Neurological Outcome of Early versus Late Surgery Following Cervical Spinal Cord Injury.

Background There are numerous retrospective studies and a few prospective studies to determine the neurologic outcome after early versus late surgical treatment for cervical spinal cord injury. Objective To compare the neurological outcome between early (within 72 hours after injury) and delayed (≥ 72 hours after injury) surgery in patients with cervical spinal injury. Method This is a retrospective analysis of the neurological outcome of early versus late surgery following cervical spinal cord trauma. Patients meeting appropriate inclusion criteria were divided into an early or a late surgical treatment group. The neurologic outcomes and other complications were recorded up to six months of follow-up. Result Overall, there was a significant difference in neurological status at presentation and at follow-up (p < 0.001). However, there was no statistically significant difference between the early versus late surgery groups (p-value 0.261) in terms of neurological outcome. Complications were found to be higher among those undergoing posterior surgical approach (OR = 23.75; 95% CI 2.65, 212.98) than those with anterior or combined approach (p=0.005). However, multivariate analysis of these variables failed to show any statistically significant difference between the two groups. Conclusion The timing of surgery does not alter the neurological outcomes and the development of complications significantly. The American Spinal Cord Injury Association (ASIA) status at the time of presentation is found to be the single most important factor correlating with the neurological outcome.

Virtual pedagogy in neurosurgery during the COVID-19 pandemic: Perspectives from university hospital in Nepal.

Objectives: Since the onset of the COVID-19 pandemic many large institutions have turned towards virtual education. Neurosurgery in our institute, recognizing its benefits, readily embraced the virtual learning experience using Zoom Inc (San Jose, California) beginning on May 21, 2020. The result of this form of educational experience may not be apparent readily. Hence, nearing the end of one year of monthly Zoom meetings, an effort was undertaken to assess the feasibility and the barriers of effective virtual teaching learning activity in neurosurgery among the participants. Methods: The participants consisted of neurosurgeons and trainees from department of neurosurgery Tribhuvan University Teaching Hospital in Nepal, neurosurgeons based in Seattle, United States of America and neurosurgeons based in Sweden, who have been regularly attending the monthly virtual education organized by Dr. Wohns. At the end of one-year experience of monthly Zoom teaching and learning activities between the participants a questionnaire comprising objective questions related to their experience of virtual education in neurosurgery was distributed to the participants and answers were collected and analyzed. Results: A total of 18 persons out of 25 responded to the questionnaire. Majority of participants responded favorably to virtual education. A few responders faced disturbance in internet connectivity affecting the quality of video and sound during the presentations. None of the participants faced inconvenience due to time difference. Most responders preferred to continue virtual education even after the pandemic. Conclusions: Overall most participants responded favorably to virtual education which has helped them increase their participation and hence broaden their knowledge in the field. Most participants look forward to continuing this form of education even in future. Thus, this form of education may be incorporated at least in part in the future of neurosurgical training.

Correction to: Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries.

[This corrects the article DOI: 10.1186/s41016-020-00194-1.].

Review of global neurosurgery education: Horizon of Neurosurgery in the Developing Countries.

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competence-based programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato-one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Research during COVID-19 Pandemic: Perspectives from the Ethics Committees of a Lower Middle Income Country.

The pandemic of Coronavirus Disease 2019 (COVID-19) has created paradoxically a good opportunity globally to conduct research in the field of health and social science, and a Lower Middle-Income Country (LMIC) like Nepal is not an exception in this regard. During this ongoing pandemic, the Ethical Review Board (ERB) of Nepal Health Research Council (NHRC) has received numerous research proposals regarding COVID-19. As its main responsibility is to ensure participants' safety, at the same time maintaining the scientific standard of research, the ERB has meticulously gone through all the proposals received so far. During this situation of a health emergency, the ERB of NHRC has had a different experience compared to the usual time. Its strength, weakness, opportunities, and threats have been like never before.

Comparative Effects of CT Imaging Measurement on RECIST End Points and Tumor Growth Kinetics Modeling.

Quantitative assessments of tumor burden and modeling of longitudinal growth could improve phase II oncology trials. To identify obstacles to wider use of quantitative measures we obtained recorded linear tumor measurements from three published lung cancer trials. Model-based parameters of tumor burden change were estimated and compared with similarly sized samples from separate trials. Time-to-tumor growth (TTG) was computed from measurements recorded on case report forms and a second radiologist blinded to the form data. Response Evaluation Criteria in Solid Tumors (RECIST)-based progression-free survival (PFS) measures were perfectly concordant between the original forms data and the blinded radiologist re-evaluation (intraclass correlation coefficient = 1), but these routine interrater differences in the identification and measurement of target lesions were associated with an average 18-week delay (range, -20 to 55 weeks) in TTG (intraclass correlation coefficient = 0.32). To exploit computational metrics for improving statistical power in small clinical trials will require increased precision of tumor burden assessments.

Estimation of renal cell carcinoma treatment effects from disease progression modeling.

To improve future drug development efficiency in renal cell carcinoma (RCC), a disease-progression model was developed with longitudinal tumor size data from a phase III trial of sorafenib in RCC. The best-fit model was externally evaluated on 145 placebo-treated patients in a phase III trial of pazopanib; the model incorporated baseline tumor size, a linear disease-progression component, and an exponential drug effect (DE) parameter. With the model-estimated effect of sorafenib on RCC growth, we calculated the power of randomized phase II trials between sorafenib and hypothetical comparators over a range of effects. A hypothetical comparator with 80% greater DE than sorafenib would have 82% power (one-sided α = 0.1) with 50 patients per arm. Model-based quantitation of treatment effect with computed tomography (CT) imaging offers a scaffold on which to develop new, more efficient, phase II trial end points and analytic strategies for RCC.

Models of excellence: improving oncology drug development.

Simulations based on disease-progression models and phase II trial results can predict phase III results and have the potential to improve oncology drug development by informing end-of-phase II decisions (EOP2Ds). Many barriers impede effective use of modeling and simulation (M&S) for EOP2Ds in oncology: concerns about model validity, lack of access to M&S results and patient-level data, limited awareness of M&S among academic oncologists, and inexperience fitting M&S into the drug development timeline.

A phase I study of sirolimus and bevacizumab in patients with advanced malignancies.

BACKGROUND: We performed a single institution, phase I study of sirolimus and bevacizumab, in order to determine the dose limiting toxicity (DLT) and recommended phase II doses. PATIENTS AND METHODS: Eligible patients had previously treated advanced malignancies and were enrolled in three cohorts. Sirolimus 90 mg PO weekly (45 mg on days 1 and 2) was combined with bevacizumab 7.5mg/kg (cohort #1) or bevacizumab 15 mg/kg (cohort #2) IV q3weeks. Sirolimus 4 mg PO daily was combined with bevacizumab 15 mg/kg IV q3weeks (cohort #3). RESULTS: Twenty-eight patients enrolled. The most common tumour types were colorectal (21%), head/neck (14%), and renal cell (11%). No DLTs were observed in cohorts #1 (4 patients) and #2 (12 patients), while two DLTs (grade 3 confusion and grade 3 fatigue) were observed in the first six patients in cohort #3 (12 patients). The most common grade 3 toxicities were fatigue (18%), hypertension (14%) and anorexia (11%). There were no responses, but one patient has had stable disease for 78 weeks. CONCLUSIONS: The combination of sirolimus and bevacizumab at full doses is tolerable in the majority of patients. The availability and cost of sirolimus compared with other mTOR inhibitors make this an attractive agent to combine with bevacizumab.

TNF-alpha production in the skin.

Upregulation of TNF-alpha is a key early response to ultraviolet B (UVB) by keratinocytes (KCs), and represents an important component of the inflammatory cascade in skin. UVB irradiation induces TNF-alpha expression in both KCs and dermal fibroblasts, with TNF-alpha mRNA induction seen as early as 1.5 h after UVB. We previously reported that the effects are wavelength-specific: TNF-alpha expression and secretion are induced by UVB (290-320 nm), but not by UVA (320-400 nm). Moreover, we found that IL-1alpha, a cytokine also present in irradiated skin, substantially and synergistically enhances the induction of TNF-alpha by UVB, and the induction of TNF-alpha by this combination of UVB with IL-1alpha is mediated through increased TNF-alpha gene transcription. We investigated the molecular mechanism for UVB-induction of the TNF-alpha gene with a series of TNF-alpha promoter constructs, ranging from 1.2 kbp (from -1179 to +1 with respect to the TNF-alpha transcription initiation site) down to 0.1 kbp (-109 to +1), each driving expression of a CAT reporter. Our results showed a persistent nine to tenfold increase of CAT activity in all TNF-alpha promoter/reporter constructs in response to UVB (30 mJ/cm(2)) exposure. These results indicate the presence of UVB-responsive cis-element(s) located between -109 and +1 of the TNF-alpha promoter, a region that contains a putative AP-1 site and a putative NFkB site. UVB-induction was abolished when the TNF-alpha promoter was mutated by one base pair at the AP-1 binding site. Cells treated with SP600125, an AP-1 inhibitor that inhibits JNK (c-Jun N-terminal kinase), also showed suppression of the 0.1 kbp TNF-alpha promoter/reporter construct. The authentic endogenous gene in untransfected cells was also blocked by the inhibitor. Electrophoretic Mobility Shift Assay indicated new complexes from UVB-treated nuclear extracts and anti-phospho-c-Jun, a regulatory component of the AP-1 transcription factor, creating a supershift indicating increased phosphorylation of c-Jun and hence higher AP-1 activity. Keratinocyte-derived TNF-alpha is a component of the early induction phase of the inflammatory cascade.

Airway management at floor level: a comparison of tracheal intubation using the Macintosh and Airtraq laryngoscopes.

Practitioners providing pre-hospital care during civilian practice and on military operations may be required to perform airway management and tracheal intubation at floor level. It has been shown that intubation using the Airtraq laryngoscope is easier to learn than standard Macintosh laryngoscopy. We hypothesised that the Airtraq would be easier to use and have shorter intubation times than Macintosh intubation. Sixty volunteers attending a medical conference with no prior Airtraq experience, who were skilled in pre-hospital Macintosh intubation, were recruited. Each was required to intubate an anatomically correct manikin at floor level using a Macintosh and Airtraq laryngoscope. The Airtraq was found to be superior in ease of use (VAS 30 mm, P < 0.001), had a shorter total intubation time (19.4seconds) and a higher intubation success rate (P = 0.012) than the Macintosh laryngoscope (VAS 50 mm, 20.4 seconds). Rotating the tracheal tube 90 degrees anticlockwise during loading into the guiding channel, made the Airtraq intubation easier (VAS 30 mm, P = 0.001) and faster (19.4 seconds, P < 0.001) than with standard orientation of the tube (VAS 40 mm, 25.3 seconds). Airtraq intubation may prove to be easier than Macintosh intubation, when utilised in the clinical pre-hospital setting, though randomised controlled clinical trials are required to confirm this.

Three-dimensional reconstruction of the recombinant type 3 ryanodine receptor and localization of its amino terminus.

Recombinant type 3 ryanodine receptor (RyR3) has been purified in quantities sufficient for structural characterization by cryoelectron microscopy and three-dimensional (3D) reconstruction. Two cDNAs were prepared and expressed in HEK293 cells, one encoding the wild-type RyR3 and the other encoding RyR3 containing glutathione S-transferase (GST) fused to its amino terminus (GST-RyR3). RyR3 was purified from detergent-solubilized transfected cells by affinity chromatography using 12.6-kDa FK506-binding protein in the form of a GST fusion as the affinity ligand. Purification of GST-RyR3 was achieved by affinity chromatography by using glutathione-Sepharose. Purified recombinant RyR3 and GST-RyR3 proteins exhibited high-affinity [(3)H]ryanodine binding that was sensitive to activation by Ca(2+) and caffeine and to inhibition by Mg(2+). 3D reconstructions of both recombinant RyR3 and GST-RyR3 appeared very similar to that of the native RyR3 purified from bovine diaphragm. Comparison of the 3D reconstructions of RyR3 and GST-RyR3 revealed that the GST domains and, hence, the amino termini of the RyR3 subunits are located in the "clamp" structures that form the corners of the square-shaped cytoplasmic region of homotetrameric RyR3. This study describes the 3D reconstruction of a recombinant ryanodine receptor and it demonstrates the potential of this technology for characterizing functional and structural perturbations introduced by site-directed mutagenesis.

Three-dimensional structure of ryanodine receptor isoform three in two conformational states as visualized by cryo-electron microscopy.

Using cryo-electron microscopy and single particle image processing techniques, we present the first three-dimensional reconstructions of isoform 3 of the ryanodine receptor/calcium release channel (RyR3). Reconstructions were carried out on images obtained from a purified, detergent-solubilized receptor for two different buffer conditions, which were expected to favor open and closed functional states of the channel. As for the heart (RyR2) and skeletal muscle (RyR1) receptor isoforms, RyR3 is a homotetrameric complex comprising two main components, a multidomain cytoplasmic assembly and a smaller ( approximately 20% of the total mass) transmembrane region. Although the isoforms show structural similarities, consistent with the approximately 70% overall sequence identity of the isoforms, detailed comparisons of RyR3 with RyR1 showed one region of highly significant difference between them. This difference indicated additional mass present in RyR1, and it likely corresponds to a region of the RyR1 sequence (residues 1303-1406, known as diversity region 2) that is absent from RyR3. The reconstructions of RyR3 determined under "open" and "closed" conditions were similar to each other in overall architecture. A difference map computed between the two reconstructions reveals subtle changes in conformation at several widely dispersed locations in the receptor, the most prominent of which is a approximately 4 degrees rotation of the transmembrane region with respect to the cytoplasmic assembly.

Amino acid residues 4425-4621 localized on the three-dimensional structure of the skeletal muscle ryanodine receptor.

We have localized a region contained within the sequence of amino acid residues 4425-4621 on the three-dimensional structure of the skeletal muscle ryanodine receptor (RyR). Mouse monoclonal antibodies raised against a peptide comprising these residues have been complexed with ryanodine receptors and imaged in the frozen-hydrated state by cryoelectron microscopy. These images, along with images of antibody-free ryanodine receptor, were used to compute two-dimensional averaged images and three-dimensional reconstructions. Two-dimensional averages of immunocomplexes in which the ryanodine receptor was in the fourfold symmetrical orientation disclosed four symmetrical regions of density located on the edges of the receptor's cytoplasmic assembly that were absent from control averages of receptor without added antibody. Three-dimensional reconstructions revealed the antibody-binding sites to be on the so-called handle domains of the ryanodine receptor's cytoplasmic assembly, near their junction with the transmembrane assembly. This study is the first to demonstrate epitope mapping on the three-dimensional structure of the ryanodine receptor.

Interactions of gender, growth hormone, and phenobarbital induction on murine Cyp2b expression.

The interactions of gender, growth hormone, and phenobarbital induction on Cyp2b expression were examined in phenotypically normal (lit/+) and growth-hormone deficient "little" (lit/lit) mice. Using an immunocrossreactive monoclonal antibody designed to identify rat CYP2B1 and 2B2 proteins, we observed three hepatic Cyp2b proteins in control (lit/+) females, but only two proteins, one at trace levels, in control males. Phenobarbital administration to lit/+ mice increased the expression of the two Cyp2b isoforms in the males by 3- to 4-fold, but produced an approximately 75% reduction in the female-expressed proteins. Whereas growth hormone depletion (lit/lit) had no effect on the expression profile of Cyp2b proteins in females, it had a de-repressive effect in males, resulting in the expression of three proteins at concentrations now comparable to those observed in female liver. Generally, phenobarbital had no inductive effects in the lit/lit mice of both sexes. In all groups, transcript levels measured by a CYP2B1 probe were in agreement with the protein findings. In contrast, Cyp2b mRNA identified by an oligonucleotide probe for CYP2B2 were repressed completely by growth hormone in both sexes, and was expressed as a female-predominant transcript in the lit/lit mice. In spite of an apparent high degree of sequence homology between the rat CYP2B and murine Cyp2b gene families, the present findings highlight fundamental differences in their constitutive and gender-dependent expression, growth hormone regulation, and phenobarbital inducibility.

Cryoelectron microscopy and image analysis of the cardiac ryanodine receptor.

The three-dimensional structure of the cardiac muscle ryanodine receptor (RyR2) is described and compared with its skeletal muscle isoform (RyR1). Previously, structural studies of RyR2 have not been as informative as those for RyR1 because optimal conditions for electron microscopy, which require low levels of phospholipid, are destabilizing for RyR2. A simple procedure was devised for diluting RyR2 (in phospholipid-containing buffer) into a lipid-free buffer directly on the electron microscope grid, followed by freezing within a few seconds. Cryoelectron microscopy of RyR2 so prepared yielded images of sufficient quality for analysis by single particle image processing. Averaged projection images for RyR2, as well as for RyR1, prepared under the same conditions, were found to be nearly identical in overall dimensions and appearance at the resolution attained, approximately 30 A. An initial three-dimensional reconstruction of RyR2 was determined (resolution approximately 41 A) and compared with previously reported reconstructions of RyR1. Although they looked similar, which is consistent with the similarity found for the projection images, and with expectations based on the 66% amino acid sequence identity of the two isoforms, structural differences near the corners of the cytoplasmic assembly were observed in both two- and three-dimensional studies.

A comparison of cytochrome P450-dependent testosterone 2alpha-hydroxylase in rat (P4502C11) and mouse (P4502alpha).

Hepatic P450 2C11 in the rat and P450(2alpha) in the mouse are unique in being the only isoforms in their respective species with testosterone 2alpha-hydroxylase activity. Comparing gender differences, tissue distribution and physicochemical properties, we investigated whether this uncommon catalytic activity shared by the two isoforms is dependent upon a high degree of homology. Using additional substrates (e.g. androstenedione, hexobarbital), we observed that P450(2alpha) and P450 2C11 produced no metabolites in common. Moreover, concentrations of antisera prepared against purified P450(2alpha) that inhibited 95% of P450(2alpha)-dependent testosterone 2alpha-hydroxylase activity had only a minimal inhibitory effect (< 20%) on P450 2C11-dependent testosterone 2alpha-hydroxylase and were similarly unreactive to the rat isoform isolated on Western blots. Comparison of the isoforms' N-terminal amino acid residues and two internal peptide fragments indicated almost no sequence homology (< 4%). Gender-dependent tissue expression levels of P450(2alpha) and P450 2C11 revealed additional dichotomies. Whereas hepatic P450(2alpha) was moderately female-predominant (M/F; 0.62), hepatic P450 2C11 was clearly male-specific (M/F; 32.9). Murine P450(2alpha) mRNA was equally and substantially expressed in liver, kidney and brain; by contrast earlier studies reported that rat P450 2C11 was exclusively expressed in liver. The present results indicate that the unique testosterone 2alpha-hydroxylase activities of P450(2alpha) and P450 2C11 are expressed by two very different proteins exhibiting minimal homology.

Purification and characterization of constituent androstenedione 15 alpha-hydroxylase (cytochrome P450(15 alpha AD)) from mouse liver. Sex- and tissue-dependent expression.

Hepatic microsomal androstenedione 15 alpha-hydroxylase (i.e.cytochrome P450(15)alpha AD was purified from female CD-1 mice. Protein purification was monitored in eluates from Fractogel, DEAE-Sephacel, and hydroxylapatite columns at heme absorbing 417 nm, by cytochrome P450 content, reactivity to monoclonal antibody against female-specific rat cytochrome P450 2C12, and androstenedione 15 alpha-hydroxylase activity. The catalytic activity for androgens of the purified cytochrome P450(15)alpha AD, exhibiting a high degree of regioselectivity and stereospecificity, was restricted to the 7 alpha- and 15 alpha-hydroxylation of androstenedione, representing, respectively, > 5% and > 93% of the total metabolites. Polyclonal antibodies against cytochrome P450(15)alpha AD exhibited a concentration-dependent and very selective inhibition of hepatic microsomal androstenedione 7 alpha- and 15 alpha-hydroxylation and a 60% inhibition of benzphetamine demethylation, the latter drug appearing to be a much more effective substrate than androgens. Cytochrome P450(15)alpha AD accounted for about 3% of the total P450 in female mouse liver microsomes. The apparent subunit molecular weight of P450(15)alpha AD was 53,000, and the protein appeared as a single band or sodium dodecyl sulfate-polyacrylamide gels. The isoform was intensely expressed in both liver and lung of CD-1 female mice and was female-predominant in the livers of five or eight strains examined; it was sex-independent in the remaining three strains. Amino-terminal sequence analysis indicates that cytochrome P450(15)alpha AD is a member of the murine cytochrome P450 2c subfamily.

Simulataneous isolation of NADPH-cytochrome P-450 reductase and cytochrome P-450 using tentacle ion-exchange chromatography and interspecies comparison of the reductase activity.

Using the same initial Fractogel (tentacle) ion-exchange chromatography to isolate murine cytochrome P-450, mouse hepatic NADPH-cytochrome P-450 reductase (EC 1.6.2.4) was simultaneously isolated from solubilized liver microsomes and purified on a DE-52 column to a single band on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The enzyme had a molecular mass of 77 kD, and its specific activity was 25.4 mumol.min-1.mg protein-1. Purified constitutive mouse liver NADPH-cytochrome P-450 reductase was successfully reconstituted in vitro with dilauroylphosphatidyl-choline and constitutive purified mouse testosterone 2 alpha-hydroxylase (cytochrome P-450(2)alpha) with an observed activity of 13.8 nmol.min-1.nmol P-450-1. Although the partially purified reductase obtained from the Fractogel column was contaminated by significant levels of two unidentified proteins, it was as equally effective in the reconstituted system as the DE-52-derived purified reductase. Lastly, we found that rat and mouse NADPH-cytochrome P-450 reductases were similarly effective in supporting the catalytic activity of rat cytochrome P-450 2B1, but the murine reductase was 50% more effective than the rat reductase in a reconstituted system containing mouse cytochrome P-450(2)alpha.