Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries.

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Profile of type 2 diabetes mellitus without overt complications of diabetes mellitus at a tertiary care center.

INTRODUCTION AND OBJECTIVES: Internal audit of an aspect of a disease at repeated intervals helps in predicting the new emerging trends. This study was planned to assess the profile of patients with diabetes mellitus (DM) without overt complications. MATERIALS AND METHODS: Patients with HbA1c between 6% and 9% on oral hypoglycemic agents and who did not have clinically overt complications of diabetes were recruited from outpatient clinic of Department of Endocrinology and Metabolism at All India Institute of Medical Sciences (AIIMS) from April 2009 to October 2011. RESULTS: A total of 91 patients (53 males and 38 females) were recruited over 3 years of period. Their mean age was 49.65 ± 11.22 years (range in years) and mean duration of diabetes was 48.09 ± 41.44 (range: 1-180) months. Biochemical evaluation revealed mean fasting blood sugar (FBS): 126.69 ± 25.80 mg/dl and mean HbA1c: 7.12 ± 0.81%. Family history of DM was present in 60.43% of patients, 6.59% were active smokers and 46.15% were obese (waist circumference ≥90 cm in males and ≥80 cm in females). All but 6.59% (n = 6) of patients were dyslipidemic and only 25 of these were on antidyslipidemic treatment. Isolated low HDL was most common abnormality (25.27%, n = 23), followed by combination of low HDL and raised LDL (17.58%, n = 16). Evaluation of complications showed retinopathy in just one patient, nephropathy in 17.68%, and neuropathy in 10.97%. MINI neuropsychiatric scale for depression was positive in four patients and four patients were on antidepressants. CONCLUSION: Type 2 diabetes mellitus (T2DM) patients have very high prevalence of dyslipidemia even in patients with good glycemic control. This study allowed us to realize lacunae in our clinical practice regarding need for better care of lipid parameters.

Does CSF composition predict shunt malfunction in tuberculous meningitis?

BACKGROUND: Hydrocephalus secondary to tuberculous meningitis (TBM) continues to be a challenging condition to treat for neurosurgeons in developing countries. Shunt complications are reportedly more frequent in patients undergoing ventriculo-peritoneal shunt in patients with TBM than in those undergoing shunt surgeries for other causes. AIM: The aim of this study was to evaluate the relationship of cerebrospinal fluid (CSF) composition on shunt malfunction. METHODS: We compared the CSF composition of 53 patients who had shunt malfunction during a five year period with that of 137 matched controls. RESULTS: Patients who had shunt malfunction had a significantly higher concentration of CSF protein. The CSF cellularity and glucose concentration did not have any significant bearing in predicting shunt malfunction. Patients with CSF protein concentration of more than 200 mg/dL had a four times higher risk of having shunt malfunction than those with a concentration of less than 100 mg/dL. Patients with CSF protein in the 100-200 mg/dL range represent an intermediate zone. CONCLUSION: To conclude, patients with CSF protein concentration of more than 200 mg/dL have a significantly higher risk of shunt malfunction and hence have to be followed up closely.

Large occipito-cervical encephalocele with Chiari III malformation.

Chiari type III is the rarest of the Chiari malformations and is usually associated with high morbidity and mortality. Treatment consists of primary closure of the encephalocele with or without cerebro-spinal fluid (CSF) shunting. In our case, the patient was treated with ventriculoperitoneal shunt followed by excision of the encephalocele. We propose that large encephaloceles should be treated with CSF shunting prior to repair of the sac so as to achieve optimal result.

Delleman (oculocerebrocutaneous) syndrome: few variations in a classical case.

Delleman syndrome involves a group of congenital abnormalities affecting the eye, skin and central nervous system. It is a rare and sporadic disorder. We report on a 4-year-old male child who presented to us with oculocerebrocutaneous syndrome featuring: focal alopecia on the left side of the scalp, left periorbital skin appendages, a left-sided orbital dermoid, a large left-sided intracranial cyst,optic atrophy. About 35 such cases have been reported in the literature so far. To our knowledge optic atrophy associated with oculocerebrocutaneous syndrome has not been reported previously. Our patient had only a single seizure and his IQ was normal.

Benzoylecgonine hydrazides: synthesis, coupling to horseradish peroxidase, and characterization of the conjugates.

Benzoylecgonine-horseradish peroxidase conjugate (BE-HRP) can be used as a diagnostic reagent for the detection of cocaine in illicit drug samples and in biological fluids. This paper describes the preparation and characterization of BE-HRP. Two hydrazide derivatives of benzoylecgonine, N-2-(tert-butyloxycarbonyl)benzoylecgonine hydrazide and mono(N-2'-benzoylecgoninoyl)adipic dihydrazide, were synthesized by carbodiimide-activated coupling of benzoylecgonine to N-2-(tert-butyloxycarbonyl) hydrazide and adipic dihydrazide, respectively. Removal of the tert-butyloxycarbonyl protecting group in N-2-(tert-butyloxycarbonyl)benzoylecgonine hydrazide with anhydrous HCl yielded benzoylecgonine hydrazide hydrochloride. NMR and high-resolution mass spectral analyses demonstrated that the benzoyl group of benzoylecgonine remained intact under the conditions of both carbodiimide coupling and anhydrous HCl treatment. By aldehyde-hydrazide condensation, the hydrazides were covalently conjugated to the carbohydrate residues of horseradish peroxidase (HRP). Dot blot analysis of the conjugates employing antibodies specific to benzoylecgonine demonstrated the presence of bound benzoylecgonine in HRP. The stoichiometry of benzoylecgonine residues to HRP was determined by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS). Mono(N-2'-benzoylecgoninoyl)adipic dihydrazide gave a 2.5-3-fold higher coupling compared with benzoylecgonine hydrazide. Conjugates were also prepared by the coupling of the carbodiimide-activated benzoylecgonine to HRP that was derivatized with adipic dihydrazide.