Ultrasound-assisted development of stable grapefruit peel polyphenolic nano-emulsion: Optimization and application in improving oxidative stability of mustard oil

Grapefruit (Citrus paradisi) peel (GP) is rich in flavonoids and phenolics which have several proven pharmacological effects. However, their chemical instability towards oxygen, light and heat limits its applications in food industries. In the present study, we evaluated the feasibility of fabricating grapefruit-peel-phenolic (GPP) nano-emulsion in mustard oil using ultrasonication. Response surface methodology (RSM) optimization revealed that sonication time of 9.5 min at 30% amplitude and 0.52% Span-80 produced the stable GPP nano-emulsion with a droplet size of 29.73 ± 1.62 nm. Results indicate that both ultrasonication and Span-80 can assist the fabrication of a stabilized nano-emulsion. This study is one of its kind where nano-encapsulation of GPP into W/O emulsion was done to stabilize the active compound inside mustard oil and then the nano-emulsion was used to extend oxidative stability of mustard oil. Findings provide a basic guideline to formulate stable nano-emulsions for their use in active food packaging, oils, and pharmaceuticals.

Aqueous ozone controls decay and maintains quality attributes of strawberry (Fragaria × ananassa Duch.)

Investigations were made on the changes in physical and biochemical attributes, fruit decay and storage life of 'Winter Dawn' strawberry fruits in response to aqueous ozone dip treatment for different exposure times. Fruits were subjected to 0.1 ppm aqueous ozone for different time intervals (1-4 min). The treated strawberries were air dried and stored under ambient (25 ± 2 °C and 45-50% RH) and low temperature (2 ± 1 °C and 90% RH) conditions. Results revealed that treatment of strawberry fruits with aqueous ozone @ 0.1 ppm for 2 min resulted in 21% lower weight loss, 16% higher firmness and 15% lesser change in fruit colour during 2 days in ambient storage. Under low temperature storage, 2 min ozone treated fruits exhibited ~ 21% lower PLW, 19% higher firmness and 46% lesser colour change as compared to control fruits during 14 days of storage. Fruit decay reduced significantly under both low and cold storage conditions. Thus, it can be concluded that application of aqueous ozone for 2 min was able to retain the strawberry fruit quality and extend its storage life till 14 days under low temperature storage and 2 days under ambient storage conditions.

Nutritional characterization of apple as a function of genotype

Twenty two apple cultivars grown in Himachal Pradesh, India were harvested at commercial maturity and analysed for different physical (fruit weight, fruit dimensions, firmness, color) and nutritional attributes (ascorbic acid, antioxidant activity, total carotenoid, sugars, organic acids, phenolic compounds and minerals). Cultivar 'Oregon Spur II' was found to have maximum fruit size and weight while the least was observed for cultivar 'Starkrimson'. Quantitative differences were found in the nutritional profile among the cultivars with respect to all the above attributes. The ascorbic acid content ranged between 19.38 mg 100 g^-1 ('Well Spur') and 32.08 mg 100 g^-1 ('Starkrimson') while the antioxidant activity varied between 2.64 μmol Trolox equivalent g^-1 ('Granny Smith') and 13.20 μmol Trolox equivalent g^-1 ('Silver Spur'). The highest total carotenoid was found in 'Red Chief' (147.06 mg kg^-1) while in 'Early Red-I' the total carotenoid was only 29.03 mg kg^-1. HPLC analysis for individual sugars, organic acids and phenolic compounds was carried out. Fructose (average 50.79 g L^-1) was the most abundant sugar. Malic acid (average 6.03 mg L^-1) predominated among the individual organic acids. Potassium (average 795.14 mg 100 g^-1) and iron (average 2.04 µg g^-1) were the predominant macro and micro elements, respectively. Chlorogenic acid was the major constituent among phenolic compounds.

Randomized Assessment of the Safety and Efficacy of Intra-Arterial Infusion of Autologous Stem Cells in Subacute Ischemic Stroke

BACKGROUND AND PURPOSE

Stroke is a debilitating illness for which treatment window is limited. Most patients present to the healthcare facility beyond that window. Autologous stem cells have shown some promise for this group of patients. This study was performed to evaluate the safety and the efficacy of intra-arterial infusion of bone marrow-derived mononuclear cells in patients with middle cerebral artery ischemic stroke.

MATERIALS AND METHODS

A prospective, randomized, open-label, blinded-end point study was performed from July 2015 to June 2016. Of 229 patients with acute stroke who presented to the hospital during this period, 20 patients who satisfied the inclusion/exclusion criteria were included and randomized into the control and intervention groups. Intra-arterial stem cell infusion into the ipsilateral MCA was performed in the patients in the intervention group at 8-15 days post-stroke ictus. Final analysis at 6 months was performed for primary (safety) and secondary outcomes (efficacy).

RESULTS

When we compared the primary end point of the study, no procedure-related mortality, complication, new infarct, or symptomatic intracranial hemorrhage was seen in the intervention group. When we compared the secondary end point of good clinical outcome, 8 (80%) patients in the intervention group showed good clinical outcome (modified Rankin Scale score < 2) with 4 (40%) patients in the control group achieving this (95% confidence interval for good outcome in patients with stem cell infusion, 49.03-94.3, and without stem cell infusion, 16.82-68.73; P = .068).

CONCLUSIONS

Intra-arterial infusion of stem cells can be carried out safely in the subacute stage of ischemic stroke. Improved clinical outcomes were observed with intra-arterial stem cell therapy; however, studies with larger cohorts are needed to validate the results.

Antioxidant degradation kinetics in apples

The effect of shelf storage under ambient conditions of cut apple dices on degradation of bioactive compounds such ascorbic acid, total phenols, antioxidant activity (% DPPH inhibition) and PPO activity were investigated. The results indicated that antioxidant activity declined significantly over 80 min storage of diced apples at ambient temperature. Similar trend was observed for ascorbic acid, total phenols and PPO activity. Ascorbic acid, total phenols and antioxidant activity degradation followed first-order kinetics where the rate constant (k) was found to be in range for all the thirteen cultivars, though initial ascorbic acid and phenol content varied in different apple cultivars. The reaction rate constant (k) for first order degradation ranged from 1.16 to 1.97, 0.89 to 1.29 and 0.37 to 1.54 for antioxidant activity, total phenols and ascorbic acid, respectively. This explains that antioxidant activity degrades at higher rate than total phenols and ascorbic acid, which also corroborates that antioxidant activity is affected by both total phenols and ascorbic acid content. In general, total antioxidant activity for apple dices kept for 80 min under ambient conditions exhibited lower values as compared to control.

Surgical Management of Moderate Sized Spontaneous Cerebellar Hematomas: Role of Intracranial Pressure Monitoring

AIM

Acute onset spontaneous cerebellar hematoma (SCH) is a neurosurgical emergency with unpredictable natural history and outcome. Specific guidelines are available for management of small ( < 2.5 cm) and large sized (4.0 cm < ) SCH. But, literature is sparse for treatment of moderate sized SCH (2.5-4.0 cm).

MATERIAL AND METHODS

In a retrospective analysis of 32 patients, with moderate sized acute SCH, external ventricular drainage (EVD) tube was inserted for evaluation of ICP and evacuation of cerebrospinal fluid. All patients with ICP > 25 mmHg underwent emergency SCH evacuation. Postoperatively, EVD was continued for 48-72 hours for ICP monitoring. Patients showing no improvement or persistent ventriculomegaly underwent ventriculoperitoneal shunt (VPS) insertion for the management of hydrocephalus.

RESULTS

29/32 patients needed operative intervention either in the form of hematoma evacuation or shunt placement. 10 patients improved to GOS 5 and 7 to GOS 4. Overall mortality was 25% (n=8). Despite SCH evacuation, none of the patients with ICP > 40 mmHg experienced good outcome (p < 0.0001).

CONCLUSION

47% of patients with moderate sized SCH need surgical evacuation. EVD insertion not only helps in ICP management but also includes the ability to gradually decompress ventricular system by varying the outflow pressure. Apart from radiologic findings, ICP measurement should be a guideline in management decisions.

Pattern of phenolic content, antioxidant activity and senescence-related enzymes in granulated vs non-granulated juice-sacs of 'Kinnow' mandarin (Citrus nobilis x C. deliciosa)

'Kinnow' is a hybrid mandarin, developed at California (USA) but could not become successful there. However, it revolutionized citrus industry in India, Pakistan and Bangladesh. Recent reports indicate that like other citrus fruits, it also suffers from juice-sac granulation but exact cause of this malady is not known. Fully-mature 'Kinnow' fruits were harvested and observations on some physical and biochemical attributes were recorded and their relationship was established with occurrence of granulation. About 12.8 % 'Kinnow' fruits were affected by juice-sac granulation. Granulated fruits had higher average weight (178 ± 2.26 g), peel thickness (3.72 ± 0.23 mm), and less soluble solids concentrates (7.4 ± 0.21 %) than non-granulated fruits. Granulated fruits exhibited lower concentrations of total phenolics compounds (4.3 ± 0.56 mg 100(-1) g gallic acid equivalent fresh weigh) and antioxidants activity (1.78 ± 0.29 μmol Trolox g(-1) FW) but produced higher rates of carbon dioxide and ethylene, and exhibited higher activities of senescent-related enzymes such as lipoxygenase (LOX) (1.3 ± 0.31 μmoles min(-1) g(-1) FW) and pectin methylesterase (PME) (0.52 ± 0.12 μmol of NaOH g(-1) FW min(-1)) and had strong relationships with the occurrence of granulation. From this study, it can be concluded that total phenolics compounds, antioxidants and PAL enzyme activity have strongly negative co-relation; whereas, senescent-related enzymes such as LOX, and PME and rates of respiration or ethylene evolution have strongly positive relationships with the occurrence of granulation in 'Kinnow' mandarin.

In vitro and in vivo activity of essential oils against major postharvest pathogens of Kinnow (Citrus nobilis × C. deliciosa) mandarin

The present study envisages the influence of essential oils namely lemon grass, eucalyptus, clove and neem on Kinnow mandarin with the objective to combat major post harvest diseases and to prolong its availability for longer time in the season. For this, in vitro and in vivo studies were conducted. Poisoned food technique was used for in vitro studies, and for in vivo studies, Kinnow fruit were pre-inoculated with pathogens (Penicillium digitatum and P. italicum), treated with different essential oils and then stored at 5 °C ±1 °C temperature and 85-90 % RH). Our results indicated that all essential oils inhibited the growth (colony diameter) of both pathogens over untreated PDA plates, but the inhibition was the strongest by lemon grass oil. Similarly, under in vivo conditions, all essential oils influenced decay incidence, decay loss, lesion diameter, respiration rate, ethylene evolution, overall acceptability and physiological loss in weight but lemon grass was the most effective. And also the incidence of Penicillium italicum was more noticed in fruits than P. digitatum, however, it was reverse under in vitro conditions. The decay rot at all stages of storage was less in EOs treated fruits than untreated fruits, thereby increasing their storage life significantly. Thus, it is evident from our studies that essential oils have the potential to control green and blue mold without causing any injury or harmful effects on Kinnow mandarin, and EOs can be recommended as a safe method for extending its storage life while maintaining fruit quality.

Transfusion-related adverse events at the tertiary care center in North India: An institutional hemovigilance effort

Aim:

This study was designed to analyze the incidence and spectrum of adverse effects of blood transfusion so as to initiate measures to minimize risks and improve overall transfusion safety in the institute.

Materials and Methods:

During the period from July 2002 to July 2003 all the adverse events related to transfusion of blood and blood components in various clinical specialties were recorded. They were analyzed and classified on the basis of their clinical features and laboratory tests. Attempt was also made to study the predisposing risk factors.

Results:

During the study period 56,503 blood and blood components were issued to 29,720 patients. A total of 105 adverse reactions due to transfusion were observed during the study period. A majority of the adverse reactions was observed in hemato-oncology patients 43% (n = 45) and in presensitized patient groups 63% (n = 66). FNHTR 41% (n = 43) and allergic reactions 34% (n = 36) were the most common of all types of adverse transfusion reactions, followed by AcHTR 8.56% (n = 9). Majority of these AcHTR were due to unmonitored storage of blood in the refrigerator of wards resulting in hemolysis due to thermal injury. Less frequently observed reactions were anaphylactoid reactions (n = 4), bacterial sepsis (n = 4), hypervolemia (n = 2), hypocalcemia (n = 2), TRALI (n = 1), DHTR (n = 1), and TAGvHD (n = 1).

Conclusion:

Analysis of transfusion-related adverse outcomes is essential for improving safety. Factors such as improvement of blood storage conditions outside the blood bank, improvement in cross-matching techniques, careful donor screening, adherence to good manufacturing practices while component preparation, bedside monitoring of transfusion, and documentation of adverse events will help in reducing transfusion-related morbidity and mortality.

Leukoreduced blood components: Advantages and strategies for its implementation in developing countries

Removal of leucocytes from various blood products has been shown to minimize Febrile nonhemolytic transfusion reactions, HLA alloimmunization, platelet refractoriness in multitransfused patients and prevention of transmission of leukotropic viruses such as EBV and CMV. Rapidly growing size of hemato-oncological patients in our country requiring multiple transfusion of blood and components during the course of their management pose a great challenge to transfusion services to provide them red cell and platelet antigen matched products in alloimmunized subjects. Thus removal of leucocytes below a certain threshold, ≤ 5 × 10⁶ in a blood component certainly helps in prevention of alloimmunization and associated risks in these patients. Currently the best Leucoreduction can be achieved with the help of 3rd and 4th generation leukofilters, both in laboratory and patient bed side, and state of the art apheresis devices. The present article briefly reviews the current literature for pros and cons of leucofilteration and its scope of implementation in the cost constrained settings.

Evaluation of heat shrinkable films for shelf life, and quality of individually wrapped Royal Delicious apples under ambient conditions

Effect of heat shrinkable films on shelf life and quality of apples under ambient conditions was studied. Fully mature Royal Delicious apples (starch index 2.5 on 4.0 point scale) were either shrink-wrapped in 3 heat shrinkable films like Cryovac (9 μ), polyolefin (13 μ) and LDPE (25 μ) or were not wrapped at all (control) and then stored at ambient conditions (22-28°C and 52-68% RH). Observations on physiological loss in weight (PLW), decay loss, firmness, juice recovery, total soluble solids (TSS), acidity, ascorbic acid content and overall sensory quality were recorded immediately before packing, and after packing at weekly intervals. Best results were obtained with Cryovac (9 μ) films, which exhibited least PLW (2.3%) and decay loss (2.8%) and higher juice recovery (65.2%) and TSS (16.4%) over other films or control. Apples wrapped in Cryovac films also had higher overall sensory acceptability (8.3 out of 9) over other films or control. These studies indicated that apples could be very well packed in Cryovac heat shrinkable films for about 35 days with least PLW or decay loss, and without any adverse effect on fruit quality.

Efficacy of autologous bone marrow-derived stem cell transplantation in patients with type 2 diabetes mellitus

Progressive and inexorable beta-cell dysfunction is the hallmark of type 2 diabetes mellitus (T2DM) and beta-cell regeneration using stem cell therapy may prove to be an effective modality. A total of 10 patients (8 men) with T2DM for >5 years, failure of triple oral antidiabetic drugs, currently on insulin (> or = 0.7 U/kg/day) at least for 1 year, and glutamic acid decarboxylase antibody negative were included. Patients on stable doses of medications for past 3 months were recruited. Primary end points were reduction in insulin requirement by > or = 50% and improvement in glucagon-stimulated C-peptide levels at the end of 6 months of autologous bone marrow-derived stem cell transplantation (SCT), while secondary end points were a change in weight and HbA1c and lipid levels as compared to baseline. Seven patients were responders and showed a reduction in insulin requirement by 75% as compared to baseline. Mean duration to achieve the primary objective was 48 days. Three patients were able to discontinue insulin completely, although it was short-lived in one. Mean HbA1c reduction was 1% and 3 of the 7 responders had HbA1c value <7%. A significant weight loss of 5.5 kg was noted in the responders, whereas, nonresponders gained 2.2 kg of weight. However, weight loss did not correlate with reduction in insulin requirement (r = 0.68, P = 0.06). There was a significant improvement in both fasting and glucagon-stimulated C-peptide level in the group (P = 0.03) and responders (P = 0.03). HOMA-B increased significantly in the whole group (P = 0.02) and responders (P = 0.04) whereas, HOMA-IR did not change significantly (P = 0.74). Reduction in insulin doses correlated with stimulated C-peptide response at the baseline (r = 0.83, P = 0.047) and mononuclear cell count of infused stem cells (r = 0.57, P = 0.04). No serious adverse effects were noted. Our observations indicate that SCT is a safe and effective modality of treatment to improve beta-cell function in patients with T2DM. However, further large-scale studies are needed to substantiate these observations.

Efficacy of autologous bone marrow-derived stem cell transplantation in patients with type 2 diabetes mellitus

Progressive and inexorable beta-cell dysfunction is the hallmark of type 2 diabetes mellitus (T2DM) and beta-cell regeneration using stem cell therapy may prove to be an effective modality. A total of 10 patients (8 men) with T2DM for >5 years, failure of triple oral antidiabetic drugs, currently on insulin (> or = 0.7 U/kg/day) at least for 1 year, and glutamic acid decarboxylase antibody negative were included. Patients on stable doses of medications for past 3 months were recruited. Primary end points were reduction in insulin requirement by > or = 50% and improvement in glucagon-stimulated C-peptide levels at the end of 6 months of autologous bone marrow-derived stem cell transplantation (SCT), while secondary end points were a change in weight and HbA1c and lipid levels as compared to baseline. Seven patients were responders and showed a reduction in insulin requirement by 75% as compared to baseline. Mean duration to achieve the primary objective was 48 days. Three patients were able to discontinue insulin completely, although it was short-lived in one. Mean HbA1c reduction was 1% and 3 of the 7 responders had HbA1c value <7%. A significant weight loss of 5.5 kg was noted in the responders, whereas, nonresponders gained 2.2 kg of weight. However, weight loss did not correlate with reduction in insulin requirement (r = 0.68, P = 0.06). There was a significant improvement in both fasting and glucagon-stimulated C-peptide level in the group (P = 0.03) and responders (P = 0.03). HOMA-B increased significantly in the whole group (P = 0.02) and responders (P = 0.04) whereas, HOMA-IR did not change significantly (P = 0.74). Reduction in insulin doses correlated with stimulated C-peptide response at the baseline (r = 0.83, P = 0.047) and mononuclear cell count of infused stem cells (r = 0.57, P = 0.04). No serious adverse effects were noted. Our observations indicate that SCT is a safe and effective modality of treatment to improve beta-cell function in patients with T2DM. However, further large-scale studies are needed to substantiate these observations.

Consensus and controversies in platelet transfusion

Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.

Vermicompost substitution influences growth, physiological disorders, fruit yield and quality of strawberry (Fragaria x ananassa Duch.)

Studies were conducted to determine the effect of vermicompost on growth, physiological disorders, fruit yield and quality of 'Chandler' strawberry. For this, 4 levels of vermicompost (2.5, 5.0, 7.5 and 10.0tha(-1)) were supplemented with inorganic fertilizers to balance fertilizer requirement of strawberry under semi-arid region of northern India. The vermicompost was incorporated into top 10cm layer of soil, which was supplemented on the basis of chemical analysis, with amount of inorganic N, P, K fertilizer calculated to equalize the recommended dose of nutrients. Vermicompost application increased plant spread (10.7%), leaf area (23.1%) and dry matter (20.7%), and increased total fruit yield (32.7%). Substitution of vermicompost drastically reduced the incidence of physiological disorders like albinism (16.1-4.5%); fruit malformation (11.5-4.0%) and occurrence of grey mould (10.4-2.1%) in strawberry indicating that vermicompost had significant role in reducing nutrient-related disorders and disease like Botrytis rot, and thereby increasing the marketable fruit yield up to 58.6% with better quality parameters. Fruit harvested from plant receiving vermicompost were firmer, have higher TSS, ascorbic acid content and lower acidity, and have attractive colour. All these parameters appeared to be dose dependent and best results were achieved @ 7.5tha(-1), however, beyond this dose of vermicompost, there was not significant influence on these parameters.

Feasibility of pre-operative autologous blood donation in Indian patients with elective orthopaedic surgery

BACKGROUND & OBJECTIVES

Pre-operative autologous blood donation (PABD) in elective orthopaedic surgeries is a well known procedure in the West. We initiated this programme at a tertiary care hospital in north India to study its feasibility in Indian patients.

METHODS

In a prospective case-control study, 144 patients undergoing primary total hip or knee replacement, inter-vertebral discectomy, mal-union and non-union reconstruction were educated and motivated to pre-donate. Patients fulfilling the inclusion criteria and making autologous donation formed the PABD group (n=22). Patients eligible for PABD, but unwilling to participate; age, sex, pre-operative haemoglobin and operative procedure matched acted as controls (n=27). Unit(s) collected was processed like an allogeneic unit. Unit(s) found reactive for infectious markers or not utilized was discarded. Mean blood losses, transfusion trigger, allogeneic exposure and wastage between the two groups were compared.

RESULTS

Of the 144 patients motivated, 40 per cent of the eligible subjects pre-deposited. The main motivational factor was fear of getting infection from someone's blood. Cardiac events and anaemia prevented 61.8 per cent patients to participate. Of the 50 units ordered, autologous units with a mean of 1.4 units/patient contributed 62 per cent. For total hip and total knee replacement (THR and TKR), autologous units met 76.2 and 80 per cent respectively of the total blood requirement. A significant decrease in the allogeneic exposure was observed between PABD and control group (18.2 vs 66.7%); 32.3 per cent of the autologous units were discarded.

INTERPRETATION & CONCLUSION

Comprehensive PABD programme may be an effective method for reducing the need for allogeneic transfusion in patients undergoing joint replacement surgeries in our country, where transfusion transmitted infections due to high percentage of replacement donations and lack of sensitive assays for testing are still a cause for concern.

Prevalence & significance of hepatitis C virus (HCV) seropositivity in blood donors

BACKGROUND & OBJECTIVES

The clinical significance of anti HCV antibodies in healthy blood donors remains uncertain. These donors are usually asymptomatic and it is difficult to elicit risk factors of acquiring HCV infection during pre-donation questioning. Limited information on donor recall and follow up studies on anti HCV positive blood donors have been reported from India. Paucity of data which is likely to have an impact on safe blood transfusion programme has prompted us to undertake this study to assess the significance of HCV seropositivity in blood donors with respect to their clinical, biochemical and virological profile.

METHODS

A total of 16,250 blood units were screened for the mandatory tests using third generation ELISA (anti HIV 1&2, anti HCV, HBsAg), VDRL and peripheral smear for malaria. Donors reactive for anti HCV were informed. Repeat anti HCV reactive donors were subjected to detailed clinical history focusing on risk factors for HCV transmission. The blood tests included liver function tests (LFT), coagulation and autoimmune profile, qualitative serum cryoglobulins and HCV RNA detection. These donors were followed at 2-3 monthly intervals for a minimum period of six months by LFT.

RESULTS

An overall seropositivity of 0.44 per cent (72/16,250) was observed in our donors which was significantly lower in first time, young voluntary donors as compared to replacement donors (0.27 vs. 0.60%). In contrast to drug abuse (6.4%) we found minor percutaneous routes like sharing of shaving kits or visit to a road side barber (32%) as the major risk factor for HCV transmission. There was no prior history of blood transfusion in any of these donors; however history of some surgical procedures was present in 25.8 per cent. Raised transaminases and HCV viraemia were observed in 87 and 71 per cent donors respectively. An association was observed between HCV RNA when the ELISA ratio was >5.

INTERPRETATION & CONCLUSION

Voluntary donors form a safe source of blood supply and efforts should be made to increase this precious source to 100 per cent. Abbreviated behavioural donor screening questionnaire for repeat donors is not advisable. Awareness and education of donors is required regarding modes of HCV transmission. HCV positive donors should be informed about their disease, counselled and referred to hepatologist, and permanently deferred for future donations.

Subgaleal migration of a ventriculoperitoneal shunt

Blockage of a ventriculoperitoneal (VP) shunt is very common. Here, we describe an unusual case of shunt blockage in an infant. He was shunted for hydrocephalus associated with a Dandy-Walker malformation diagnosed at birth. At surgery, the entire VP shunt was found to have migrated into the subgaleal space, which clinically presented as shunt obstruction. We suggest techniques to avoid this rare, but preventable, complication of shunt surgery.

Algorithm for recall of HIV reactive Indian blood donors by sequential immunoassays enables selective donor referral for counseling

BACKGROUND

HIV/AIDS pandemic brought into focus the importance of safe blood donor pool.

AIMS

To analyze true seroprevalence of HIV infection in our blood donors and devise an algorithm for donor recall avoiding unnecessary referrals to voluntary counseling and testing centre (VCTC).

MATERIALS AND METHODS

39,784 blood units were screened for anti-HIV 1/2 using ELISA immunoassay (IA-1). Samples which were repeat reactive on IA-1 were further tested using two different immunoassays (IA-2 and IA-3) and Western blot (WB). Based on results of these sequential IAs and WB, an algorithm for recall of true HIV seroreactive blood donors is suggested for countries like India where nucleic acid testing or p24 antigen assays are not mandatory and given the limited resources may not be feasible.

RESULTS

The anti-HIV seroreactivity by repeat IA-1, IA-2, IA-3 and WB were 0.16%, 0.11%, 0.098% and 0.07% respectively. Of the 44 IA-1 reactive samples, 95.2% (20/21) of the seroreactive samples by both IA-2 and IA-3 were also WB positive and 100% (6/6) of the non-reactive samples by these IAs were WB negative. IA signal/cutoff ratio was significantly low in biological false reactive donors. WB indeterminate results were largely due to non-specific reactivity to gag protein (p55).

CONCLUSIONS

HIV seroreactivity by sequential immunoassays (IA-1, IA-2 and IA-3; comparable to WHO Strategy-III) prior to donor recall results in decreased referral to VCTC as compared to single IA (WHO Strategy-I) being followed currently in India. Moreover, this strategy will repose donor confidence in our blood transfusion services and strengthen voluntary blood donation program.

Platelet alloimmunization in multitransfused patients with haemato-oncological disorders

BACKGROUND

We studied the incidence of platelet alloimmunization in multitransfused patients with haemato-oncological disorders and determined the factors influencing alloimmunization. We also assessed the effect of alloimmunization on response to platelet transfusion.

METHODS

Fifty patients with haemato-oncological disorders who received multiple transfusions were included. The patients were tested for antibodies before they received any transfusion and then after 3-4 weeks of transfusion. Lymphocytotoxicity and platelet immunofluorescence suspension tests were used to detect antiplatelet antibodies. Symptomatic improvement was used to assess the response to platelet transfusions.

RESULTS

Thirty patients were positive by the lymphocytotoxicity test, giving an incidence of 60% for anti-HLA antibodies. The panel reactivity of the antibodies ranged from 3% to 100%. Nineteen patients were positive by the platelet immunofluorescence suspension test, 16 of whom were also positive by the lymphocytotoxicity test. The overall incidence of antiplatelet antibodies was 66%. The number of transfusions received and the underlying haemato-oncological disorder were not risk factors for the development of antibodies. Patients with a past history of transfusions and those with a positive obstetric history had a significantly higher incidence of antibodies. The response to transfusion therapy was poor in patients with antibodies, as 71.4% of patients with antibodies were nonresponsive compared to only 26.6% of antibody-negative patients.

CONCLUSION

A high percentage of multitransfused patients developed antiplatelet antibodies. Previous sensitization was an important risk factor for the development of antibodies. Patients with high panel reactivity (HLA) showed non-responsiveness to platelet transfusions. Testing for the presence of antiplatelet antibodies and provision of compatible platelets should be important components in the management of patients with platelet transfusion refractoriness.

Prevalence of markers of transfusion transmissible diseases in voluntary and replacement blood donors

BACKGROUND

Transfusion of safe blood requires a safe donor. The voluntary donor movement encompasses the concept of a donor who is free from transfusion transmissible infections. It is now mandatory to screen blood for hepatitis B surface antigen, antibodies to HIV-1 and HIV-2, antibodies to hepatitis C virus, syphilis and malarial parasites.

METHODS

Between 1996 and 2002, 235 461 donors were screened for markers of hepatitis B virus, and HIV-1 and HIV-2 using commercially available ELISA kits, VDRL test for syphilis and Geimsa stain for the malarial parasite, respectively. A total of 56 476 donors were screened for hepatitis C virus antibodies from June 2001 to December 2002, using third-generation ELISA kits.

RESULTS

The proportion of voluntary donors increased from 47% to 56% during the study period. The prevalence of HIV showed a steady increase from 0.16% in 1996 to 0.3% in 2002. The prevalence of hepatitis B surface antigen decreased from 1.55% to 0.99%. VDRL reactivity did not show any trend and ranged between 0.11% and 0.66%. Hepatitis C virus antibodies showed a prevalence of 0.4%. The prevalence of all markers was significantly less in voluntary donors. Among the voluntary donors, transfusion transmissible disease markers were significantly less in student donors as compared to other donors.

CONCLUSION

A change-over to a voluntary donor service would considerably reduce the number of infectious donors and, among voluntary donors, student donors are the safest.

Local control of high-grade gliomas with limited volume irradiation versus whole brain irradiation

INTRODUCTION

To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM).

MATERIAL AND METHODS

From July '96 to January '98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field.

RESULTS

20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups.

CONCLUSIONS

Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.

Choroid plexus papilloma of the posterior third ventricle during infancy & childhood: report of two cases with management morbidities

We report two cases of posterior third ventricular choroid plexus papilloma, one in an 8-month-old infant and another in a two-year-old child. These cases presented with features of obstructive hydrocephalus. Both these patients underwent a ventriculo-peritoneal (VP) shunt surgery prior to the tumor excision. Following the VP shunt surgery both patients developed ascitis requiring exteriorization of the abdominal end of the shunt. There was a clear proof of CSF overproduction: 1400-1500 ml/day in the eight-month-old infant and 900-1200 ml/day in the two-year-old child. In the former it was transient and could be treated with revision of the VP shunt whereas in the second case a ventriculo-arterial shunt had to be done. In the second case a staged reduction cranioplasty was also performed for an enormously enlarged head (head circumference--74 cm). Interesting clinical and radiological findings and useful management strategies are described.

Angiolipoma of the right inferior colliculus: a rare central cause of hearing loss and limb ataxia

Intracranial angiolipomas are rare entities and are infrequently symptomatic. These benign lesions are adherent to the surrounding neurovascular structures as they share the same blood supply, which limits their resectability, and impose a possibility of persistence of symptoms. However, due to recent advancements in the neuro-radiological fields and microneurosurgical techniques it has been possible to localise precisely and excise these lesions with low morbidity and mortality. The authors present an interesting rare case of intracranial angiolipoma of the right inferior colliculus situated in the quadrigeminal plate cistern. The patient had presented with ipsilateral hearing loss and upper limb ataxia. Interesting clinical findings, neuro-imaging studies and peroperative features are presented and discussed along with a brief review of the literature.

Intracranial migration of Foley catheter--an unusual complication

Profuse nasal bleeding in cases of severe head injury is mostly associated with facial and skull base fractures and various methods have been tried to control such bleeding. Anterior nasal packing, producing a tamponade effect with a Foley catheter and other inflatable balloon devices are time proven methods. We describe a case of severe head injury with such fractures where a Foley catheter tamponade was attempted to control the severe nasal bleeding and the CT brain scan revealed inadvertent malposition of the catheter into the cranial cavity. This rare entity is described to highlight the potential danger associated with a proven method of controlling severe nasal bleeding and suggestions are outlined as to how to avoid such a mishap, along with a brief review of the literature.

Sudden bilateral foot drop: an unusual presentation of lumbar disc prolapse

Bilateral acute foot drop is reported in a 30-year-old healthy male. He presented with a 7-day history of sudden severe backache, radiating to both the lower limbs and 1-day history of sudden bilateral ankle weakness that progressed to bilateral foot drop within 6 hours. He also developed retention of urine. Investigations revealed a large central disc prolapse at L3-4 with significant canal stenosis at that level. Following surgery the patient had progressive improvement.

Long term outcome in patients with severe head injury and bilateral fixed dilated pupils

Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.

Comparison of electrolyzed oxidizing water with various antimicrobial interventions to reduce Salmonella species on poultry

Foodborne pathogens in cell suspensions or attached to surfaces can be reduced by electrolyzed oxidizing (EO) water; however, the use of EO water against pathogens associated with poultry has not been explored. In this study, acidic EO water [EO-A; pH 2.6, chlorine (CL) 20 to 50 ppm, and oxidation-reduction potential (ORP) of 1,150 mV], basic EO water (EO-B; pH 11.6, ORP of -795 mV), CL, ozonated water (OZ), acetic acid (AA), or trisodium phosphate (TSP) was applied to broiler carcasses inoculated with Salmonella Typhimurium (ST) and submerged (4 C, 45 min), spray-washed (85 psi, 25 C, 15 s), or subjected to multiple interventions (EO-B spray, immersed in EO-A; AA or TSP spray, immersed in CL). Remaining bacterial populations were determined and compared at Day 0 and 7 of aerobic, refrigerated storage. At Day 0, submersion in TSP and AA reduced ST 1.41 log10, whereas EO-A water reduced ST approximately 0.86 log10. After 7 d of storage, EO-A water, OZ, TSP, and AA reduced ST, with detection only after selective enrichment. Spray-washing treatments with any of the compounds did not reduce ST at Day 0. After 7 d of storage, TSP, AA, and EO-A water reduced ST 2.17, 2.31, and 1.06 log10, respectively. ST was reduced 2.11 log10 immediately following the multiple interventions, 3.81 log10 after 7 d of storage. Although effective against ST, TSP and AA are costly and adversely affect the environment. This study demonstrates that EO water can reduce ST on poultry surfaces following extended refrigerated storage.

Symptomatic cranial fibrous dysplasias: clinico-radiological analysis in a series of eight operative cases with follow-up results

Cranial fibrous dysplasias are rare and comprise less than one percent of all primary bone lesions. These painless progressively expanding destructive bone swellings produce cosmetic deformities (commonest), sino-orbital and auditive complications (less common), peripheral compressive cranial neuropathies (uncommon) and compressive central neurological manifestations (rarest). Until recently some of the primary dysplastic skull base lesions were either treated expectantly or excised incompletely. In a significant percentage of cases, these lesions were considered inaccessible. However, with the development of modern neuro-imaging (CT and MRI) and the applications of current skull base approaches, the more aggressive and radical surgical procedures are being undertaken, with a significant improvement in overall outcome. We present a series of 8 cases of fibrous dysplasia in the age group of 10-33 years with a mean age of 19.75 years. Four cases each had monostotic type and polyostotic type. All patients presented with mild to moderate headaches, and seven cases with some form of cosmetic deformity. In 4 patients there was a unilateral proptosis, while only two had visual deterioration. One patient had anosmia and one hearing impairment. In one case fibrous dysplasia was hemicranial, and in another case the disease was pancranial. Neuro-imaging studies have well delineated the extent of the lesions. In two patients with unilateral fronto-orbital fibrous dysplasia, the removal of dysplastic bone, autoclaving and remodeling and replacement were performed. In two patients of sphenoidal wing fibrous dysplasia a total excision was possible. In the remaining four patients, a partial excision was performed. Overall outcome was good. There was no mortality. One patient had recurrent post-operative extradural haematomas. The authors present the results of an analysis of eight surgically treated cases of symptomatic cranial fibrous dysplasias along with their long-term outcome and the lessons learnt from this series.

An unusual posterior mediastinal lipoblastoma with spinal epidural extension presenting as a painful suprascapular swelling: case report and a brief review of the literature

Lipoblastoma is a rare benign pediatric neoplasm of fetal-embryonal fat with little risk of recurrence following total microsurgical excision, but it may progress to local invasion or infiltration if not treated surgically. No adjuvant therapies are usually necessary once the tumor is excised. It is best diagnosed on histopathological studies following excision. An unusual posterior mediastinal lipoblastoma in a 2-year-old Omani girl with spinal epidural extension clinically manifested as a progressive painful suprascapular swelling is reported. It was initially construed to be a benign lipoma, but progressively increasing pain and mild imbalance whilst walking with a tendency to fall on the right side prompted neurosurgical referral and eventual total excision without any added morbidity. Interesting clinical and neuroimaging (CT & MRI) findings are presented and discussed, with a brief review of the literature.

Rathke's cleft cyst presenting as pituitary apoplexy

Sellar lesions mainly constitute pituitary adenomas, craniopharyngiomas and benign cysts. Rathke's pouch cyst is a developmental sellar and/or suprasellar cystic lesion lined by a single layer of ciliated cuboidal or columnar epithelium, which rarely be comes symptomatic. The authors present an interesting case of intrasellar Rathke's pouch cyst, with a presenting feature of acute pituitary apoplexy. This was a 19 year old healthy male who had developed sudden headache and visual disturbance. Neuro-radiological imaging revealed a mass in the sella. Via transsphenoidal approach a haemorrhagic intrasellar cystic lesion was removed and was confirmed as a haemorrhagic Rathke's cleft cyst by histopathological examination. Interesting clinical presentations and the neuroimaging findings are described and discussed.

Intracranial Salmonella infections: meningitis, subdural collections and brain abscess. A series of six surgically managed cases with follow-up results

Focal intracranial infections due to Salmonella are rare. So far, around 80 cases have been reported in the world literature. The authors present their experience of 6 cases of intracranial Salmonella infections, mainly subdural empyema in 5 and effusion in 1. In 1 case, subdural empyema was bilateral, and in another case, there was an associated brain abscess. Positive blood cultures and positive Widal tests were noticed in 2 patients each. Early diagnosis and prompt evacuation of subdural collections and brain abscess and antibiotic therapy lead to satisfactory results. This study suggests that a high index of suspicion, early diagnosis and quick evacuation lead to success; this point is highlighted with the help of a review of the literature.

Craniospinal giant cell tumors: clinicoradiological analysis in a series of 11 cases

Primary craniospinal giant cell tumors are rare (5-15% of all giant cell tumors), locally destructive bone lesions which are generally not associated with Paget's disease. Clinical behavior of the craniospinal giant cell tumor (GCT) is unpredictable but often very aggressive and therefore optimal management of the lesions remains controversial. Wide resection of the involved bone is required, preferably with a wide margin of normal tissue, which may be difficult to achieve in the craniospinal region. The authors analysed a series of 11 patients, which included five cases of cranial and six cases of spinal GCTs. Their ages ranged from 12 to 46 years with a male preponderance. In the five cranial cases, all the tumors involved the skull base, three involved the spheno - ethmoidal region and in two cases the petroclival region was involved. Common presenting symptoms were frontotemporal swelling, epistaxis, local pain and neurological deficits attributable to the neurovascular compression. Proptosis, visual loss, nasal mass and cranial nerve involvement were the common findings. In the six patients with spinal lesions (one cervical, four thoracic and one thoracolumbar), local pain, progressive sensory motor deficits and bladder involvement were common presentations. Neuroimaging studies were performed in various combinations for preoperative evaluation and surgical planning. In cranial cases, multidisciplinary approaches were used to perform a near total or a total excision. In the spinal GCTs, only a partial excision was possible. Postoperative radiotherapy was delivered in ten patients. Histopathological studies were diagnostic. All patients were followed up for periods ranging from one to 10 years, with a mean of 2 years and 3 months. No significant increase in the residual tumor or recurrences, as seen on periodic neuroimaging studies, were noted during their follow-up period.

Immunohistochemistry for core and surface antigens in chronic hepatitis

BACKGROUND

Hepatitis B virus infection constitutes a significant proportion of patients presenting with chronic hepatitis. Chronic hepatitis is said to be due to HBV if HBsAg is demonstrated in the serum with or without replication as determined by the presence of HBeAg in the serum. Immunohistochemical staining for HBsAg and HBcAg in liver tissue has been reported to improve the detection rate of HBV.

AIM

To study positivity of immunohistochemical staining of liver tissue for HBsAg and HBcAg in patients of chronic hepatitis and correlate it with histological activity index.

METHODS

One hundred consecutive patients of chronic hepatitis were selected for this study. Histological scoring of liver biopsies was done using Knodell's numerical scoring system. Immunohistochemical staining was done by the Indirect immunoperoxidase technique using goat polyclonal anti-HBsAg and rabbit polyclonal anti-HBsAg. ELISA was used to detect HBsAg in the serum.

RESULTS

Serum HBsAg was positive in only 40 patients whereas tissue HBsAg was positive in 48 patients. Thirteen of these forty-eight tissue positive HBsAg patients also showed HBcAg on immunohistochemical staining of liver tissue. Patients with higher grades of histological activity index (HAI) score had higher values of serum bilirubin and prothrombin time as compared to the patients with a low HAI score. Significantly higher levels of serum transaminases (AST/ALT) were observed in patients who were positive for both HBsAg and HBcAg when compared with patients positive for HBsAg or HBsAg negative patients. A mixed pattern (diffuse/focal cytoplasmic and membranous) of surface antigen expression was seen in 83.3% patients, whereas expression of core antigen was predominantly nuclear (77%). There was no significant correlation between the pattern of antigen expression and HAI score.

Congenital intra-extracranial dumbbell schwannoma of temporal fossa unassociated with any major cranial nerve

Intracranial schwannomas commonly arise from the vestibular nerve and less commonly from other cranial nerves. On rare occasions, they may be intraparenchymatous, intraventricularor intrasellar. However, the occurrence of a congenital solitary intracranial extradural schwannoma unrelated to any cranial nerve in the absence of von Recklinghausan's syndrome is exceptional. The authors report a unique, heretofore unreported case of a congenital temporal extradural schwannoma, unassociated with any known cranial nerve and with a transcranial extension presenting as a temporal fossa mass since birth in a 16-year-old female patient. Total resection of this tumour was uncomplicated. A brief review of the relevant literature is presented.

Trans-sellar trans-sphenoidal encephaloceles: report of two cases

Trans-sphenoidal encephaloceles are rare entities. Only about 20 such cases have been reported in the world literature to date. Among these, the trans-sellar variety is rarest (five cases). We present two cases of trans-sellar trans-sphenoidal encephaloceles seen over the last 12 years. The first case was a 5 month old male infant presenting with nasal obstruction and a mass in the mouth. The second case was a 14 year old boy presenting with chronic nasal obstruction since early childhood. In the first case, the mass was coming to the mouth through the split palate. In the second case, the mass could be seen in the posterior half of the nose by rhinoscopy. The computed tomography scans including coronal and sagittal reconstructions had revealed trans-sellar trans-sphenoid encephaloceles in both the patients. The magnetic resonance imaging in the second case showed the cavity and the structures of the floor of the third ventricle forming the main fundal contents. The magnetic resonance angiography revealed dipping of the ectatic anterior cerebral arteries in the neck of the encephalocele sac in this case. Extracranial trans-palatal approach and the repair of encephalocele was done in the first case with the palatal reconstruction at the same sitting. In the second patient, a trans-nasal approach with bilateral maxillotomies was performed to repair the encephalocele, and the skull base defect was repaired by a split rib graft, which was fixed with mini-plate and screws posteriorly at the clivus and anteriorly at the anterior edge of the bony defect. The cleft lip and hypertelorism also were corrected at the same sitting. Our first case had CSF leak on the 10th postoperative day and developed fulminant meningitis, despite appropriate antibiotics, and succumbed. The second patient had a good postoperative recovery and a satisfactory follow up for 2 years.

An unusual presentation of an intra-parenchymatous frontal yolk sac tumour : case report

Yolk sac tumours are rare conditions among the germ cell tumours. Intracerebral germ cell tumours are exceedingly rare. A 15 year old girl presenting with a one week history of raised intracranial pressure is described. She had bilateral papilloedema and a right 6th nerve palsy. CT scan showed an intra-parenchymatous right frontal ring enhancing lesion of 2 cms diameter. The patient underwent microsurgical total excision of the tumour, followed by chemotherapy. She was asymptomatic at three years following surgery.

Hypersensitivity to glucocorticoids in patients with raised ICP : report of two cases

Corticosteroids are widely used in patients with raised intracranial pressure associated with cerebral neoplasms, cerebral vascular malformations, cerebral ischaemia and benign intracranial hypertension. In general clinical practice, anti-allergic, anti-inflammatory and immuno-suppressive properties of corticosteroids are commonly utilised in the management of allergic and immunological diseases. However in exceptionally rare circumstances, steroids may be the cause of hypersensitive reactions. Authors report two patients with raised intracranial pressure who developed steroid hypersensitivity. A review of the relevant literature is discussed.

Fatal rhino-orbito-cerebral mucormycosis in an apparently normal host: case report and literature review

Fungal infections of the central nervous system (CNS) are fortunately rare but remain challenging problems occurring mostly in immunocompromised individuals, with protean manifestations, unpredictable course and unfavorable outcome in many cases despite aggressive neurosurgical intervention and recent antifungal drugs. Rhino-orbito-cerebral mucormycosis is a potentially lethal opportunistic fungal infection with rapid progression and high mortality. Its pathogenic nature becomes evident when the patient's general resistance is compromised. We present a case of an invasive rhino-orbito-cerebral mucormycosis in an apparently normal adult who initially developed mild paranasal sinusitis and later developed status epilepticus and despite an aggressive management died. Interesting clinical, neuroimaging and histological findings are described, and the possibility of fatal mucormycosis in an apparently normal host is highlighted.