Ventriculoperitoneal Shunt Malfunction Due to a Fibrous Capsule Obstructing the Peritoneal Catheter.

Ventriculoperitoneal shunt obstruction is a common neurosurgical condition. Obstruction of the peritoneal catheter is less common than other sites of blockage in the system. We present a case of a ventriculoperitoneal shunt blockage caused by a sheath of hyalinised fibrous tissue that had encased the distal side slits of the peritoneal catheter resulting in sub-total blockage. The patient made a complete recovery following the removal of this fibrous tissue from the distal peritoneal catheter without the need to revise the entire shunt.

Microbiologic profile and clinical practices in urinary tract infections in a tertiary care center in Southern India.

CONTEXT: Studies reported differences in clinical profiles of urinary tract infections (UTIs) in patients with and without type 2 diabetes mellitus (T2DM). Studies on the impact of the pattern of antibiotic resistance of organisms causing UTI on actual clinical practice are lacking. OBJECTIVES: 1. To study the clinical and microbiologic profiles of UTIs. 2. To compare treatment given with the prevailing antimicrobial sensitivity. SETTINGS AND DESIGN: This is a cross-sectional study conducted in a tertiary care hospital. METHODS AND MATERIALS: Retrospective chart review of inpatients with UTI (N = 200, 100 each of patients with and without T2DM), aged >18 years with a positive urine culture. STATISTICAL ANALYSIS: We used the statistical package SPSS version 17. The categorical variables were analyzed by the Chi-square test. Data were considered significant if P value was less than 0.05. RESULTS: Similar to previous Indian studies, T2DM patients with UTI had significantly more asymptomatic bacteriuria, asymptomatic bacteriuria (32% vs. 6%), previous history of UTI (25% vs. 2%), and prior catheterization (16% vs. 1%). Escherichia coli (E. coli) was the most common organism isolated and showed sensitivity pattern of meropenem > netilmicin > amikacin > nitrofurantoin. Ceftriaxone was the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. All ASB cases were treated unlike recommendations. CONCLUSIONS: Ceftriaxone is the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. Cases of ASB were treated unlike recommendations.

Expression of Cathepsins B, D, and G in WHO Grade I Meningioma.

Aim: We have recently demonstrated the presence of putative tumor stem cells (TSCs) in World Health Organization (WHO) grade I meningioma (MG) localized to the microvessels, which expresses components of the renin-angiotensin system (RAS). The RAS is known to be dysregulated and promotes tumorigenesis in many cancer types, including glioblastoma. Cathepsins B, D, and G are isoenzymes that catalyze the production of angiotensin peptides, hence providing bypass loops for the RAS. This study investigated the expression of cathepsins B, D, and G in WHO grade I MG in relation to the putative TSC population we have previously demonstrated. Methods: 3,3-Diaminobenzidine (DAB) immunohistochemical (IHC) staining with antibodies for cathepsins B, D, and G was performed on WHO grade I MG tissue samples from 10 patients. Three of the MG samples subjected to DAB IHC staining underwent immunofluorescence (IF) IHC staining to investigate co-expression of each of these cathepsins using combinations of smooth muscle actin (SMA) and embryonic stem cell marker OCT4. NanoString mRNA expression (n = 6) and Western blotting (WB; n = 5) analyses, and enzyme activity assays (EAAs; n = 3), were performed on snap-frozen WHO grade I MG tissue samples to confirm transcriptional activation, protein expression, and functional activity of these proteins, respectively. Results: DAB IHC staining demonstrated expression of cathepsins B, D, and G in all 10 MG samples. NanoString mRNA expression and WB analyses showed transcriptional activation and protein expression of all three cathepsins, although cathepsin G was expressed at low levels. EAAs demonstrated that cathepsin B and cathepsin D were functionally active. IF IHC staining illustrated localization of cathepsin B and cathepsin D to the endothelium and SMA+ pericyte layer of the microvessels, while cathepsin G was localized to cells scattered within the interstitium, away from the microvessels. Conclusion: Cathepsin B and cathepsin D, and to a lesser extent cathepsin G, are expressed in WHO grade I MG. Cathepsin B and cathepsin D are enzymatically active and are localized to the putative TSC population on the microvessels, whereas cathepsin G was localized to cells scattered within the interstitium, These results suggest the presence of bypass loops for the RAS, within WHO grade I MG.

Expression of cancer stem cell markers in metastatic melanoma to the brain.

We have recently characterized cancer stem cell (CSC) subpopulations in different types of cancer. This study aimed to identify and characterize CSCs within metastatic melanoma (MM) to the brain. 3, 3-diaminobenzidine (DAB) immunohistochemical (IHC) staining of ten samples of MM to the brain demonstrated the expression of the embryonic stem cell (ESC) markers OCT4, NANOG, SALL4, SOX2 and pSTAT3. Protein expression of all five ESC markers except SALL4 were confirmed by Western blotting on five samples and transcriptional activation of all five markers was demonstrated using NanoString mRNA analysis on four samples. Immunofluorescence IHC staining suggested the presence of CSCs that stained for OCT4, SALL4, SOX2 or NANOG. Some of these cells also stained for Melan-A. Also, a pSTAT3+/CD34+ primitive subpopulation was detected on the endothelium of microvessels. These CSCs may be a novel therapeutic target for MM to the brain.

Perceptions of Unprofessional Social Media Behavior Among Emergency Medicine Physicians.

BACKGROUND: Use of social media (SM) by physicians has exposed issues of privacy and professionalism. While guidelines have been created for SM use, details regarding specific SM behaviors that could lead to disciplinary action presently do not exist. OBJECTIVE: To compare State Medical Board (SMB) directors' perceptions of investigation for specific SM behaviors with those of emergency medicine (EM) physicians. METHODS: A multicenter anonymous survey was administered to physicians at 3 academic EM residency programs. Surveys consisted of case vignettes, asking, "If the SMB were informed of the content, how likely would they be to initiate an investigation, possibly leading to disciplinary action?" (1, very unlikely, to 4, very likely). Results were compared to published probabilities using exact binomial testing. RESULTS: Of 205 eligible physicians, 119 (58%) completed the survey. Compared to SMB directors, EM physicians indicated similar probabilities of investigation for themes involving identifying patient images, inappropriate communication, and discriminatory speech. Participants indicated lower probabilities of investigation for themes including derogatory speech (32%, 95% confidence interval [CI] 24-41 versus 46%, P < .05); alcohol intoxication (41%, 95% CI 32-51 versus 73%, P < .05); and holding alcohol without intoxication (7%, 95% CI 3-13 versus 40%, P < .05). There were no significant associations with position, hospital site, years since medical school, or prior SM professionalism training. CONCLUSIONS: Physicians reported a lower likelihood of investigation for themes that intersect with social identity, compared to SMB directors, particularly for images of alcohol and derogatory speech.

A study of emotional intelligence and perceived parenting styles among adolescents in a rural area in Karnataka.

CONTEXT: Adolescence is the time which is crucial for the overall development of a person both mentally and physically. In this period, along with academic intelligence, emotional intelligence (EI) also plays an equal or strong role in student life. AIMS: This study was to assess EI, parental bonding, and their association among adolescents in high schools under Sarjapur PHC area. SUBJECTS AND METHODS: This was a cross-sectional study conducted among high school students under Sarjapur PHC area. The EI was assessed using EI scale which measured self-awareness, self-regulation, motivation, empathy, and social skills. The parental bonding instrument was utilized to determine the parental styles of both the parents and was interpreted in terms of care and protection as neglectful parenting, affectionless control, optimal parenting, and affectionate control. RESULTS: A total of 300 adolescents were interviewed. It was seen that most of them had low EI in self-awareness, i.e., 92 (30.7%), motivation 99 (33%), and social skills 101 (33.7%). It was also observed that most of them had high EI in self-regulation, i.e., 98 (32.7%) and moderately high EI in empathy 117 (39%). The study group perceived that 147 (49%) of the fathers and 109 (36.3%) of the mothers had affectionless control. CONCLUSION: Along with poor parenting, most of the respondents also have low EI in self-awareness, motivation, and social skills which has to be addressed for the future of the country.

Separation of Craniopagus Twins.

Separation of craniopagus twins is fraught by ethical issues. The surgery is high risk and may involve the sacrifice of one twin. We review surgical successes in separation of craniopagus twins and consider ethical and legal concepts affecting the decision to undertake such procedures. Our discussion considers how Gillett's potentiality principle and the concept of moral permissibility may be used to arrive at fair and realistic decisions.

Hierarchical structure from motion optical flow algorithms to harvest three-dimensional features from two-dimensional neuro-endoscopic images.

Technical advances have led to an increase in the use of the endoscope in neurosurgery in recent years, particularly for intraventricular procedures and pituitary and anterior skull base surgery. Recently stereoscopic three-dimensional (3D) endoscopes have become available and may over time replace traditional two-dimensional (2D) imagery. An alternative strategy would be to use computer software algorithms to give monocular 2D endoscopes 3D capabilities. In this study our objective was to recover depth information from 2D endoscopic images using optical flow techniques. Digital images were recorded using a 2D endoscope and a hierarchical structure from motion algorithm was applied to the motion of the endoscope in order to calculate depth information for the generation of 3D anatomical structure. We demonstrate that 3D data can be recovered from 2D endoscopic images taken during endoventricular surgery where there is a mix of rapid camera motion and periods where the camera is nearly stationary. These algorithms may have the potential to give 3D visualization capabilities to 2D endoscopic hardware.

Regulation of cognitive enhancement devices: commentary.

Maslen et al. (2013) have provided us with a comprehensive overview of the current legislation regulating non-clinical cognitive enhancement devices (CEDs) in the European Union and have proposed a specific model whereby CEDs would be regulated in the same way as medical devices. An alternative model would be to require manufacturers to quantify risks only. Irrespective of the purported 'benefits' of a product, this would allow the consumer freedom of choice to use the product at their will and allow the periodic review of worthwhile indications and unexpected adverse events. Although this departs from the standard Cochrane-type assessment, it takes into account the facts that (i) the evaluation of clinically used cognitive enhancement techniques may not be as rigorous as one might expect, (ii) variations and case-by-case use might be widespread, and (iii) independent variables of significance and useful endpoints may not be obvious ab initio. We consider cerebrospinal fluid diversion techniques which are widely used clinically to enhance cognition in patients with normal pressure hydrocephalus despite any large-scale clinical studies demonstrating substantial benefit, and the real risks of paralysis and death from these invasive procedures. The risks of CEDs which have been available for some time need to be kept in perspective: are the risks really more than using conventional cognitive enhancement techniques such as imbibing too caffeinated drinks? Furthermore, the loss of Europe as a market for CEDs which do not comply with the proposed regulatory model implies a potential gain in the market for other parts of the world. This could impact on the ability of companies in Europe being able to compete in an evolving market demand for CEDs. Legislation to regulate CEDs should be guided by the principle of 'do no harm' and allow for innovation and competition.

Adult idiopatic occlusion of Monro foramina: intraoperative endoscopic reinterpretation of radiological data and review of the literature.

Adult idiopathic occlusion of the foramen of Monro (AIOFM) is a rare condition, with only few cases described in the modern literature. We propose that AIOFM may result from unilateral or bilateral occlusion of Monro foramina, as well as from progression of a monolateral hydrocephalus. Different surgical strategies may be required for effective treatment according to the type of occlusion. To date, only 12 cases of AIOFM have been reported in the literature. We report the cases of two patients, aged 20 and 47 years respectively, who presented with intracranial hypertension secondary to bilateral ventricular dilatation due to obstruction at the level of the foramen of Monro. Both patients were successfully treated with endoscopic fenestration of the primarily obstructed foramen of Monro and, in one patient, fenestration of the septum. We propose that septum pellucidum displacement could play a role in the occlusion of the second foramen of Monro. AIOFM can, therefore, result also from unilateral stenosis of Monro. The difference in AIOFM (i.e. unilateral vs bilateral) will be useful in guiding the most suitable surgical approach in this rare condition.

The "combined eye" of surgeon and artist: evaluation of the artists who illustrated for Cushing, Dandy and Cairns.

Medical illustration is an essential device for the teaching of anatomy, physiology and pathology. In surgery, illustration is more than a teaching aid and has been instrumental in the development the surgical art. This has required a close collaboration between surgeon and artist. This has been particularly evident in neurosurgery where surgeon and artist worked together with a "combined eye", to help develop and disseminate surgical techniques. In this article we review the lineage of medical illustration in neurosurgery and three important partnerships between artist and neurosurgeon that have helped forge a lineage of surgical and artistic technique. Max Brödel and Harvey Cushing worked closely together at The Johns Hopkins Hospital, a collaboration which led to the opening of the Department of Art as Applied to Medicine. Brödel trained two talented artists, Hager Padget and Audrey Arnott, who worked for Walter Dandy and Hugh Cairns respectively. The techniques used in these collaborations between artist and surgeon were inspired by the art of Da Vinci, and the work of the anatomist Vesalius and the artist Jan Stefan van Calcar in the 16th century. We discuss how the combined eye of artist and surgeon is an important aspect of art history and we consider whether the illustrations of Brödel, Padget and Arnott can be considered as works of art.

Technical aspects of decompressive craniectomy for malignant middle cerebral artery infarction.

Decompressive craniectomy is considered a life-saving procedure for malignant middle cerebral artery territory infarction in selected patients. However, the procedure is associated with a significant risk of morbidity and mortality, and there is no universal agreement as to how this operation should be combined with optimal medical management. In this review we consider the goals of this procedure and the technical aspects which may be employed to optimise results.

Decompressive craniectomy for malignant middle cerebral artery infarction: evidence and controversies.

Malignant middle cerebral artery (MCA) infarction (MMI) is associated with a mortality rate of 80%. Decompressive craniectomy is considered a life-saving procedure for patients with this devastating condition. Preclinical and clinical data suggest that this procedure should be undertaken as early as possible, prompting increasing demand for emergency surgery. This article reviews the pathophysiology of MMI, and the experimental and clinical evidence supporting this procedure. We consider some of the controversies surrounding patient selection for this procedure and discuss the role of intracranial pressure monitoring in MMI.

Endoscopic fenestration of middle cranial fossa arachnoid cysts: does size matter?

The middle cranial fossa (MCF) is the commonest location for intracranial arachnoid cysts and there has long been controversy regarding the optimal surgical management. Over the last 10 years there has been an increased interest in the potential of endoscopic techniques to treat these. In a review of the literature we identified 91 patients with MCF cysts treated with endoscopic techniques. Clinical improvement was seen in 95% of patients and radiological improvement was seen in 74%. The most common complications reported are subdural hygromas (9%) and subdural haematomas (5%). There does not appear to be an undue increased risk of complications compared to open surgical techniques. Reported methods of endoscopic fenestration advocate making as wide an opening as possible without damage to the surrounding neurovascular structures. We consider the possibility that smaller cystocisternostomy may be effective in achieving therapeutic goals while reducing potential risks to the patient.

Perioperative seizures following deep brain stimulation in patients with multiple sclerosis.

Following a total of 386 deep brain stimulation (DBS) procedures in Oxford, only two seizures have been recorded in the peri-operative period. Both patients had MS and underwent thalamic DBS for tremor and these 2 cases are presented here. The incidence of peri-operative seizures in MS patients undergoing DBS procedures is more than 8-fold greater than that expected for patients undergoing DBS procedures. Further experience with DBS procedures in MS patients is needed to determine whether there is a role for peri-operative anticonvulsants in these patients.

Audrey Juliet Arnott (1901-1974): the legacy of an artist in neurosurgery.

Audrey Arnott, a graduate of the Royal College of Art, was first employed as an artist by Hugh Cairns at the London Hospital. Cairns arranged for Arnott to be trained as a medical illustrator under Max Brödel, a close friend of Harvey Cushing and founder of the first 'Department of Art as Applied to Medicine' at Johns Hopkins University. During her time at John Hopkins Arnott developed a close friendship with Dorcas Padget, medical illustrator to Walter Dandy. Arnott was a highly accomplished artist and trained numerous other British medical illustrators and was one of the founders of the Medical Artists Association. Arnott's training and friendship with Brödel and Padget enabled her to pass on a legacy of neurosurgical illustration to the United Kingdom.

SNARE proteins and schizophrenia: linking synaptic and neurodevelopmental hypotheses.

Much of the focus of neurobiological research into schizophrenia is based on the concept that disrupted synaptic connectivity underlies the pathology of the disorder. Disruption of synaptic connectivity is proposed to be a consequence of both disrupted synaptic transmission in adulthood and abnormalities in the processes controlling synaptic connectivity during development of the central nervous system. This synaptic hypothesis fits with neurodevelopmental models of schizophrenia and our understanding of the mechanisms of antipsychotic medication. This conceptual model has fostered efforts to define the exact synaptic pathology further. Synaptic proteins are obvious candidates for such studies, and the integral role of the SNARE complex, and SNARE-associated proteins, in synaptic transmission will ensure that it is the focus of much of this research. Significant new insights into the role of this complex are arising from new mouse models of human disease. Here the evidence from both animal and human clinical studies showing that the SNARE complex has a key role to play in the aetiology and pathogenesis of schizophrenia is discussed.

A dominant mutation in Snap25 causes impaired vesicle trafficking, sensorimotor gating, and ataxia in the blind-drunk mouse.

The neuronal soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) complex is essential for synaptic vesicle exocytosis, but its study has been limited by the neonatal lethality of murine SNARE knockouts. Here, we describe a viable mouse line carrying a mutation in the b-isoform of neuronal SNARE synaptosomal-associated protein of 25 kDa (SNAP-25). The causative I67T missense mutation results in increased binding affinities within the SNARE complex, impaired exocytotic vesicle recycling and granule exocytosis in pancreatic beta-cells, and a reduction in the amplitude of evoked cortical excitatory postsynaptic potentials. The mice also display ataxia and impaired sensorimotor gating, a phenotype which has been associated with psychiatric disorders in humans. These studies therefore provide insights into the role of the SNARE complex in both diabetes and psychiatric disease.