Transient anesthetic-induced worsening of existing left-sided weakness in a patient undergoing elective anterior cervical discectomy

The differential diagnosis of new or worsening focal neurologic deficits on emergence from anesthesia is broad. Cerebral ischemia or hemorrhage, focal seizures, and acute metabolic abnormalities can all result in similar neurologic findings. Intravenously administered anesthetic agents also have been reported to cause new or worsening focal neurologic deficits in patients with a history of preexisting deficits. A patient who suffered such a reversible deficit related to anesthesia is presented.     

Spinal Glioblastoma Multiforme: Unusual Cause of Post-Traumatic Tetraparesis

Background/Objective:

Glioblastoma multiforme (GBM) is the most common glial cell tumor of the adult brain. However, primary GBM of the spinal cord is a rare condition.

Methods:

Case report.

Results:

A young man presented with acute onset quadriparesis after a whiplash injury. A magnetic resonance scan showed the typical appearance of a high-grade intramedullary tumor with fusiform expansion of the entire cervical cord. Subtotal decompression and biopsy was done by posterior laminectomy, followed by external beam radiotherapy. Signs and symptoms improved after the completion of radiotherapy but did not resolve completely. Death caused by respiratory failure occurred 3 months later.

Conclusions:

This presentation of GBM of the cervical cord is rare; an intramedullary tumor should be considered when minor cervical trauma results in disproportionate neurologic deficit. To the best of our knowledge, this is the first reported case of spinal GBM with extensive pan-cervical involvement.     

Tarlov Cyst and Infertility

Background/Objective:

Tarlov cysts or spinal perineurial cysts are uncommon lesions. These are mostly incidental findings on magnetic resonance imaging or myelograms. The objectives of this study were to describe Tarlov cysts of the sacral region as a potential cause for retrograde ejaculations and review available management options.

Methods:

Case report and literature review.

Results:

A 28-year-old man presented with back pain and retrograde ejaculations resulting in infertility. After microsurgical excision of large perineurial cysts, back pain resolved, but semen quality showed only marginal improvement. Later, the couple successfully conceived by intrauterine insemination. To the best of our knowledge, this is the first reported case of Tarlov cyst associated with retrograde ejaculation and infertility.

Conclusions:

Despite being mostly asymptomatic and an incidental finding, Tarlov cyst is an important clinical entity because of its tendency to increase in size with time. Tarlov cysts of the sacral and cauda equina region may be a rare underlying cause in otherwise unexplained retrograde ejaculations and infertility. Microsurgical excision may be a good option in a select group of patients.     

Lipoblastoma--a rare paediatric foot tumour

Lipoblastoma, a rare benign tumour arising from embryonic fat, is usually found in areas of abundant adipose tissue. Various reports describe a predilection of lipoblastoma for sites with primitive adipose tissue such as axilla, neck, retroperitoneum and prevertebral soft tissue. The plantar aspect of the foot is an extremely rare site due to scarcity of fatty tissue. Differential diagnosis includes lipomas, fibromyxolipomas and liposarcomas. Age of presentation, chromosomal markers and histopathological examination help in arriving at final diagnosis. Radical surgeries are not advocated; however, complete excision is necessary to avoid recurrence.     

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents

BACKGROUND: Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model. METHODS: Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed. RESULTS: The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively. CONCLUSION: The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.     

Internal fixation in compound type III fractures presenting after golden period

Objective:

Patients often reach the hospital late after passage of golden hours (initial 6 hours) after sustaining high-velocity injuries. The decision of internal fixation in Gustilo''s Type IIIA and IIIB fractures becomes a formidable challenge in patients reaching late. The purpose of the present study was to find out if internal fixation could be safely undertaken in these patients.

Materials and Methods:

Sixty-three patients, having 70 compound fractures (46 Type IIIA and 24 IIIB), which were internally fixed after 6h but within 24h after injury, were included in the present analysis. Follow-up ranged from 18 to 48 months with mean of 28 months.

Result:

Overall infection rate noted was (n = 11) 15.71% (8.7% in IIIA, and 29.16% in IIIB). The difference in deep infection rate between Type IIIA and Type IIIB was found to be statistically significant (P value < 0.01). Nonunion was seen in five fractures. Functional evaluation using Katenjian''s criteria, showed 62.85% (44 fractures of 70) good to excellent results.

Conclusion:

Satisfactory results may be obtained in Gustilo''s Type IIIA and IIIB fractures even if fixed after the golden period, provided strict protocol such as aggressive debridement, prophylactic antibiotic coverage, early soft tissue reconstruction and timely bone grafting is followed. The primary coverage of the wound is discouraged.     

Humoral immune responses and protective efficacy of sequential B- and T-cell epitopes of V antigen of <Emphasis Type="Italic">Yersinia pestis</Emphasis> by intranasal immunization in microparticles

Capsular F1 and secretory V antigen are the putative vaccine candidates for plague, caused by Yersinia pestis. Contemplating this, we studied the immunogenicity and protective efficacy of collinearly synthesized B- and T-cell epitopes (B-T constructs) of V antigen entrapped in poly (dl-lactide-co-glycolide) microparticles immunized intranasally using single dose immunization schedule in outbred, H-2^b and H-2^d mice. High antibody levels were observed in terms of IgG, IgA and SIgA peak titers in sera and mucosal washes to different B-T constructs. The constructs ai, bi and fi especially showed high peak antibody titers ranging from 51,200 to 204,000, which were maintained till day 120 post immunization. IgG/IgA Specific activity in sera and washes correlated well with the peak antibody titers. Moreover, all the B-T constructs showed mixed IgG1 and IgG2a/2b response, variable immunoreactivity as well as memory response with V antigen. B-T constructs, viz ai, ak, bi, fi, di and ik showed comparatively high isotype levels. These constructs showed high immunoreactivity, and good recall response with V antigen. Finally, in vivo protective study in BALB/c mice demonstrated the protective efficacy of three B-T constructs (ai, bi and fi) against lethal doses of Yersinia pestis till day 20 post challenge, while construct ‘id’ showed partial protection.     

Functional changes of the cortical motor system in hereditary spastic paraparesis

Background – Hereditary spastic paraparesis (HSP) is a heterogeneous group of disorders characterized by progressive bilateral lower limb spasticity. Functional imaging studies in patients with corticospinal tract involvement have shown reorganization of motor circuitry. Our study investigates functional changes in sensorimotor brain areas in patients with HSP. Methods – Twelve subjects with HSP and 12 healthy subjects were studied. Functional magnetic resonance imaging (fMRI) was used to measure brain activation during right‐hand finger tapping. Image analysis was performed using general linear model and regions of interest (ROI)‐based approach. Weighted laterality indices (wLI) and anterior/posterior indicies (wAI and wPI) were calculated for predefined ROIs. Results and discussion – Comparing patients and controls at the same finger‐tapping rate (1.8 Hz), there was increased fMRI activation in patients’ bilateral posterior parietal cortex and left primary sensorimotor cortex. No differences were found when comparing patients and controls at 80% of their individual maximum tapping rates. wLI of the primary sensorimotor cortex was significantly lower in patients. Subjects with HSP also showed a relative increase in the activation of the posterior parietal and premotor areas compared with that of the primary sensorimotor cortex. Our findings demonstrate an altered pattern of cortical activation in subjects with HSP during motor task. The increased activation probably reflects reorganization of the cortical motor system.     

Antinociceptive effect of the essential oil of Zingiber zerumbet in mice: possible mechanisms

Ethnopharmacological relevance

Zingiber zerumbet (L.) Smith, a wild edible ginger species or locally known as “lempoyang”, commonly used in the Malays traditional medicine as an appetizer or to treat stomachache, toothache, muscle sprain and as a cure for swelling sores and cuts.

Aim

The present study was conducted to investigate the possible mechanism of actions underlying the systemic antinociception activity of the essential oil of Zingiber zerumbet (EOZZ) in chemical-induced nociception tests in mice.

Materials and methods

Acetic acid-induced abdominal constriction, capsaicin-, glutamate- and phorbol 12-myristate 13-acetate-induced paw licking tests in mice were employed in the study. In all experiments, EOZZ was administered systemically at the doses of 50, 100, 200 and 300 mg/kg.

Results

It was shown that EOZZ given to mice via intraperitoneal and oral routes at 50, 100, 200 and 300 mg/kg produced significant dose dependent antinociception when assessed using acetic acid-induced abdominal writing test with calculated mean ID₅₀ values of 88.84 mg/kg (80.88-97.57 mg/kg) and 118.8 mg/kg (102.5-137.8 mg/kg), respectively. Likewise, intraperitoneal administration of EOZZ at similar doses produced significant dose dependent inhibition of neurogenic pain induced by intraplantar injection of capsaicin (1.6 μg/paw), glutamate (10 μmol/paw) and phorbol 12-myristate 13-acetate (1.6 μg/paw) with calculated mean ID₅₀ of 128.8 mg/kg (118.6-139.9 mg/kg), 124.8 mg/kg (111.4-139.7 mg/kg) and 40.29 (35.39-45.86) mg/kg, respectively. It was also demonstrated that pretreatment with l-arginine (100 mg/kg, i.p.), a nitric oxide precursor significantly reversed antinociception produced by EOZZ suggesting the involvement of l-arginine/nitric oxide pathway. In addition, methylene blue (20 mg/kg, i.p.) significantly enhanced antinociception produced by EOZZ. Administration of glibenclamide (10 mg/kg, i.p.), an ATP-sensitive K⁺ channel antagonist significantly reversed antinociceptive activity induced by EOZZ.

Conclusion

Together, the present results suggested that EOZZ-induced antinociceptive activity was possibly related to its ability to inhibit glutamatergic system, TRPV1 receptors as well as through activation of l-arginine/nitric oxide/cGMP/protein kinase C/ATP-sensitive K⁺ channel pathway.