. Contrast-enhanced computed tomography of brain was carried out in all patients to rule out retrograde migration of infection in the cranial cavity.

Materials and Methods:

Eight patients of abnormal migration and extrusion of lower end of VP shunt were included.

Results:

The distal end of VP shunt was extruded from the anus (n = 3), vagina (n = 2), and anterior abdominal wall (n = 3). In five of these patients, shunt catheter was draining cerebrospinal fluid (CSF), the children were afebrile and CSF was sterile. In three children with extrusion of the shunt through the abdominal wall, the shunt tract was infected. Two of these patients had abscess in the shunt tract, which required incision and drainage. Both these patients had meningitis with a growth of Streptococcus species from CSF. Seven patients required further CSF diversion such as endoscopic third ventriculostomy (n = 3) or placement of VP shunt (n = 4).

Conclusion:

Distal tip migration of VP shunt may prove to have potentially serious complications such as meningitis. A prompt and aggressive protocol of management is recommended.

The importance of the deep volar compartment in crush injuries of the forearm

Two cases are described of blunt injury to the forearm in the absence of bone injury, resulting in an acute deep volar compartment syndrome. The importance of the deep flexor compartment of the forearm is noted. The diagnostic pitfalls and the use of intra-compartmental monitoring are discussed. We emphasize that all such cases must be admitted and carefully studied as a matter of routine. If operation is undertaken, both the superficial and deep volar compartments must be adequately decompressed.

The role of transforaminal percutaneous endoscopic discectomy in lumbar disc herniations

OBJECTIVES

To study 1)the efficacy of transforaminal percutaneous endoscopic lumbar discectomy in lumbar disc herniations.2) limitations and advantages of the surgical procedure. 3)morbidity and complications associated with the procedure.

MATERIALS AND METHODS

This study was carried out on 120 patients who had single level herniated disc Pre-operative assessment of VAS and MSS scoring systems were documented one day prior to surgery. Post operative results were determined by MacNab criteria and by modified Suezawa and Schreiber clinical scoring system (MSS score).

RESULTS

Maximum patients were in the age group of 31 to 40 years and 83.43% of the patients were males. 80% patients had lumbar disc herniation at L4-L5 level, The mean operative time of endoscopic discectomy was 52.28 minutes and the mean hospital stay was 2.1days.8 cases of L5-S I were abandoned due to high iliac bone and hence their disc could not be accessed. Out of 112 patients who underwent operation, 2 patients developed discitis and 1 was found to have dysesthesia. Also recurrent prolapsed intervertebral disc was seen in 6 cases The mean preoperative and 6 months follow-up VAS score was 8.4 and 1.89 respectively. Mean preoperative and 6 months follow-up Modified Suezawa And Schreiber Clinical Scoring System(MSS Score) was 3.47 and 7.92 respectively. MSS score showed excellent and good outcome in 82.12% patients and Modified Macnab Criteria showed excellent and good outcome in 89.3% patients at 6months follow-up.

CONCLUSION

TPELD can be a reasonable alternative to conventional microscopic discectomy for the treatment of patients with LDH. We also conclude that TPELD is not an effective procedure for L5-S 1 disc and an open procedure should be opted for better outcomes.

Microendoscopic discectomy for lumbar disc herniations

Introduction:

Lumbar disc herniation is one of the main causes of discogenic low back pain and reported to affect 60%–80% of people during their lifetime. The two main surgical modalities for intervertebral disc surgery are standard open discectomy and minimally invasive discectomy which include percutaneous endoscopic lumbar discectomy and microendoscopic discectomy (MED). We report our experience with the same technique of MED to evaluate the efficacy of MED for lumbar disc pathology.

Aims and Objectives:

The aims and objectives were to study the efficacy, advantages, and associated limitations and complications of MED in lumbar disc herniations.

Materials and Methods:

This study was carried out on 300 patients who had single-level herniated disc. The procedure was done by Microscopic Endoscopic Tubular Retraction System. Preoperative assessment of Visual Analog Scale (VAS) and modified Suezawa and Schreiber (MSS) clinical scoring system was documented 1 day prior to surgery. Postoperative results were determined to be excellent, good, fair, or poor according to MacNab criteria and also evaluated by MSS clinical scoring system on postoperative day 7 and after 6 months.

Results:

A total of 187 patients were males and 113 patients were females and a majority of patients were in the age group of 31–40 years. A total of 192 patients had disc herniations at L4–L5 level. The mean operative time was 82 min and the mean hospital stay was 5.3 days. Eighteen cases (6%) developed postoperative complications including discitis, dysesthesia, recurrent prolapsed intervertebral disc, residual disc, dural tear, and nerve root injury. Mean preoperative VAS score was 8.7 and the mean postoperative VAS scores at postoperative day 7 and at 6 months were 2.25 and 1.12, respectively. The mean preoperative MSS score was 3.27 and the MSS scores at postoperative day 7 and at 6 months were 7.42 and 8.2, respectively. The overall successful outcome of the endoscopic discectomy after 6-month follow-up on the basis of VAS improvement percentage was 87.6%, MSS scoring percentage was 91.6%, and MacNab scoring percentage was 92.67%.

Conclusion:

MED is a safe and effective technique. It offers decreased blood loss, shorter operative time, shorter in-hospital stay, decreased need for pain medication, decreased rate of infection, and a shorter return to work time. Limitations of this technique include a learning curve which is related to surgery time, complications, conversion to open procedures, and recurrent disc herniation.

Giant intradural intramedullary epidermoid cyst Report of two cases with varied presentations

We report two cases with giant intramedullary epidermoid cysts in the thoracolumbosacral and lumbosacral regions with varied presentations. Magnetic resonance (MR) imaging of the thoraco lumbar spine in case 1revealed an intramedullary elongated mass extending from T10 to S2 level causing significant widening of the spinal canal while MR imaging of lumbosacral spine in case 2 showed straightening of the lumbar spine and spina bifida at L5 level with conus at L3 and a lobulated long segment intramedullary solid cystic lesion extending from L2 to S2 veterbrae. The lesion was surgically resected and the pathology revealed an epidermoid cyst. Epidermoid cysts of the spinal cord are rare tumours in the adult population which may be congenital or acquired. Symptoms arising from epidermoid cysts vary with the level of involvement. The treatment of epidermoid cysts is surgical and if possible, complete removal is the goal.

A rare case of an aneurysmal bone cyst of the temporal bone

Aneurysmal bone cysts (ABCs) are benign bone lesions mainly occurring at the metaphyseal end of long bones and are a rarity in the calvarium. The reported incidence of this lesion in the skull is 1% of all the ABC. It is a benign condition that may extend intracranially. We report here a case of a 3½-year-old male child who presented with a bony hard, painless, and gradually enlarging swelling over his right temporal region. Radiological investigations and histology revealed that the lesion was an ABC. A total surgical excision was achieved despite its intracranial extension along with the involvement of dura. Prognosis is excellent with total removal as a total surgical removal of the lesion is considered curative. The rarity of the lesion along with a good surgical result despite an intracranial extension with dural involvement prompted this report.

Calculation of pulsed NMR signal in I = 3/2 quadrupolar spin system

The rf pulse response of I = 3/2 spin system experiencing first order quadrupolar splitting is studied using density matrix approach. A general expression is derived in terms of spin populations, quadrupole splitting and duration and amplitude of the rf pulse for calculating the NMR signal arising due to the centre line and satellite resonances for the situation where the impressed rf pulse excites the resonances selectively as well as non-selectively. The necessary 4 X 4 transformation matrix obtained analytically by diagonalyzing the Hamiltonian are used to get the expression for the centre line response. The satellite signals are obtained in the same way but by using the numerical values of the roots of the related quartics. The widths of the corresponding pi/2-pulses are calculated for different initial spin populations. The variations of this pulse-width and the corresponding signal amplitude as a function of satellite splitting are studied.

A Rare Chronic Presentation of Schwannoma with Hemorrhage

Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.

A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma

Primary pituitary tuberculosis (PTA) is a very rare disease. The clinical diagnosis is difficult as it is clinically radiologically indistinguishable from other sellar lesions. We present a case of PTA without any predisposing etiology and radiologically mimicking a pituitary macroadenoma. The patient underwent endoscopic transsphenoidal resection where pus admixed with mucoid was seen coming out of the lesion intraoperatively. Histology of the cyst wall was suspective of tuberculous etiology and QuantiFERON Tb Gold done for confirmation was positive. Postoperatively patient showed obvious improvement in visual symptoms. Patient developed diabetes insipidus and was put on desmopressin and was started with anti-tuberculosis medication for 18 months. Timely surgical intervention followed by anti-tubercular therapy and hormone replacement is the mainstay of treatment in these cases. For intraoperative management, we advise thorough wash with antibiotic and saline rather than curetting the walls of the abscess to decrease the postoperative incidence of endocrine abnormalities.

Neuroophthalmic Manifestations of Intracranial Tumours in Children

BACKGROUND

All children between 0 and 16 years presenting with brain tumours confirmed by Magnetic Resonance Imaging (MRI) and treated surgically in our institute were included in this study.

OBJECTIVE

The aim of this study is to evaluate the neuroophthalmic and clinical characteristics of intracranial space occupying lesions in children.

METHODS

Neuroophthalmic manifestations along with location of the tumour by contrast-enhanced MRI, type of surgical intervention, and postoperative histopathological diagnosis were evaluated.

RESULTS

In pediatric brain tumours, male preponderance was seen and supratentorial location was more common in general, while in older children, infratentorial tumours were more common than supratentorial tumours. Headache, vomiting, and cerebellar signs were the commonest neurological features. Diminution of vision, diplopia, and strabismus were the commonest ophthalmic symptoms. Papilledema, ophthalmoparesis, and nystagmus were the most frequent ophthalmological signs. Neurological manifestations of seizures, altered sensorium and motor deficits were more frequently seen in supratentorial tumours, while cranial nerve involvement and ataxia were seen in infratentorial tumours. Ophthalmological manifestations including diplopia, strabismus, ophthalmoparesis, and nystagmus were more frequently seen in infratentorial tumours. Astrocytoma was the most frequent histopathological diagnosis followed by medulloblastoma.

CONCLUSION

Diagnosis of pediatric intracranial tumours is complex and requires a multidisciplinary approach for prompt management. An ophthalmologist should have a high index of suspicion for brain tumours especially in patients presenting with common ocular symptoms like diminution of vision, diplopia, and strabismus without any neurological symptoms.

Clinical Efficacy of a 2-Week Treatment Course of Zuranolone for the Treatment of Major Depressive Disorder and Postpartum Depression: Outcomes From the Clinical Development Program

Introduction

Antidepressants that offer a rapid onset of action without requiring chronic use are greatly needed in both major depressive disorder (MDD) and postpartum depression (PPD). Zuranolone is an investigational, oral, neuroactive steroid and GABA_A receptor positive allosteric modulator in clinical development as a 2-week treatment course for MDD and PPD.

Objectives

To present the efficacy and safety of zuranolone vs placebo in Phase 2 and 3 trials.

Methods

In the studies presented (Table 1), improvements in depressive symptoms were assessed by least-squares mean (LSM) using a mixed-effects model for repeated measures on the change from baseline (CFB) at Day 15 in the 17-item Hamilton Rating Scale for Depression total score (HAMD-17; primary endpoint for all trials) and the Montgomery–Åsberg Depression Rating Scale (MADRS; secondary endpoint) following a 14-day treatment course of once-daily zuranolone.

Results

Compared with placebo, zuranolone treatment led to rapid improvements in depressive symptoms across clinical trials, with significant improvements (LSM treatment difference [SE] in CFB) in HAMD-17 and MADRS scores at Day 15 in 3 of the 4 trials (Table 2). Common treatment-emergent adverse events (≥5% in zuranolone treatment arms) were headache, somnolence, dizziness, nausea, sedation, diarrhea, upper respiratory tract infection, and fatigue (Table 3). No incidences of loss of consciousness or excessive sedation were observed.

Conclusions

Across the completed studies in the zuranolone clinical trial program, patients receiving zuranolone consistently experienced improvement in depressive symptoms following a 2-week treatment course. Treatment with zuranolone was generally well tolerated with a consistent safety and tolerability profile.

Disclosure

The MDD-201B, MOUNTAIN, and ROBIN studies were sponsored by Sage Therapeutics, Inc; the WATERFALL study was sponsored by Sage Therapeutics, Inc, and Biogen. Medical writing and editorial support were provided by MediTech Media, Ltd, and funded by Biogen.

A rare case of subependymal giant cell astrocytoma presenting with spontaneous intratumoral hemorrhage

ABSTRACT

Subependymal giant cell astrocytomas (SEGAs) are low-grade gliomas usually arising in the periventricular regions near the foramen of Monro seen exclusively with tuberous sclerosis complex. Incidence of hemorrhage in SEGA is less than 1% with only 10 cases reported in English literature. We present a similar case of SEGA with spontaneous intratumoral hemorrhage in a 35-year-old male with cutaneous manifestations of tuberous sclerosis complex and acute onset headache with convulsion.

Radiologic Imaging in Third Nerve Palsy: A Case Series Investigating Etiology, Patterns, and Clinical Implications

Third nerve palsy (TNP) is a neurologic condition characterized by dysfunction of the oculomotor nerve, leading to various ocular manifestations. Optic nerve evaluation is of utmost important among all cranial nerve palsies affecting the eye. Dysfunction of the third nerve can indicate an underlying neurologic emergency, such as cavernous arteriovenous fistula or giant cell arteritis. Early recognition and prompt treatment are vital in reversing the clinical and visual impairments associated with oculomotor nerve palsy. The typical presentation of isolated TNP involves deviation of the eye in a downward and outward direction, accompanied by ptosis (drooping of the eyelid) and, potentially, pupil involvement. The decision to use vascular imaging is influenced by factors such as age and clinical risk for an aneurysm. If TNP is isolated or partially present with pupil involvement, it suggests compression of the third nerve and necessitates immediate imaging. Given the serious implications of an intracranial aneurysm, physicians often prioritize vascular imaging during the initial evaluation, if available. However, if clinical findings indicate underlying microvascular ischemia, a delay in imaging may be considered. This case series aims to explore the role of radiologic imaging in understanding the etiology, patterns, and clinical implications of TNP.