Calvarial hyperpigmentation.

Background: Osseous hyperpigmentation of the calvarium is an extremely rare finding with only few reported cases in literature. Case Description: The case is of a 59-year-old Caucasian male who presented with an acute history of generalized tonic clonic seizures and progressive weakness of the right upper limb. He had a background history of a malignant melanoma which had been resected from his left external acoustic meatus 4 weeks prior. Neuroimaging of the brain showed an intra-axial space-occupying lesion in his left parietal lobe with no associated osseous changes. A left mini parietal craniotomy was performed which revealed black discoloration of the parietal bone. The lesion was successfully resected and the bone flap was secured back in place. The patient was discharged on the 4th day postoperatively with no complications. The unusual finding of black discoloration of the calvarium was found to be secondary to adolescent tetracycline use. Conclusion: Calvarial hyperpigmentation is a phenomenon encountered incidentally and will often come as surprise for surgeons. Once encountered, thorough history taking and examination should be done to investigate the cause.

Evaluation of Nanoleakage Depth and Pattern of Cervical Restorations Bonded with Different Adhesive Systems.

Aim: To evaluate nanoleakage depth and pattern of cervical restorations bonded with different adhesive systems. Materials and methods: Thirty-six extracted human premolar teeth were used for the study and grouped according to different bonding agents.Group I: fifth generation dentin bonding agent-ONE COAT SL.Group II: sixth generation dentin bonding agent-PARABOND.Group III: seventh generation dentin bonding agent-ONE COAT 7.0.For nanoleakage depth evaluation, 36 teeth were divided into three groups of 12 teeth each, according to adhesive systems used. For each adhesive system, teeth were subdivided into three subgroups of four teeth each, according to storage period, 24 hours, 1 month, and 3 months before the examination. In each tooth, two cavities were prepared (buccal and lingual), each cavity was lined with different adhesive systems and restored using a nanohybrid composite. The restored teeth were then immersed in water bath at temperature 37oC for intended period of time and then stored in 50% silver nitrate for 24 hours and photo developing solution for 8 hours. After this, the teeth were cut in buccolingual direction and subjected to scanning electron microscope (SEM) analysis for nanoleakage depth analysis. Results: Group II showed the highest nanoleakage at all three periods. At 24 hours, group III showed more leakage than group I (mean = 0.2869 > 0.2506). At 1 month storage period, there was no significant difference in the leakage. At 3 months storage period, group III showed less leakage than group I (mean = 0.5544 < 0.7313). How to cite this article: Bhupanapadu N, Sattar MA, Deb A. Evaluation of Nanoleakage Depth and Pattern of Cervical Restorations Bonded with Different Adhesive Systems. Int J Clin Pediatr Dent 2022;15(3):299-303.

Supraorbital eyebrow approach: A single-center experience.

Background: Keyhole neurosurgery is the notion of safely removing brain and skull base lesions through smaller and more precise openings that lessen collateral damage to the surrounding scalp, brain, blood vessels, and nerves. The traditional frontal and pterional approaches require large craniotomies and this predisposes patients to significant and avoidable morbidity. With the growing expectation for minimally invasive surgery, we present our experience with the supraorbital keyhole craniotomy for surgical lesions in the anterior cranial fossa and parasellar regions. Methods: We retrospectively analyzed and evaluated all cases of neoplastic, vascular, trauma, and infective pathologies of the anterior fossa and parasellar regions treated using a keyhole approach, the supraorbital eyebrow (SOE) approach from January 2018 to June 2022. Treatment outcomes were evaluated based on pathology. Results: A total of 50 patients underwent a SOE craniotomy during the study period (28 females and 22 males). Their average age ranged from 12 to 86 years, with a mean age of 47.4 years. All patients had anterior skull base and/or anterior frontal lobe pathologies: (23 tumors, 17 ruptured aneurysms, five traumatic frontal hematomas, three extradural empyema, one cerebral cavernous malformation, and one traumatic frontal skull base fracture with dural tear and CSF leak). Gross total tumor resection was achieved in 87% of cases (13 meningiomas of which six were giant, three gliomas, two craniopharyngiomas, and two cerebral metastases). Clip ligation occlusion rate for our aneurysm cases was 100% and intraoperative rerupture was observed in three cases. Mean ICU stay was 2.2 days for the entire series. The overall 30-day mortality rate for our series was 16% (eight deaths). This was highest in the ruptured aneurysm subgroup, with all 5 mortality cases in the aneurysmal subgroup presenting as World Federation of Neurological Surgeons (WFNS) grades ≥ III. 4 of the deaths were in WFNS IV and V patients. The most frequent perioperative complication was transient periorbital swelling which resolved within 7 days. It was observed in 18 of the 50 patients. The next common complications in descending frequency were eyebrow alopecia (three cases), supraorbital hypoesthesia (two cases), CSF leak (two cases), and surgical site infection (one case). There was one approach-related intraoperative complication secondary to carotid injury in a giant meningioma redo case. Conversion to a larger craniotomy was never necessary. Clinical outcome for our cases was evaluated according to the Modified Rankin Scale (mRS) at 3-month postsurgery. A good clinical outcome (mRS ≤ 2) was achieved for 78% of our patients. Conclusion: The SOE approach craniotomy is an effective minimally invasive approach for various pathologies of the anterior cranial base and parasellar regions. With experience, giant tumors and complex vascular pathology can be addressed with this keyhole approach.

Rickettsial Illnesses as Important Causes of Febrile Illness in Chittagong, Bangladesh.

We conducted a yearlong prospective study of febrile patients admitted to a tertiary referral hospital in Chittagong, Bangladesh, to assess the proportion of patients with rickettsial illnesses and identify the causative pathogens, strain genotypes, and associated seasonality patterns. We diagnosed scrub typhus in 16.8% (70/416) and murine typhus in 5.8% (24/416) of patients; 2 patients had infections attributable to undifferentiated Rickettsia spp. and 2 had DNA sequence-confirmed R. felis infection. Orientia tsutsugamushi genotypes included Karp, Gilliam, Kato, and TA763-like strains, with a prominence of Karp-like strains. Scrub typhus admissions peaked in a biphasic pattern before and after the rainy season, whereas murine typhus more frequently occurred before the rainy season. Death occurred in 4% (18/416) of cases; case-fatality rates were 4% each for scrub typhus (3/70) and murine typhus (1/28). Overall, 23.1% (96/416) of patients had evidence of treatable rickettsial illnesses, providing important evidence toward optimizing empirical treatment strategies.

Use of buccal morphine in the management of pain in children with life-limiting conditions: Results of a laboratory study.

BACKGROUND: Children and infants with impaired swallow or compromised enteral absorption require alternative routes for administration of analgesia. Recent clinical guidance and practice for paediatric palliative care teams, who often treat such children, supports buccal morphine sulphate as a fast acting, effective and easily administered agent for pain relief. However, a consideration of the physicochemical properties and potency of morphine would suggest that it is not a suitable candidate for delivery via the transmucosal route, raising questions about its use in children and infants. AIM: To explore the permeability of buccal morphine sulphate in an established ex vivo porcine buccal mucosa as a necessary step in examining efficacy for use in children with life-limiting conditions and life-threatening illnesses. DESIGN: A permeation study conducted with morphine sulphate in an ex vivo porcine buccal tissue model. Flux values and pharmacokinetic data were used to calculate the plasma values of morphine that would result following buccal administration in a 20kg child. RESULTS: Results show that the estimated steady state plasma values of morphine sulphate following buccal administration in this model do not achieve minimum therapeutic concentration. CONCLUSION: These data strongly suggest that morphine sulphate is not suitable for buccal administration and that further research is needed to establish its efficacy in relief of pain in children with life-limiting conditions and life-threatening illnesses.

Oral transmucosal delivery of naratriptan.

Naratriptan (NAR) is currently used as the hydrochloride salt (NAR.HCl) for the treatment of migraine and is available in tablet dosage forms for oral administration. Buccal drug delivery offers a number of advantages compared with conventional oral delivery including rapid absorption, avoidance of first pass metabolism and improved patient compliance. We have previously prepared and characterised the base form of NAR and shown that it has more favourable properties for buccal delivery compared with NAR.HCl. This study describes the design and evaluation of a range of formulations for oral transmucosal delivery of NAR base. Permeation studies were conducted using excised porcine buccal tissue mounted in Franz cells. Of the neat solvents examined, Transcutol® P (TC) showed the greatest enhancement effects and was the vehicle in which NAR was most soluble. The mechanisms by which TC might promote permeation were further probed using binary systems containing TC with either buffer or Miglyol 812® (MG). Mass balance studies were also conducted for these systems. The permeation of TC as well as NAR was also monitored for TC:MG formulations. Overall, TC appears to promote enhanced membrane permeation of NAR because of its rapid uptake into the buccal tissue. Synergistic enhancement of buccal permeation was observed when TC was combined with MG and this is attributed to the increased thermodynamic activity of NAR in these formulations. Significantly enhanced permeation of NAR was achieved for TC:MG and this was also associated with less TC remaining on the tissue or in the tissue at the end of the experiment. To our knowledge this is the first report where both enhancer and active have been monitored in buccal permeation studies. The findings underline the importance of understanding the fate of vehicle components for rational formulation design of buccal delivery systems.

Preparation, characterization and buccal permeation of naratriptan.

Naratriptan (NAR) is currently used for the management of migraine as the hydrochloride salt (NAR.HCl) and is administered as an oral tablet. This work evaluates the feasibility of buccal delivery of NAR in order to ensure faster onset of action and avoid the side-effects associated with conventional oral formulations. We hypothesized that the unionized form of NAR would permeate buccal tissue to a greater extent than the salt. Therefore the first stage of this work required preparation of the free base from NAR.HCl. Characterisation of the base with thermal and elemental analyses confirmed its purity; logP and logD values were also determined. The pH permeation profile of NAR was also determined in the range 7.4-10. Solubility studies in non-aqueous solvents indicated that Transcutol™ (TC) and dipropylene glycol (DPG) were suitable vehicles for the free base. Maximum amounts of NAR which permeated after 6h were ∼ 130 µg/cm(2). Based on the pH permeation results and studies conducted at two different doses NAR appears to permeate porcine buccal tissue via the transcellular route. Finally, estimates of likely systemic values suggest that optimised formulations should be taken forward for in vivo evaluation.

Oral transmucosal drug delivery--current status and future prospects.

Oral transmucosal drug delivery (OTDD) dosage forms have been available since the 1980s. In contrast to the number of actives currently delivered locally to the oral cavity, the number delivered as buccal or sublingual formulations remains relatively low. This is surprising in view of the advantages associated with OTDD, compared with conventional oral drug delivery. This review examines a number of aspects related to OTDD including the anatomy of the oral cavity, models currently used to study OTDD, as well as commercially available formulations and emerging technologies. The limitations of current methodologies to study OTDD are considered as well as recent publications and new approaches which have advanced our understanding of this route of drug delivery.

Foramen magnum decompression for Chiari I malformation: a procedure not to be underestimated.

OBJECTIVE: Chiari I malformation may be treated with foramen magnum decompression (FMD). We aim to describe the symptoms with which patients initially present, and to determine the number and type of complications occurring after FMD for Chiari I malformation. METHODS: Retrospective review of medical records for patients who had FMD performed for Chiari I malformation between January 2009 and December 2011. Post-operative outcomes were recorded and analysed. Patient demographic details and other relevant medical conditions were also noted. RESULTS: Between January 2009 and December 2011, 54 FMDs were performed for Chiari I malformation. Among them, 40(74%) patients were female and 14 patients (26%) were male. The majority of patients (42.6%) were aged 16-39 years and 24.07% of patients were children aged < 16 years. A total of 30(55.6%) patients had documented evidence of a syrinx pre-operatively. 18(33.3%) patients developed complications. Nine of these developed multiple complications while nine had a single problem. One mortality was reported. Ten (18.5%) patients developed hydrocephalus requiring shunting. Two patients developed subdural collections requiring evacuation associated with hydrocephalus. Six (11.1%) patients developed post-operative infections: two CNS infections; one wound infection; and three other infections. CONCLUSIONS: FMD for Chiari I malformation is a procedure which carries risk. In particular, the risk of developing post-operative hydrocephalus requiring permanent shunting is relatively high. ICP monitoring prior to FMD may be required to definitively rule out raised intracranial pressure.