Repair of Dural Defects in Awkward Areas-Technical Note

Summary  Dural tears located at the base of the skull are difficult to repair due to the difficulties in the appropriate access and the fragility of the dura in such areas.  In our experience the biggest problem when attempting to perform a dural repair in a deep narrow field is not to place the stitches, but rather to set the knots. A newly designed, easy-to-learn technique has been developed for dural closure in these situations. We present here a new technique for dural suturing of special interest when the space available is limited.  In our hands it is possible to obtain a watertight dural closure in most microsurgical operations performed through a small hole and/or into a narrow, deep surgical field. These techniques can also be applied during a secondary procedure following development of a postoperative CSF leak. While simple and easy to learn, these techniques require practice in the laboratory setting before clinical application.     

Retrospective Study of the Clinical Profile and Prognostic Indicators in Patients of Alcoholic Liver Disease Admitted to a Tertiary Care Teaching Hospital in Western Nepal

Background/Aim:

Alcohol is the most common substance abused in Nepal. Liver disease caused by alcohol abuse, including its end stage, cirrhosis, is a major health care problem, which is difficult to treat.

Objectives:

To study the demographic profile, laboratory parameters, complications and their prognostic implications among patients of alcoholic liver disease (ALD).

Materials and Methods:

Records of all patients of ALD admitted from January 1'' 2005 to December 31'' 2006 were studied and followed up to December 31, 2007. A total of 181 patients were analyzed. Their clinical profile and laboratory parameters were noted and analyzed using SPSS-10.0 software.

Results:

Among the 181 patients, 80.7% were male, 30.9% were army/ex-army and 65.2% were documented smokers. The mean age of presentation was 52.08 years. Jaundice (57.5%) was the most common presentation followed by hepatomegaly (51.4%). Hypoalbuminemia (50.3) followed by ascites (48.1) were common complications. Death occurred in 19.1% of the patients, the most common cause being hepatic encephalopathy (72.2%) followed by variceal bleeding and hepatorenal syndrome. Jaundice, ascites and hepatic encephalopathy at presentation and female sex were significantly associated with increased mortality along with discriminant score >32, aspartate aminotransferase (AST): Alanine aminotranferase (ALT) ≥ 2, ultrasonography (USG)-proven cirrhosis, rise in prothrombin time ≥5 s, total bilirubin ≥ 4mg/dL and ESR ≥34.

Conclusion:

ALD was predominantly seen among the productive age group with a high morbidity and mortality. Jaundice, ascites, hepatic encephalopathy at presentation and female sex are poor prognostic indicators along with discriminant score > 32, AST:ALT ≥ 2, USG-proven cirrhosis, coagulopathy, hyperbilirubenemia and high ESR.     

Operative monitoring of hand and axillary temperature during endoscopic superior thoracic sympathectomy for the treatment of palmar hyperhidrosis.

OBJECTIVE: To find out how much the temperature in the palm rises after upper thoracic sympathectomy for palmar hyperhidrosis, and correlate the temperature with the outcome. DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 73 patients (34 women and 39 men, age range 16-42 years, mean 26) who were operated for palmar hyperhidrosis between 1 January 1995 and 31 December 1997. INTERVENTIONS: Bilateral thoracic endoscopic sympathectomy during which the temperature was monitored on the skin of both axillae and thenar eminences, and in the oesophagus. MAIN OUTCOME MEASURES: Morbidity, alleviation of hyperhidrosis, recurrence rate, and differences in temperature postoperatively. RESULTS: There was minor bleeding during operation in 25 cases (34%), but in only 4 was it sufficient to require insertion of a drain; 2 patients developed transient Homer's syndrome; but the most common complication was compensatory hyperhidrosis (n = 52, 71%). In only 5 was this other than mild and required treatment with aluminium chloride in ethanol 25%. Palmar hyperhidrosis was alleviated in all cases, axillary sweating was considerably improved, and there was improvement in the feet in 56 (77%). There were 5 recurrences, all on the right side, during a mean follow up of 9 months (range 2-36), but in no case was the sweating severe. In almost all cases the temperature of the palm was less than that of the axilla before operation by a mean (SD) of 0.9 (0.3) degrees C. The rise in temperature varied from 1.7 (0.4) degrees C to 2.6 (0.4) degrees C. In the 5 patients who developed recurrences the increase was less (0.5 (0.4) degrees C). CONCLUSION: Thoracic endoscopic sympathectomy is safe, simple, and effective in treating palmar hyperhidrosis that has not responded to conservative treatment. Intradermal monitoring is an accurate and cost-effective way of monitoring temperature during operation. Although it is essential to achieve a rise in temperature of 1 degrees C, our most important finding was that the final temperature in both hands and axillae should be above 35 degrees C and as near as possible to 36 degrees C.     

Melanoma in Hispanic and black Americans

BACKGROUND: Although age-adjusted incidence rates (per 100,000) for melanoma are lower among Hispanics and blacks (4.5 and 1.0, respectively) compared with white non-Hispanics (21.6), melanomas among minority populations in the United States are more likely to metastasize and have poorer outcomes. METHODS: A review of the literature was conducted on melanomas affecting Hispanic and black Americans. RESULTS: Because of the low index of suspicion in both the medical community and these ethnic populations, diagnosis is often delayed, resulting in advanced presentation and a poorer prognosis. CONCLUSIONS: More comprehensive medical training, expanded public educational campaigns, and increased awareness among patients of all skin types to perform self skin checks are recommended. Further studies elucidating the etiology and risk factors for melanoma among minority populations are warranted.     

Circumvention of nuclear factor kappaB-induced chemoresistance by cytoplasmic-targeted anthracyclines

Nuclear factor kappaB (NF-kappaB) has been implicated in inducible chemoresistance against anthracyclines. In an effort to improve the cytotoxicity of anthracyclines while reducing their cardiotoxic effects, we have developed a novel class of extranuclear-localizing 14-O-acylanthracyclines that bind to the phorbol ester/diacylglycerol-binding C1b domain of conventional and novel protein kinase C (PKC) isoforms, thereby promoting an apoptotic response. Because PKCs have been shown to be involved in NF-kappaB activation, in this report, we determined the mechanism of NF-kappaB activation by N-benzyladriamycin-14-valerate (AD 198) and N-benzyladriamycin-14-pivalate (AD 445), two novel 14-O-acylanthracylines. We show that the induction of NF-kappaB activity in response to drug treatment relies on the activation of PKC-delta and NF-kappaB-activating kinase (NAK), independent of ataxia telengectasia mutated and p53 activities. In turn, NAK activates the IKK complex through phosphorylation of the IKK-2 subunit. We find that neither NF-kappaB activation nor ectopic expression of Bcl-X(L) confers protection from AD 198-induced cell killing. Overall, our data indicate that activation of novel PKC isoforms by cytoplasmic-targeted 14-O-acylanthracyclines promotes an apoptotic response independent of DNA damage, which is unimpeded by inducible activation of NF-kappaB.     

Surgical and non-surgical debridement for the treatment of peri-implantitis: a two-center 12-month randomized trial

Clinical Oral Investigations - To compare surgical (ST) and non-surgical (NST) debridement for the treatment of peri-implantitis in a two-center randomized trial. Forty-five individuals with 63...     

Inhibition of CK2 activity by TGF-beta1 promotes IkappaB-alpha protein stabilization and apoptosis of immortalized hepatocytes

Nuclear factor kappaB (NF-kappaB) is an antiapoptotic factor involved in development, regeneration, and neoplastic progression of the liver. Previously, we have shown that stabilization of inhibitor kappaB (IkappaB)-alpha protein following treatment of hepatocytes with transforming growth factor (TGF)-beta1 promoted NF-kappaB repression, which then permitted induction of AP-1/SMAD-mediated liver cell death. Because basal IkappaB-alpha protein turnover is regulated by protein kinase CK2, here we have elucidated the regulation of CK2 kinase activity and its role in control of NF-kappaB levels following treatment with TGF-beta1. We show that both messenger RNA (mRNA) and protein levels of the CK2alpha catalytic subunit are down-regulated following TGF-beta1 stimulation in murine hepatocyte cells. The ensuing inhibition of CK2 kinase activity promotes stabilization of IkappaB protein, which is followed by the shutoff of constitutive NF-kappaB activity and induction of apoptosis. Ectopic expression of CK2alpha inhibits TGF-beta1-induced apoptosis through sustained activation of NF-kappaB. Conversely, expression of a kinase-dead mutant of CK2alpha potentiates TGF-beta1 cell killing. Importantly, we show that hepatocellular carcinomas (HCCs) derived from TGF-beta1 transgenic mice and human HCC cell lines display enhanced CK2 IkappaB kinase activity that contributes in part to an elevated NF-kappaB activity in vivo. In conclusion, inhibition of CK2 expression levels by TGF-beta1 is crucial for the induction of apoptosis of hepatocytes. Circumvention of this process by up-regulation of CK2 activity in transformed cells may contribute to the promotion of TGF-beta1-induced liver carcinogenesis.