Radiologic Evaluation Criteria for Chronic Subdural Hematomas: Recommendations for Clinical Trials.

Embolization of the middle meningeal artery has gained substantial interest as a therapy for chronic subdural hematomas. For the results of the currently running chronic subdural hematoma trials to inform clinical practice, sufficient accuracy and matching definitions are necessary. We summarized the current practice in chronic subdural hematoma evaluation and derived suggestions on reporting standards using the {Nested} Knowledge AutoLit living review platform. On the basis of the most commonly reported data elements, we suggested a set of standardized image-based study end points for chronic subdural hematoma evaluation for future trials. The measurement methods and reporting standards as proposed in this article have been derived from published best practices and are endorsed by the European Society of Minimally Invasive Neurological Therapy's research committee. The standardization of radiologic outcome measures and measurement techniques in chronic subdural hematoma embolization trials would increase the impact and implication of each trial as well as facilitate data pooling for increased statistical power and, therefore, translation to clinical practice.

Catalytic ozonation of aqueous phenol over metal-loaded HZSM-5.

The performances of HZSM-5 and transition metal-loaded HZSM-5 (Mn, Cu, Fe, Ti) catalysts during catalytic ozonation of phenol have been investigated. It was observed the performance order for removal of phenol and COD was Mn/HZSM-5 > Fe/HZSM-5 > Cu/HZSM-5 > Ti/HZSM-5 > HZSM-5. The presence of metals on HZSM-5 enhanced the phenol removal capability of HZSM-5. Mn loading on HZSM-5 was optimized due to its high phenol removal capability amongst metal-loaded HZSM-5 catalysts. Experimental results suggested that low amount of Mn loading on HZSM-5 was sufficient for HZSM-5 to act as catalyst and adsorbent. A maximum of 95.8 wt% phenols and 70.2 wt% COD were removed over 2 wt% Mn/HZSM-5 in 120 min. It was supposed that transition metals mainly acted as ozone decomposers due to their multiple oxidation states that enhanced the ozonation of phenol.

Excision Versus Fixation of the Radial Head: A Comparative Study of the Functional Outcomes of the Two Techniques.

INTRODUCTION: The management of displaced and comminuted radial head fractures has been a matter of debate amongst surgeons for many years. Radial head excision formed the mainstay of surgical management of these injuries. Over the years, there have been improvements in the surgical techniques and availability of better implants and instrumentation techniques, hence, open reduction and internal fixation of these fractures is gaining popularity. AIM: To compare the outcome of elbow function between radial head excision and open reduction and internal fixation of the radial head with mini screws of Mason Type II and Type III radial head fractures and to assess the complications that occur in both techniques. MATERIALS AND METHODS: A prospective study was conducted in the Department of Orthopaedic Surgery of Justice K.S.Hegde Charitable hospital. A total of 40 patients between the age group of 30-50 years with Mason Type II and Type III fresh closed radial head fractures were included in the study. Group I consisted of 20 patients who underwent radial head excision and Group II consisted of 20 patients who underwent open reduction and internal fixation with mini screws. Patients were reviewed at postoperative week 3, 6 and 24. Radiographs were taken and functional outcome assessment of the elbow was done during all the follow ups. Elbow physiotherapy was started on postoperative week three. Scoring of elbow function was done as per the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system. Results were tabulated, compared and analysed statistically using the 'chi-square test'. RESULTS: At the end of six months, the patients of the open reduction and internal fixation group had lower DASH scores (4.82±2.73 points) than the radial head excision group (14.23±5.60 points). This inferred that patients who underwent open reduction and internal fixation had better functional outcomes than the excision group. Complications of proximal radial migration was noted in three patients, elbow osteoarthritis was noted in two and periarticular ossification was noted in six patients who underwent radial head excision. CONCLUSION: Open reduction and internal fixation of Mason Type II and Type III radial head fractures is a better management technique as compared to radial head excision for management of Mason Type II and III radial head fractures.

A Prospective Study of the Functional Outcome of Anterior Cervical Discectomy With Fusion in Single Level Degenerative Cervical Disc Prolapse.

INTRODUCTION: Cervical spondylotic myelo-radiculopathy is a form of spinal cord dysfunction syndrome and usually accompanies age related degeneration of the spine. AIM: To determine the functional outcome of anterior cervical discectomy with fusion and plating in single level degenerative cervical disc prolapse. MATERIALS AND METHODS: A total of 20 patients diagnosed with degenerative single level cervical disc prolapse who presented to the Department of Orthopaedic Surgery, Justice KS Hegde Charitable Hospital, Mangalore from the period of November 2012 to May 2014 were enrolled in the study. Complete clinical and radiological evaluation of the patients was done. A trial of conservative management was tried in all these patients for a period of two months. They were taken up for surgery only when conservative management had failed. Scoring of neck function before the surgery was done as per the Modified Japanese Orthopaedic Association (MJOA) score. All patients underwent anterior cervical discectomy and fusion (ACDF) with tricortical iliac crest bone grafting. Fixation was performed with titanium locking cervical plates. All patients were reviewed at 6 weeks and 6 months postoperatively. Assessment of neck function was done as per the MJOA scoring during all the reviews. Radiographic assessment was also done during all the reviews. The complications noted were documented. The statistical analysis was done using percentages; the arithmetic mean was calculated using SPSS software (version 16.0). RESULTS: Amongst the 20 patients included in the study, 1 patient died postoperatively due to oesophageal rupture. of the remaining 19 patients reviewed and followed up, all of them had improvement of symptoms and were reported to be in the 'mild category' as per the MJOA score. One patient developed dysphonia, in the immediate postoperative period due to recurrent laryngeal nerve palsy which recovered in a period of three months postoperative. CONCLUSION: Single level anterior cervical discectomy with fusion and anterior cervical plating for degenerative cervical disc prolapse with or without myelo-radiculopathy is an effective and safe surgical procedure with minimal complication rate.

Solitary Fibrous Tumour of the Clavicle: A Rare Case Report.

A Solitary Fibrous Tumour (SFT) is the preferred term by most of the pathologists than "haemangiopericytoma". SFT is a heterogeneous group of benign and malignant neoplasms along a morphologic continuum. Here we report a case of SFT of the clavicle in a 26-year-old male patient, who presented to us with complaints of pain and swelling over the dominant shoulder. No signs of metastasis were noted clinically and radiologically. He underwent surgical resection of swelling. At 6 months after resection and after 22 cycles of radiotherapy, he was noted to have excellent prognosis with satisfactory shoulder function.

A Prospective Study on Functional Outcome of Internal Fixation of Tibial Pilon Fractures with Locking Plate using Minimally Invasive Plate Osteosynthesis Technique.

INTRODUCTION: Managing pilon fractures is still a great challenge for surgeons in terms of reduction and fixation. The soft tissue anatomy and the bony configuration, results in angular and rotational instability and other bony and soft tissue complications. AIM: To evaluate the results of minimally invasive plate osteosynthesis using locking plates in management of fractures of tibial pilon in terms of radiological fracture union, restoration of ankle function and complications. MATERIALS AND METHODS: A total of 18 patients with Ruedi Allgower class I, II & III fresh pilon fractures were taken into this study. All the patients underwent ankle spanning external fixator application on the day of presentation as a first stage. Wound debridement was done in patients with open fractures. Associated distal fibula fractures were fixed in the first stage. The second stage comprised of a definitive plate fixation using the minimally invasive plate osteosynthesis technique. This employed minimal periosteal and soft tissue dissection through a medial approach to the ankle. Postoperatively, all patients were reviewed at week six and 12 when partial weight bearing and full weight bearing mobilization was started respectively. The final review was done at 24 weeks when the final assessment of function was done as per the Mazur's scoring criteria. Analyses were done using frequency and proportions. Chi-square tests were used to assess the test of association. RESULTS: Three patients had excellent inference, nine patients had good inference, five patients had fair and one patient had poor inference as per the Mazur's scoring criteria. Two patients had scar dehiscence as a complication and one patient had a fixed equines deformity of the ankle who was under RuediAllgower class III. CONCLUSION: Minimally invasive plate osteosynthesis is an excellent method of treating pilon fractures with very good functional results and minimal complication rate.

Insertion/deletion polymorphism in the angiotensin-converting enzyme gene and risk of and prognosis after myocardial infarction.

OBJECTIVES: We sought to prospectively investigate whether genetic variation at the angiotensin-converting enzyme gene locus defined by an insertion (I)/deletion (D) polymorphism influences the risk of myocardial infarction or prognosis after infarction, or both. BACKGROUND: It has been suggested that the deletion allele of the angiotensin-converting enzyme gene, and specifically the DD genotype, may increase the risk of myocardial infarction, although previous studies have produced conflicting reports. No studies have yet examined the effect of I/D polymorphism on survival after infarction. METHODS: Angiotensin-converting enzyme genotypes in 684 patients with myocardial infarction recruited at the time of the acute event through coronary care units in two centers were compared with those of 537 control subjects recruited from the base populations. All patients were followed up to assess the impact of the angiotensin-converting enzyme genotype on prognosis. RESULTS: We found no difference (p = 0.89) in the genotype distribution between patients and control subjects (patients DD 31%, ID 47%, II 22%; control subjects DD 30%, ID 48%, II 22%). The odds ratio for myocardial infarction for DD compared with II/ID genotype adjusted for age, gender and center was 1.16 (95% confidence interval [CI] 0.82 to 1.65, p = 0.44). The study had 90% power to detect a 1.5-fold increase in risk of myocardial infarction associated with the DD genotype. For one center, data were available for other risk factors (hypertension, diabetes, angina, previous myocardial infarction, smoking, body mass index, total and high density lipoprotein cholesterol) in both patients and control subjects. In a stepwise logistic regression analysis the odds ratio for DD versus ID/II genotypes remained nonsignificant (1.44, 95% CI 0.84 to 2.46, p = 0.20) for these subjects. Over a median follow-up period of 15 months (range 3 to 22), 155 patients (22.7%) died. There was no difference in mortality between subjects with the DD genotype and those with ID/II genotypes. (21.8% vs. 23.1%, p = 0.25). Likewise, there was no difference in the distribution of survival times in the two groups (p = 0.62). The study had 70% power to detect a 1.5-fold increase in mortality during follow-up associated with the DD genotype. CONCLUSIONS: We conclude that in the groups studied, genetic variation at the angiotensin-converting enzyme gene locus defined by I/D polymorphism does not significantly influence either the risk of or the short- to medium-term prognosis after myocardial infarction.

Neurofibromatosis 2 (NF2) and malignant mesothelioma in a man with a constitutional NF2 missense mutation.

Neurofibromatosis 2 (NF2) is caused by inactivating mutations of the NF2 tumor suppressor gene. Somatic NF2 mutations also occur in a high proportion of human primary malignant mesotheliomas. We report an elderly man with NF2, malignant mesothelioma, and a constitutional NF2 missense mutation. The long latent period for mesothelioma in this patient (61 years) raises the possibility that the type of mutant NF2 allele could affect mesothelioma tumorigenesis or progression.

Antigenotoxic activity of natural chlorophylls.

Chlorophyllin, a man-made water-soluble form of chlorophyll, is a focus of intensive studies from many laboratories for its antimutagenic and anticarcinogenic properties. Natural chlorophylls, in contrast, have been little studied in this regard. Since yellow-green vegetables are implicated to be protective against human cancers by epidemiological studies, it is important to explore the antigenotoxic properties of natural chlorophylls. Previously, we reported that a chlorophyll sample prepared from Chlorella vulgaris inhibited the mutagenicity of 3-hydroxyamino-1-methyl-5H-pyrido[4,3-b]indole, a direct-acting mutagen, in Salmonella, and that the chlorophyll also showed inhibition of wing spot formation in Drosophila induced by 3-amino-1-methyl-5H-pyrido[4,3-b]indole (Trp-P-2). We have now prepared several samples of chlorophyll from spinach and chlorella, and studied their effect on the genotoxicity of 4-nitroquinoline 1-oxide (4NQO) in Drosophila. The results showed that the genotoxicity of orally given 4NQO was suppressed by simultaneous administration of the chlorophylls. The mechanisms of this inhibition are discussed.

Iron-chlorophyllin-mediated conversion of 3-hydroxyamino-1-methyl-5H-pyrido[4,3-b]indole (Trp-P-2(NHOH)) into its nitroso derivative.

Early work from our laboratory has shown that the mutagenicity of heterocyclic amines in Salmonella can be inhibited by hemin and chlorophyllins. We have speculated that the inhibition is a result of complex formation between heterocyclic amines and the pigments, and the speculation has been given a line of experimental evidence. We have now found that ferric-chlorophyllin (Fe-chlorophyllin) can modify the mutagenicity of 3-hydroxyamino-1-methyl-5H-pyrido[4, 3-b]indole (Trp-P-2(NHOH)), a metabolically activated form of 3-amino-1-methyl-5H-pyrido[4,3-b]indole (Trp-P-2). The mutagenicity of Trp-P-2(NHOH) in Salmonella typhimurium TA 98 (without S9) was strongly inhibited by an addition of an equimolar Fe-chlorophyllin in the pre-incubation mixture. Fe-chlorophyllin also inhibited the mutagenicity of 2-hydroxyamino-6-methyldipyrido[1,2-a:3',2'-d] imidazole (Glu-P-1(NHOH)). A rapid change in the UV spectrum of a mixture of Trp-P-2(NHOH) and Fe-chlorophyllin was observed. Analysis by high performance liquid chromatography showed that Trp-P-2(NHOH) was converted into 3-nitroso-1-methyl-5H-pyrido[4,3-b]indole (Trp-P-2(NO)), the mutagenic potency of which is a quarter of that of Trp-P-2(NHOH). Furthermore, the mutagenicity of Trp-P-2(NO), in turn, was inhibited by Fe-chlorophyllin. We conclude that the suppression of the mutagenicity of Trp-P-2(NHOH) is ascribable to the oxidative function of Fe-chlorophyllin, coupled with its ability to form complex formation with the planar surface of the heterocyclic amine molecules.

Inhibitory effect of hemin, chlorophyllin and related pyrrole pigments on the mutagenicity of benzo[a]pyrene and its metabolites.

Hemin and chlorophyllin are known to inhibit strongly the mutagenicity of benzo[a]pyrene in the Salmonella assay. To further investigate this phenomenon, a series of these pyrrole pigments including pure samples of Cu- and Fe-chlorins were tested for their potency to inhibit the mutagenicity of benzo[a]pyrene and its metabolites, benzo[a]pyrene-7,8-diol, benzo[a]pyrene-4,5-epoxide, and benzo[a]pyrene-7,8-diol-9,10-epoxide. Hemin was the most potent among the pigments tested for these inhibitions. Both hemin and Cu-chlorin accelerated efficiently the degradation of benzo[a]pyrene-7,8-diol-9,10-epoxide, and this acceleration seemed to be the predominant mechanism by which these pigments inhibit the overall mutagenicity of benzo[a]pyrene in Salmonella. Based on spectroscopic evidence, we speculate that a complex formation between hemin and benzo[a]pyrene-7,8-diol-9,10-epoxide takes place and that this complexing is the cause of the accelerated degradation.

Binding of polycyclic planar mutagens to chlorophyllin resulting in inhibition of the mutagenic activity.

Chlorophyllin is known to inhibit the mutagenicity of a variety of compounds. Using highly purified samples of chlorophyllin and its family compounds, we studied the mechanism of the inhibition. Since mutagens with polycyclic planar structures are particularly strongly inhibited, it seemed likely that the inhibition arises by trapping of the mutagens by chlorophyllin through complex formation at the planar surfaces of these molecules. To explore this possibility, we prepared a Sepharose bearing covalently linked chlorophyllin as ligand, and the adsorption of mutagens to this Sepharose was measured. Three different chlorophyllin derivatives were used, i.e., copper-chlorin, iron-chlorin and chlorin, to investigate the role of metal in the center of the chlorophyllin chromophore. Adsorption of 37 different compounds, mostly mutagens, in 0.02 M Tris-HCl buffer at pH 8.0 to these chlorophyllin-Sepharose preparations was studied in a quantitative manner. The results showed that most of the compounds having three or more fused rings were strongly adsorbed with apparent dissociation constants of 10(-5)-10(-6) M, whereas those having two fused rings or one ring were only poorly adsorbed. Since the three Sepharose adsorbents gave similar adsorption profiles, it appeared that the central metal in the chlorophyllin molecule does not play a crucial role in the adsorption. We also measured the inhibitory effect of copper-chlorin against the mutagenicity of some of these compounds using the Salmonella assay. The results showed that those mutagens that were strongly adsorbable to copper-chlorin-Sepharose were subject to efficient inhibition by copper-chlorin, whereas many of those only poorly adsorbed were inhibited only weakly. We concluded that trapping by complex formation plays a role in the antimutagenic actions of chlorophyllin against many mutagens, particularly notable being the actions against ICR-170, quinacrine, aflatoxin B1, Trp-P-1 and Trp-P-2. An unusual behavior of Trp-P-2 in the adsorption process, i.e., a very tight complex formation at an extremely low Trp-P-2 concentration, was found; the implication of this phenomenon in relation to the real environmental setting is discussed.

Microchimerism in female renal transplant recipients from male donors.

Microchimerism in 23 female renal transplant recipients from male donors was studied using nested polymerase chain reaction (nPCR) and fluorescence in situ hybridization (FISH) to detect Y-chromosome. nPCR was a sensitive and specific assay enabling a detection rate of 1/10(6) male/female cells, compared with a sensitivity of 1/10(2) by standard PCR (sPCR). None of the 23 patients with a male allograft demonstrated Y-chromosome using sPCR. In contrast, 1 3 (56.5%) patients demonstrated Y-chromosome with nPCR. Of 9 patients proven to have microchimerism by nPCR, only 3 also demonstrated Y-chromosome using FISH. The existence of B cells and CD8 cells in donor chimeric cells were proved by separation with Dynabeads class I and class II. Dynamic changes of microchimerism occurred in 4 of 5 patients. Four patients were proven to have microchimerism within a year of transplantation and the microchimerism later disappeared in 3, although the sequential change was variable in individual patients. There was no correlation between microchimerism and patients'clinical factors such as donor-specific blood transfusion, HLA matching, immunosuppression, past history of acute rejection and chronic rejection. The degree of microchimerism in renal transplant recipients was relatively low, and its existence did not seem to be compatible with long-term graft acceptance. However, further studies are required to elucidate the immunological mechanism of microchimerism, and it might be an important clue to immunological tolerance.

Endoscopic sphincterotomy for common bile duct stones with and without gall bladder/'T' tube 'in situ'.

Eighty-seven patients underwent endoscopic sphincterotomy (ES) for common bile duct (CBD) stones. Out of these, 66 patients had post-cholecystectomy CBD stones and 21 had CBD stones with gall bladder 'in situ'. In post-cholecystectomy group, 15 patients had 'T' Tube 'in situ'. The presenting symptoms in the post-cholecystectomy group were: pain abdomen, jaundice and cholangitis in 51, 20 and 11 patients respectively. The fifteen patients with 'T' tube used to experience pain after clamping of 'T' tube. Those with gall bladder 'in situ' had cholangitis in 12 and jaundice only in 9 patients. CBD clearance was achieved in 80 patients (91.95%). The sphincterotomy cut had to be extended in 19 patients. There was no mortality following sphincterotomy. Nine patients (10.3%) had minor complications such as bleeding (4), cholangitis (3), pancreatitis and impaction of Dormia basket in one patient each. Thus ES is a safe and effective treatment for CBD stones with or without gall bladder/'T' tube 'in situ'.

Balloon dilatation in achalasia cardia.

Treatment of achalasia cardia by pneumatic dilatation is an established method. However, data on results of pneumatic dilatation in Indian patients with achalasia cardia are scarce. We report our experience with treatment of achalasia cardia by pneumatic dilatation in 38 patients. The diagnosis of achalasia cardia was based on clinical examination, barium swallow and upper gastrointestinal (GI) endoscopy. Twenty nine (76.3%) patients improved with first dilatation, 8 (21%) patients had to undergo second dilatation and 1 (2.6%) required a third. Most of the patients remained asymptomatic during a follow-up of 6 months to 6 years. Immediate and late complications occurred in 5 (13%) and 2 (5.2%) patients, respectively. Thus, pneumatic dilatation is a simple, safe and effective method for treating Indian patients with achalasia cardia.

Quality at general practice consultations: cross sectional survey.

OBJECTIVES: To measure quality of care at general practice consultations in diverse geographical areas, and to determine the principal correlates associated with enablement as an outcome measure. DESIGN: Cross sectional multipractice questionnaire based study. SETTING: Random sample of practices in four participating regions: Lothian, Coventry, Oxfordshire, and west London. PARTICIPANTS: 25 994 adults attending 53 practices over two weeks in March and April 1998. MAIN OUTCOME MEASURES: Patient enablement, duration of consultation, how well patients know their doctor, and the size of the practice list. RESULTS: A hierarchy of needs or reasons for consultation was created. Similar overall enablement scores were achieved for most casemix presentations (mean 3.1, 95% confidence interval 3.1 to 3.1). Mean duration of consultation for all patients was 8.0 minutes (8.0 to 8.1); however, duration of consultation increased for patients with psychological problems or where psychological and social problems coexisted (mean 9.1, 9.0 to 9.2). The 2195 patients who spoke languages other than English at home were analysed separately as they had generally higher enablement scores (mean 4.5, 4.3 to 4.7) than those patients who spoke English only despite having shorter consultations (mean 7.1 (6. 9 to 7.3) minutes. At individual consultations, enablement score was most closely correlated with duration of consultation and knowing the doctor well. Individual doctors had a wide range of mean enablement scores (1.1-5.3) and mean durations of consultation (3. 8-14.4 minutes). Doctors' ability to enable was linked to the duration of their consultation and the percentage of their patients who knew them well and was inversely related to the size of their practice. At practice level, mean enablement scores ranged from 2.3 to 4.4, and duration of consultation ranged from 4.9 to 12.2 minutes. Correlations between ranks at practice level were not significant. CONCLUSIONS: It may be time to reward doctors who have longer consultations, provide greater continuity of care, and both enable more patients and enable patients more.

A rare case of vaginal vault evisceration and its management.

A 66 year old woman presented to A&E with per vagina bleeding and a mass protruding from the vagina. The patient was examined under anaesthesia, which revealed vaginal prolapse with evisceration of approximately 20-30 cm of bowel. The patient had received an abdominal hysterectomy 30 years ago for menorrhagia. In the last decade, the patient had experienced other recurrent episodes of prolapse (cystocoele and retrocoele). Vaginal vault evisceration is a recognised rare complication of hysterectomy and is a gynaecological emergency. This patient's condition was rapidly recognised and surgically managed. The repair was achieved in two surgeries. Initially, the small bowel was re-inserted into the peritoneal cavity through the vaginal wall defect and the vaginal defect repaired. After sufficient time for healing, a sacrocolpopexy was performed to repair the prolapse.