Risk Factors and Management of Incisional Cerebrospinal Fluid Leakage After Craniotomy: A Retrospective International Multicenter Study.

BACKGROUND: Incisional cerebrospinal fluid (iCSF) leakage is a serious complication after intradural cranial surgery. OBJECTIVE: To determine the incidence and risk factors of iCSF leakage after craniotomy. Secondarily, the complications after iCSF leakage and the success rate of iCSF leakage treatment was studied. METHODS: All patients who underwent an intradural cranial surgery from 2017 to 2018 at 5 neurosurgical centers were retrospectively included. Data were retrieved from medical records with 2 months of follow-up. First, univariate regression analyses were performed. Subsequently, identified risk factors were evaluated in a multivariate regression analysis. RESULTS: In total 2310 consecutive patients were included. Total iCSF leakage rate was 7.1% (n = 165). Younger age, male, higher body mass index, smoking, infratentorial surgery, and use of a dural substitute were associated with increased iCSF leakage risk, and use of a sealant reduced that risk. The odds for developing a wound infection and/or meningitis were 15 times higher in patients with iCSF leakage compared with patients without leakage. Initial conservative iCSF leakage treatment failed in 48% of patients. In 80% of cases, external cerebrospinal fluid drainage ceased the iCSF leakage. A total of 32% of patients with iCSF leakage required wound revision surgery. CONCLUSION: iCSF leakage risk increases by younger age, higher body mass index, smoking, infratentorial craniotomy, and dural substitute use, whereas sealant use reduced the risk for iCSF leakage. The leak increases the risk of postoperative infections. When iCSF leakage occurs, immediate external cerebrospinal fluid drainage or wound revision should be considered.

Multidisciplinary management of carotid body tumors: a single-institution case series of 22 patients.

OBJECTIVE: Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT. METHODS: All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology-head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded. RESULTS: Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1-4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%-95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal. CONCLUSIONS: This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors' institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat-head and neck surgeons work together to optimally manage each patient with CBT.

Identification and surgical ligation of spinal CSF-venous fistula.

BACKGROUND: CSF-venous fistulas (CVF) may cause incapacitating positional headaches resulting from spontaneous intracranial hypotension/hypovolemia (SIH). Their etiology remains unknown, although unrecognized local trauma may precipitate SIH. In addition, they are diagnostically challenging despite various imaging tools available. Here, we present CVF identification using magnetic resonance myelography (MRM) and elaborate on their surgical management techniques. METHODS: Retrospective charts of confirmed and treated CVF patients with attention to their diagnostic imaging modalities and management techniques were further reviewed. RESULTS: Six cases were identified of which three are presented here. There were two females and one male patient. All had fistulas on the left side. Two were at T7-T8 while the third was at T9-T10 level. Two underwent hemilaminotomies at the T7-T8 while the third underwent a foraminotomy at T9 level to access the fistula site. All CVF were closed with a combination of an aneurysm clip and a silk tie. On follow-up, all had complete resolution of symptoms with no evidence of recurrence. CONCLUSION: Of the various imaging modalities available, MRM is particularly sensitive in localizing CVF spinal nerve level and their laterality. In addition, the technique of aneurysm clip ligation and placement of a silk tie is curative for these lesions.

Transition metal-free approach to azafluoranthene scaffolds by aldol condensation/[1+2+3] annulation tandem reaction of isocyanoacetates with 8-(alkynyl)-1-naphthaldehydes.

A transition metal-free aldol condensation/[1+2+3] annulation reaction of isocyanoacetates with 8-(alkynyl)-1-naphthaldehydes has been developed for the general synthesis of azafluoranthenes. This domino reaction enables successive formation of three new bonds and two rings from readily accessible starting materials in a single operation. Furthermore, this methodology can also be utilized to construct chromeno[4,3-c]pyridines and benzo[c][2,6]naphthyridines in moderate yields.

Metal-free tandem reactions of 2-iodoaryl ynones with sodium azide for the synthesis of benzoisoxazole containing 1,2,3-triazoles.

A metal-free approach has been developed for the synthesis of benzo[c]isoxazole (anthranils) containing 1,2,3-triazoles. The reaction proceeded efficiently through a [3 + 2] azide-alkyne cycloaddition, SNAr azidation and denitrogenative cyclization sequence. The metal-free protocol enabled effective construction of one N-O and three C-N bonds in one pot. In addition, the synthetic utility of the current methodology was further demonstrated by late stage modification of the obtained products.

Metal-Free Tandem Approach for Triazole-Fused Diazepinone Scaffolds via [3 + 2]Cycloaddition/C-N Coupling Reaction.

A novel metal-free, efficient cascade reaction has been developed to construct 1,2,3-triazole-fused 1,4-diazepinone skeletons. Mechanism investigation indicated that sodium azide has not only served as a 1,3-dipoles synthon in [3 + 2] cycloaddition but also prompted C-N bond formation. Furthermore, the potential utility of this protocol was demonstrated by scale-up synthesis of 1,2,3-triazole-fused diazepinone derivatives and the derivatization of them.

Chitin/chitosan derivatives and their interactions with microorganisms: a comprehensive review and future perspectives.

Chitosan, obtained as a result of the deacetylation of chitin, one of the most important naturally occurring polymers, has antimicrobial properties against fungi, and bacteria. It is also useful in other fields, including: food, biomedicine, biotechnology, agriculture, and the pharmaceutical industries. A literature survey shows that its antimicrobial activity depends upon several factors such as: the pH, temperature, molecular weight, ability to chelate metals, degree of deacetylation, source of chitosan, and the type of microorganism involved. This review will focus on the in vitro and in vivo antimicrobial properties of chitosan and its derivatives, along with a discussion on its mechanism of action during the treatment of infectious animal diseases, as well as its importance in food safety. We conclude with a summary of the challenges associated with the uses of chitosan and its derivatives.

miR-208a-3p Suppresses Osteoblast Differentiation and Inhibits Bone Formation by Targeting ACVR1.

Emerging evidence indicates that many microRNAs (miRNAs) are indispensable regulators of osteoblast differentiation and bone formation. However, the role of miRNAs in mechanotransduction of osteoblasts remains to be elucidated. This study aimed to identify a mechanosensitive miRNA that regulates Activin A receptor type I (ACVR1)-induced osteogenic differentiation. After 4 weeks of hindlimb unloading (HLU) suspension of 6-month-old male C57BL/6J mice, femurs and tibias were harvested to extract total bone RNAs. Elevated levels of miR-208a-3p correlated with a lower degree of bone formation in whole-bone samples of HLU mice. However, in vitro overexpression of miR-208a-3p inhibited osteoblast differentiation, whereas silencing of miR-208a-3p by antagomiR-208a-3p promoted expression of osteoblast activity, bone formation marker genes, and matrix mineralization under mechanical unloading condition. Bioinformatics analysis and a luciferase assay revealed that ACVR1 is a target gene of miR-208a-3p that negatively regulates osteoblast differentiation under mechanical unloading environment. Further, this study also demonstrates that in vivo pre-treatment with antagomiR-208a-3p led to an increase in bone formation and trabecular microarchitecture and partly rescued the bone loss caused by mechanical unloading. Collectively, these results suggest that in vivo, inhibition of miRNA-208a-3p by antagomiR-208a-3p may be a potential therapeutic strategy for ameliorating bone loss.

An infant with biliary ascites.

Biliary ascites in children due to perforation of bile duct is a rare entity. The exact pathogenesis is not known but there are proposed mechanisms including congenital weakness of ductal wall, pancreaticobiliary malunion, tuberculosis, necrotizing enterocolitis and rupture of choledochal cyst. Presentation may be acute or sub-acute. Progressive insidious course is the common presentation in children with jaundice, clay colored stool, abdominal distension with slightly elevated liver enzymes but well documented cholestasis. Clinical suspicion with ultrasound, CT, MRCP and ascitic tap provides clue to the diagnosis. Both conservative and surgical interventions are in practice for managing these children. We report a 7 months old infant with biliary ascites due to perforation of bile duct.

Chronic hives associated with Helicobacter pylori in a child.

Chronic urticaria is fairly a common disorder in children and management is sometime challenging. Helicobacter pylori (H. pylori) should be considered as one of the causes for chronic urticaria when the response to conventional treatment is not appropriate. A nine years old girl with suspicion of wheat allergy (celiac disease) and chronic urticaria was referred for endoscopy. Antral nodularity with H. pylori gastritis was observed and confirmed on biopsy specimen with normal small bowel mucosa. Treatment for H. pylori cured her chronic urticaria. H. pylori should be considered as one of the differential if conventional medication does not help curing chronic urticaria.

Complementary and Alternative Medicine: Perceptions of Medical Students from Pakistan.

BACKGROUND: In view of the increasing popularity of complementary and alternative medicine (CAM), it is imperative that medical students, the health professionals of tomorrow, possess adequate knowledge on the topic. OBJECTIVES: This is a descriptive study designed to assess the knowledge, attitudes and behavior of medical students about CAM and to capture their perceptions and opinions about its integration into the medical curriculum. METHODS: A questionnaire-based cross-sectional survey was done on 198 medical students selected randomly from a Pakistani medical college. Associations between different variables were tested using the χ2-test of significance. RESULTS: Among the 198 participants, a majority believed that some of the CAM modalities are useful; they lacked knowledge, however, about their safety and efficacy. Most of the students believed that it should be used in conjunction with conventional medicine and that, if given adequate training, they would incorporate it in their future medical practice. One-third of the respondents voted in favor of incorporation of CAM into the medical curriculum. CONCLUSION: Despite being aware of the usefulness of CAM only a few medical students had pursued further knowledge. In order to prepare the medical students of today to better fulfill their duties as tomorrow's physicians, consideration should be given to incorporating CAM in the medical curriculum.

Pharmacological basis for the use of turmeric in gastrointestinal and respiratory disorders.

This study was carried out to provide scientific basis for the medicinal use of turmeric (Curcuma longa) in gastrointestinal and respiratory disorders. The crude extract of turmeric (Cl.Cr), relaxed the spontaneous and K+ (80 mM)-induced contractions in isolated rabbit jejunum as well as shifted the CaCl2 concentration-response curves. In rabbit tracheal preparation, Cl.Cr inhibited carbachol and K(+)-induced contractions. In anesthetized rats, Cl.Cr produced variable responses on blood pressure with a mixture of weak hypertensive and hypotensive actions. In rabbit aorta, Cl.Cr caused a weak vasoconstrictor and a vasodilator effect on K+ and phenylephrine-induced contractions. In guinea-pig atria, Cl.Cr inhibited spontaneous rate and force of contractions at 14-24 times higher concentrations. Activity directed fractionation revealed that the vasodilator and vasoconstrictor activities are widely distributed in the plant with no clear separation into the polar or non-polar fractions. When used for comparison, both curcumin and verapamil caused similar inhibitory effects in all smooth muscle preparations with relatively more effect against K(+)-induced contractions and that both were devoid of any vasoconstrictor effect and curcumin had no effect on atria. These data suggest that the inhibitory effects of Cl.Cr are mediated primarily through calcium channel blockade, though additional mechanism cannot be ruled out and this study forms the basis for the traditional use of turmeric in hyperactive states of the gut and airways. Furthermore, curcumin, the main active principle, does not share all effects of turmeric.