Opportunities and constraints for cleaner production policy in the developing world: a case study of Sindh Region, Pakistan.

The current industrial and economic activities in Sindh Province, Pakistan, polluted the region's water, air, soil, and marine resources. However, there is a rising demand for eco-friendly production, and it is important to develop new policies and tools to combat environmental degradation and enhance economic development. Cleaner Production (CP) provides opportunities to address many of these issues. Employed method for this study was based on three approaches: a literature review and stakeholder mapping; a collection of data and information from key stakeholders through focal group discussions, consultative workshops, and one-on-one meetings; and analysis and synthesis of data that were gathered from different sources. The analysis of collected information provides an overview of CP strategies moving forward. Participant workshops gave in-depth information on policy implementation, technological impediments to methods that have been employed elsewhere, and needed capacity building as well as financial consequences of policy implementation. Through increasing financial resources and institutional resources, the expansion of CP will help to replace the conventional methods of waste treatment with an eco-efficiency approach to preventing pollution at the source, thus reducing the need for expensive pollution control and management costs for environmental compliance. Experiences, achievements, and implementation pitfalls from this study can provide a lesson to other developing countries to improve their economic and environmental sustainability.

Modifications in lumbar facet joint are associated with spondylolisthesis in the degenerative spine diseases: a comparative analysis.

BACKGROUND: Magnetic resonance imaging (MRI) is important in the assessment of degenerative spine disease. However, its role is limited in the identification of spinal instability; therefore, weight-bearing and dynamic studies like X-rays are required. The supine position eliminates the gravitational pull, corrects the vertebral slippage, and opens the facet joints leading to the collection of the synovial fluid into the joint space, which is detected on the MRI and can serve as a marker for instability. We aim to compare the facet fluid, facet hypertrophy, facet angle, and disc degenerative changes among the patients presenting with degenerative spondylolisthesis (DS) and those without. METHODS: We performed a retrospective review for all the patients treated at our institution from January 2015 to December 2016. Facet Fluid Index (FFI) (ratio of facet fluid width and facet joint width) was calculated to assess the joint fluid. The percentage of spondylolisthesis was measured on X-rays. Each radiological parameter was compared between the two groups, i.e., patients with DS and patients without DS. A p value < 0.05 was considered significant. RESULTS: In total, 61 patients, 28 with DS and 33 without DS, were enrolled. Baseline characteristics were similar in the two groups (p > 0.05). The average values of FFI, facet fluid width, and the difference between the superior and inferior facet were significantly higher in the group with instability (p < 0.05). Multivariate analysis demonstrated a 4.44 (95% confidence interval [CI] 2.03-5.365) times increase in the odds of instability with a unit increase in FFI, p < 0.0001. CONCLUSIONS: We report a positive linear correlation between the facet joint effusion and facet hypertrophy on MRI and the percentage of vertebral translation on X-ray. Prospective studies will determine if these markers can play a role in predicting spinal instability.

Contribution of Attenuation of TNF-α and NF-κB in the Anti-Epileptic, Anti-Apoptotic and Neuroprotective Potential of Rosa webbiana Fruit and Its Chitosan Encapsulation.

Rosa webbiana L. (Rosaceae) is one of the least reported and most understudied members of this family. It is native to the Himalayan regions of Pakistan and Nepal. The anti-convulsant effect of n-hexane extract of fruit of Rosa webbiana was investigated in a pentylenetetrazole (PTZ)-induced animal model of epilepsy. Male Sprague-Dawley rats were divided into six groups (n = 7) including control, PTZ (40 mg/kg), diazepam (4 mg/kg) and n-hexane extract (at 50, 150 and 300 mg/kg). Convulsive behavior was observed and resultant seizures were scored, animals sacrificed and their brains preserved. Chitosan nanoparticles were prepared using the ionic gelation method and characterized by UV-analysis, zeta potential and Fourier transform infrared spectroscopy (FTIR). The effects of all the treatments on the expression of phosphorylated cytokine tumor necrosis factor α (p-TNF-α) and phosphorylated transcription factor nuclear factor kappa B (p-NF-κB) expression in the cortex and hippocampus of the brains of treated rats were studied through enzyme linked immunosorbent assay (ELISA) and morphological differences and surviving neuronal number were recorded through hematoxylene and eosin (H&E) staining. Significant changes in seizures score and survival rate of rats were observed. Downregulation of neuro-inflammation, p-TNF-α and p-NF-κB was evident. Gas Chromatography-Mass Spectrometry (GC-MS) analysis of this fraction showed multiple constituents of interest, including esters, alkanes and amines.

Phytochemical and GCMS approaches to identify active constituents in Erythrina suberosa bark extract and evaluation of its therapeutic potency.

Humans rely on plants as a necessitous source of their food, energy, cosmetics and medicines, as medicinal plants are rich source of new therapeutically active compounds from decades. Current study was designed to separate and identify active constituents of Erythrina suberosa bark extract using phytochemical screening and gas chromatography and mass spectroscopy, respectively and evaluated their therapeutic activities. E. suberosa bark extract contained saponins, glycosides, alkaloids, tannins, terpenoids, phenols and 44 active compounds identified by phytochemical and gas chromatography and mass spectroscopic analysis. Therapeutic potentials of E. suberosa bark extract was evaluated by such as cytotoxicity, anti-inflammatory and antioxidant assay. Surprisingly, bark extract shows the concentration dependent cytotoxicity against human fibroblast malignant melanoma-144 cell lines and remarkably inhibited (15.18(plusmn;1.13%, at 400mg/ml) growth of cancer cells after 24 hours treatment. In addition, the E. suberosa bark extract also exhibited anti-inflammatory effect at higher doses (400mg/kg) and moderate antioxidant activity is also noticed through (2, 2-diphenyl-1-picrylhydrazyl radical) assay. These findings indicate that E. suberosa bark extract exhibited prominent anticancer and anti-inflammatory activities and might be serve as a potent therapeutic agent in future.

Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers.

BACKGROUND: The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA. METHODS: After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique. RESULTS: In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively. CONCLUSIONS: This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.

Role of stereotactic radiosurgery in the treatment of acromegaly.

Acromegaly is a rare, indolent disease due to overproduction of growth hormone. Surgery is identified as primary treatment, but has its limitation, thus frequently requiring alternate treatment options as adjunct to surgery. Stereotactic radiosurgery (SRS) has been used as adjuvant and alternate therapy in patients with inoperable or residual disease; or those not fit for surgery. It has shown reasonable results for treating macroadenoma and tumours invading cavernous sinuses with significant reduction in tumour size and durable endocrinological remission. Factors favouring better outcomes include time from last resection to SRS, older age, peri-procedural withdrawal of medication, higher margin and maximum dose.Hypopituitarism is the most common side effects and requires yearly screening. With the new advances in the field Fractionated-stereotactic radiosurgery and cyber-knife robotic radiosurgery have been introduced with promising preliminary results..

In vitro inhibition of protease-activated receptors 1, 2 and 4 demonstrates that these receptors are not involved in an Acanthamoeba castellanii keratitis isolate-mediated disruption of the human brain microvascular endothelial cells.

Granulomatous amoebic encephalitis is a rare but serious human disease leading almost always to death. The pathophysiology of amoebic encephalitis is better understood, while events leading to the constitution of brain infection are largely unknown. Traversal of the blood-brain barrier is a key step in amoebae invasion of the central nervous system and facilitated by amoebic extracellular proteases. By using specific inhibitors of protease-activated receptors 1, 2 and 4, here we studied the role of these host receptors in Acanthamoeba castellanii-mediated damage to human brain microvasculature endothelial cells (HBMEC), which constitute the blood-brain barrier. The primary HBMEC were incubated with A. castellanii-conditioned medium in the presence or absence of FR-171113 (selective inhibitor of protease-activated receptor 1), FSLLRY-NH2 (inhibitor of protease-activated receptor 2), and tcY-NH2 (inhibitor of protease-activated receptor 4). The HBMEC monolayer disruptions were assessed by microscopy using Eosin staining, while host cell cytotoxicity was determined by measuring the release of cytoplasmic lactate dehydrogenase. Zymographic assays were performed to determine the effects of inhibitors of protease-activated receptors on the extracellular proteolytic activities of A. castellanii. A. castellanii-conditioned medium produced severe HBMEC monolayer disruptions within 60 min. The selective inhibitors of protease-activated receptors tested did not affect HBMEC monolayer disruptions. On the contrary, pre-treatment of A. castellanii-conditioned medium with phenylmethylsulfonyl fluoride, a serine protease inhibitor, or heating for 10 min at 95°C abolished HBMEC monolayer disruptions. Additionally, inhibitors of protease-activated receptors tested, failed to block A. castellanii-mediated HBMEC cytotoxicity and did not affect extracellular proteolytic activities of A. castellanii. Protease-activated receptors 1, 2 and 4 do not appear to play a role in A. castellanii-mediated dysfunction of HBMEC, which constitute the blood-brain barrier. The role of additional protease-activated receptors in amoebic invasion of the central nervous system is discussed further.

Medico-Legal Implications of Video Recordings of Clinic Visits in Malpractice Claims Against Medical Providers.

OBJECTIVE: Although audio-video recordings of clinic visits improve patient satisfaction and recall, the associated presumed risk of increased malpractice claims limits their use. In this study, we identified whether video recording clinic visits was associated with increases in professional liability claims. METHODS: From 2015 to 2017, the institution's loss run was analyzed, and the rates of medical malpractice claims per physician-year were compared between physicians who used video recordings of clinic visits (V-RoCs) and those who did not. The term "users" was applied to all physicians whose mean percentage of patient visits with video recording was greater than the mean percentage for the practice overall. RESULTS: Over three years, 15,254 patients used V-RoCs. The use of video recordings for clinic visits increased at a rate of 23% per year. No association was found between video recordings and increased malpractice claims. The rate of all claims between users and nonusers did not differ significantly (P=0.66). Of seven paid claims or lawsuits from 2000 to 2017, none were against physicians who used video recordings. CONCLUSION: Video recording of patient-physician encounters was not associated with an increase in malpractice lawsuits. According to federal law, a patient can legally record a clinic encounter without physician consent, which has many ethical implications. Formalizing the recording process is beneficial for both parties and allows the resource to be used to its maximum potential.

Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

OBJECTIVE: The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. METHODS: A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). RESULTS: Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. CONCLUSIONS: With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Redundant nerve roots indicate higher degree of stenosis in lumbar spine stenotic patients.

OBJECTIVES: Redundant Nerve Root (RNR) is a tortuous and elongated radiological appearance of cauda equina on Magnetic Resonance Imaging (MRI) in Lumbar Spinal Canal Stenosis (LSCS) patients. This study evaluated preoperative spinal morphometry associated with the development of RNR. METHODS: The retrospective cohort was conducted at The Aga Khan University Hospital, and included patients undergoing decompressive spinal surgery secondary to degenerative LSCS in 2015. The patients were divided into two groups with respect to the presence of preoperative RNR. Spinal morphometry was defined by several radiological parameters, including areas of dural sac (DSA), spinal canal, spinal foramen, facets, and spinal joints, and bilateral angles based on vertebral anatomy. RESULTS: A total of 55 patients were enrolled with a mean age of 57.1 years, in which 22 (40%) expressed RNR in their MRI. The RNR group had significantly lower mean DSA (59.64 vs 84.01 mm2; p = 0.028), bilateral posterior facet angle (Right: 33.84 vs 46.21, p = 0.004; Left: 36.43 vs 43.80, p = 0.039) and higher bilateral anterior facet angles (Right: 54.85 vs 44.57, p = 0.026; Left: 55.27 vs 46.36, p = 0.050) compared to the non-RNR group. The other bidimensional and angular parameters did not observe any statistical difference between the two groups. CONCLUSION: RNR was associated with a higher degree of stenosis in patients with LSCS. Bilateral anterior and posterior facets angles contribute to its development, indicating particular spinal morphology to be vulnerable to the stenotic disease.

Single-position prone lateral transpsoas approach: early experience and outcomes.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach. METHODS: A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence. RESULTS: Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3-4 (n = 15), L2-3 (n = 12), and L4-5 (n = 11). L1-2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale-back and leg pain) identified significant improvement. CONCLUSIONS: This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.

Effect of Rumex dentatus on Gastrointestinal Protection and Toxicology in Rodents via Investigating H+/K+-ATPase, Calcium Channels, and PDE Mediated Signaling.

This present study aims to delineate Rumex dentatus crude extract (Rd.Cr), n-Hexane, ethyl acetate, aqueous fractions (Rd.n-Hex, Rd.ETAC, and Rd.Aq), and emodin for antidiarrheal, antisecretory effects, anti-spasmodic, gastrointestinal transient time, anti-H. pylori, antiulcer effects, and toxicology. Plant extracts attributed dose-dependent protection against castor oil-induced diarrhea and dose-dependently inhibited intestinal fluid secretions in mice. They decreased the distance transverse by charcoal in the gastrointestinal transit model in rats. In rabbit jejunum preparations, it causes a concentration-dependent relaxation of both spontaneous and K+ (80 mM)-induced contraction, Rd.n-Hex and verapamil were relatively potent against K+-induced contractions and shifted the Ca2+ concentration-response curves (CRCs) to the right, Rd.Cr and Rd.ETAC shifted the isoprenaline-induced inhibitory CRCs to the left, showing potentiating effect similar to papaverine. Rd.n-Hex showed anti-H. pylori effect. Extracts and emodin also show an inhibitory effect against H+/K+-ATPase. Rumex dentatus showed a gastroprotective and antioxidant effect. Histopathological evaluation showed improvement in cellular architecture and decrease in the expression of inflammatory markers such as cyclooxygenase (COX2), tumor necrosis factor (TNF-α), and phosphorylated nuclear factor kappa B (p-NFƙB), validated through immunohistochemistry, ELISA, and western blot techniques. In RT-PCR, it decreases H+/K+-ATPase mRNA levels. Rumex dentatus was analyzed for certain safety aspects and exhibited a relative safety profile as no impairment was observed in kidneys, heart, liver, and brain further assisted by biochemical and hematological analysis. Docking studies revealed that emodin against H+/K+-ATPase pump and voltage gated L-type calcium channel showed E-value of -7.9 and -7.4 kcal/mol, respectively. MD simulations and molecular mechanics Poisson Boltzmann surface area and molecular mechanics Generalized Born surface area MMPBSA/GBSA findings are consistent with the in-vitro, in-vivo, and docking results. In conclusion, Rumex dentatus extracts and its phytoconstituent could be considered a potent antioxidant and anti-inflammatory drug candidates that possess anti-diarrheal, anti-secretary, antispasmodic, anti-H. pylori, and anti-ulcer potential. Toxicity studies were done according to OECD standards 425. It belongs to group 5 (LD50 > 2000 mg/kg), which suggests that it is in the lower toxicity class.

Spinal Radiology associated with Redundant Nerve Roots of cauda equina in lumbar spine stenosis.

OBJECTIVES: Redundant Nerve Roots (RNR) is a common radiological observation of elongated tortuous appearance of cauda equina nerve roots in sagittal MRI. It is considered a poor prognostic factor, but the associated spinal morphometry remains unfamiliar. METHODS: A retrospective cohort study was conducted at the Aga Khan University Hospital, Pakistan. Patients, aged 18 or above, undergoing decompressive spinal surgery due to degenerative Lumbar Spinal Canal Stenosis (LSCS) in 2015 were included. Patients were divided in groups as per presence of RNR and assessed for spinal morphometric parameters. RESULTS: Fifty-two patients, aged 57.52 ± 12.08 years, were enrolled in the study. The patients in RNR group were older than those in non-RNR group (p = 0.023). RNR was significantly associated with sedimentation sign (15 vs 11; p = 0.011), as well as L2/L3 (12 vs 9; p = 0.043) and L3/L4 (18 vs 18; p = 0.034) stenosis. Ligamentum flavum hypertrophy at the most stenotic level was more common in the RNR group (20 vs 19; p = 0.006). The only quantitative parameter statistically associated with RNR was lower ligamentous interfacet distance (5.07 ± 1.95 vs 8.07 ± 4.26 mm; p = 0.010). All other parameters did not contribute to the development of RNR in LSCS patients. The multivariate model revealed significant contribution of age, male sex, ligamentous interfacet distance and disc bulge to develop RNR. CONCLUSION: Certain spinal morphometric parameters contribute towards RNR formation, which represents higher degree of spinal stenosis. These parameters, along with RNR, should be regularly reported for preoperative consideration of LSCS management.

Upadacitinib protects against cisplatin-induced renal and hepatic dysfunction without impairing its anticancer activity.

Cisplatin-induced renal and hepatic dysfunctions are major drawbacks and obstacles to its clinical applications. Induction of inflammation is a part of its molecular mechanism of toxicity. The impact of upadacitinib, a selective JAK1-inhibitory anti-inflammatory agent, on cisplatin-induced adverse effects, histopathologic changes, kidney and liver functions, oxidative stress, and inflammatory biomarkers were investigated compared to silymarin and losartan in male Wistar rats. The animals were treated with upadacitinib (10 mg/kg/day) for two weeks in addition to one dose of cisplatin (10 mg/kg) on the seventh day of treatment. The liver and kidney functions as well as the oxidative biomarkers and inflammatory burst, were biochemically measured. Upadacitinib pre-treatment significantly improved liver function markers (ALT and AST) and inhibited cisplatin-induced lipid profile aberrations (total cholesterol and triglycerides). Moreover, it protected the kidney functions as indicated by blood urea nitrogen, serum creatinine, creatinine clearance, and albumin levels. Upadacitinib also attenuated cisplatin-induced hepatic and renal inflammatory events, as indicated by the reduction of MDA and TNFα levels. In addition, it improved the superoxide dismutase (SOD) activity. Upadacitinib effectively diminished histopathologic structural damage in liver and kidney tissues. Western blotting of NF-kB and p-Akt confirmed the renoprotective effect of upadacitinib. Furthermore, the cell viability assay shows that upadacitinib did not have any inhibitory activity on cisplatin anticancer potency in MCF-7 and A549 cells. Moreover, upadacitinib has improved the potency of cisplatin against lung cancer cells in a dose-dependent pattern. These results highlight upadacitinib's protective effects from cisplatin-induced toxicity without impairing its anticancer activity.

Comparative analysis of the combined petrosal and the pretemporal transcavernous anterior petrosal approach to the petroclival region.

OBJECTIVE: The combined petrosal (CP) approach has been traditionally used to resect petroclival meningioma (PCM). The pretemporal transcavernous anterior petrosal (PTAP) approach has emerged as an alternative. A quantitative comparison of both approaches has not been made. This anatomical study compared the surgical corridors afforded by both approaches and identified key elements of the approach selection process. METHODS: Twelve cadaveric specimens were dissected, and 10 were used for morphometric analysis. Groups A and B (n = 5 in each) underwent the CP and PTAP approaches, respectively. The area of drilled clivus, lengths of cranial nerves (CNs) II-X, length of posterior circulation vessels, surgical area of exposure of the brainstem, and angles of attack anterior and posterior to a common target were measured and compared. RESULTS: The area of drilled clivus was significantly greater in group A than group B (mean ± SD 88.7 ± 17.1 mm2 vs 48.4 ± 17.9 mm2, p < 0.01). Longer segments of ipsilateral CN IV (52.4 ± 2.33 mm vs 46.5 ± 3.71 mm, p < 0.02), CN IX, and CN X (9.91 ± 3.21 mm vs 0.00 ± 0.00 mm, p < 0.01) were exposed in group A than group B. Shorter portions of CN II (9.31 ± 1.28 mm vs 17.6 ± 6.89 mm, p < 0.02) and V1 (26.9 ± 4.62 mm vs 32.4 ± 1.93 mm, p < 0.03) were exposed in group A than group B. Longer segments of ipsilateral superior cerebellar artery (SCA) were exposed in group A than group B (36.0 ± 4.91 mm vs 25.8 ± 3.55 mm, p < 0.02), but there was less exposure of contralateral SCA (0.00 ± 0.00 mm vs 7.95 ± 3.33 mm, p < 0.01). There was no statistically significant difference between groups with regard to the combined area of the exposed cerebral peduncles and pons (p = 0.75). Although exposure of the medulla was limited, group A had significantly greater exposure of the medulla than group B (p < 0.01). Finally, group A had a smaller anterior angle of attack than group B (24.1° ± 5.62° vs 34.8° ± 7.51°, p < 0.03). CONCLUSIONS: This is the first study to quantitatively identify the advantages and limitations of the CP and PTAP approaches from an anatomical perspective. Understanding these data will aid in designing maximally effective yet minimally invasive approaches to PCM.

Bergapten Attenuates Nitroglycerin-Induced Migraine Headaches through Inhibition of Oxidative Stress and Inflammatory Mediators.

The present study intended to examine the effect of bergapten and possible mechanisms involved in the treatment of migraine-associated symptoms in the rat model. Five doses of nitroglycerin (10 mg/kg) were injected intraperitoneal to induce migraine headaches in rats with a one-day break between each dose. Treatment groups received nitroglycerin followed after 1 day by bergapten (50 or 100 mg/kg), saline (10 mL/kg), or sumatriptan (50 mg/kg) once daily for 10 days. Behavioral observations were analyzed 2 h after nitroglycerin injections and 1 h 40 min after treatment. The animals were sacrificed 24 h after the last treatment dose. Samples of trigeminal nucleus caudalis (TNC) and cerebral cortex were collected and analyzed for antioxidant activity and expression of inflammatory markers by immunohistochemistry and enzyme-linked immunosorbent assay. Our findings revealed that bergapten notably decreases headache by altering mechanical allodynia, thermal allodynia, light phobicity, and the number of head-scratching incidence in rats. In the cortex and TNC regions, antioxidant factors were restored, and lipid peroxidation was significantly reduced. Furthermore, bergapten decreased the expression of inflammatory markers, such as nuclear factor kappa B (NF-Kb) and tumor necrosis factor-alpha (TNF-α), as evidenced by immunohistochemistry and ELISA. These results suggest that bergapten exhibits headache-relieving activity, possibly mediated through antioxidant and anti-inflammatory pathways.

Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism.

Introduction Venous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries. Methods Data were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018. Results We identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery. Conclusions Based on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.

Prone Single-Position Lateral Lumbar Interbody Fusion With Posterior Decompression and Pedicle Screw Fixation for the Treatment of Grade II Spondylolisthesis: 2-Dimensional Operative Video.

Lateral lumbar interbody fusion (LLIF) provides indirect decompression without disruption of the posterior elements. It involves a larger implant footprint than that of posterior approaches. LLIF is typically performed with the patient in the lateral decubitus position. When a posterior fixation is indicated, a second-stage procedure is performed with the patient in the prone position. Single-position surgery provides the potential advantage of decreased operative time because both procedures can be performed without patient repositioning. Single-position LLIF and posterior fixation in the prone position have not been well validated to date. Herein, techniques for LLIF, percutaneous pedicle screw fixation, and facetectomy in the prone position are shown. A 76-yr-old woman with osteoporosis presented with severe back and bilateral leg pain refractory to conservative management and imaging findings of grade 2 dynamic anterolisthesis at L4-L5 with severe stenosis. She underwent LLIF with percutaneous pedicle screw fixation and facetectomy. She was placed on a Jackson table in the prone position for the entire procedure, which was performed in a single stage. Percutaneous pedicle screws were placed, followed by a left-sided minimally invasive facetectomy. A left-sided retroperitoneal transpsoas approach was used to perform the LLIF in standard fashion. Finally, the rods were locked into place. Postoperatively, the patient was neurologically stable, and imaging confirmed good hardware placement. At the 6-wk follow-up, the patient was doing well. This case demonstrates the feasibility of performing LLIF and posterior fixation in a single stage in the prone position. The patient provided informed consent. Used with permission from Barrow Neurological Institute.