Antimicrobial drug resistant features of Mycobacterium tuberculosis associated with treatment failure

Tuberculosis stands as a prominent cause of mortality in developing countries. The treatment of tuberculosis involves a complex procedure requiring the administration of a panel of at least four antimicrobial drugs for the duration of six months. The occurrence of treatment failure after the completion of a standard treatment course presents a serious medical problem. The purpose of this study was to evaluate antimicrobial drug resistant features of Mycobacterium tuberculosis associated with treatment failure. Additionally, it aimed to evaluate the effectiveness of second line drugs such as amikacin, linezolid, moxifloxacin, and the efflux pump inhibitor verapamil against M. tuberculosis isolates associated with treatment failure. We monitored 1200 tuberculosis patients who visited TB centres in Lahore and found that 64 of them were not cured after six months of treatment. Among the M. tuberculosis isolates recovered from the sputum of these 64 patients, 46 (71.9%) isolates were simultaneously resistant to rifampicin and isoniazid (MDR), and 30 (46.9%) isolates were resistant to pyrazinamide, Resistance to amikacin was detected in 17 (26,5%) isolates whereas resistance to moxifloxacin and linezolid was detected in 1 (1.5%) and 2 (3.1%) isolates respectively. Among MDR isolates, the additional resistance to pyrazinamide, amikacin, and linezolid was detected in 15(23.4%), 4(2.6%) and 1(1.56%) isolates respectively. One isolate simultaneously resistant to rifampicin, isoniazid, amikacin, pyrazinamide, and linezolid was also identified. In our investigations, the most frequently mutated amino acid in the treatment failure group was Serine 315 in katG. Three novel mutations were detected at codons 99, 149 and 154 in pncA which were associated with pyrazinamide resistance. The effect of verapamil on the minimum inhibitory concentration of isoniazid and rifampicin was observed in drug susceptible isolates but not in drug resistant isolates. Rifampicin and isoniazid enhanced the transcription of the efflux pump gene rv1258 in drug susceptible isolates collected from the treatment failure patients. Our findings emphasize a high prevalence of MDR isolates linked primarily to drug exposure. Moreover, the use of amikacin as a second line drug may not be the most suitable choice in such cases.

Fractionated Stereotactic Radiotherapy in the Management of Dural Recurrence of Olfactory Neuroblastoma

PURPOSE/OBJECTIVE(S)

Treatment protocols for dural recurrence among esthesioneuroblastoma patients have not been standardized. We assess the outcomes of fractionated stereotactic radiotherapy (FSR) for patients with olfactory neuroblastoma (ONB) dura-based recurrences.

MATERIALS/METHODS

We identified ONB patients with dura-based recurrences treated with FSR after prior radiotherapy who were enrolled between 2013 and 2022 in our prospective head and neck reirradiation and skull base registries. In-field tumor control (within 2 cm of prescribed radiotherapy volume) and out-of-field tumor control (non-contiguous or contralateral dura, nodal, or distant metastases) were analyzed.

RESULTS

Thirteen patients with 28 dural lesions were included in this analysis. All patients were initially treated with surgery to their primary paranasal sinus disease; 69% with a craniofacial approach followed by adjuvant radiotherapy to a median dose of 63 Gy (range 60-72.4 Gy) prescribed to the resected tumor bed. Patients re-presented with dural recurrence at median 58.3 months (range 35.0 - 163.0 months) from completion of their initial treatment. Two patients underwent dural resections. On presentation of recurrence, 4 patients had 1 lesion treated, with a median of 2 lesions treated (range 1-4 lesions). All dural based tumors were treated with FSR to a median dose of 27 Gy in 3 fractions delivered QOD. 68Ga-DOTATATE PET/CT was utilized for FSR treatment planning in 31% of cases. The median follow up from FSR was 23.3 months (range: 13.1 - 51.6 months). The 1-year overall survival and progression free survival was 75% and 38%, respectively. The 1- and 2-year in-field control rate was 85% and 75%, respectively. Among treated lesions, 25 of 28 (89%) responded or remained stable following FSR. Two patients (3 lesions) had evidence of in-field radiographic progression at 17 and 9 months, respectively. Five patients (38%) experienced progression in the contralateral or non-contiguous dura, and 5 patients (38%) developed distant metastases. The overall out-of-field progression rate was 58% at 1 year. There was no grade 3 or higher toxicity observed. Three patients (23%) developed asymptomatic changes on MRI consistent with brain necrosis, all of which occurred in a previously irradiated region.

CONCLUSION

In the largest single institution study of FSR reirradiation for ONB dural recurrence to date, high local control rates with minimal toxicity are attainable. However, subsequent out-of-field dural recurrences and/or distant metastases remain problematic.

A Case Report on Rare Case of Pancreatic Metastasis from Primary Lung Adenocarcinoma: Treated Through a Non-surgical Approach

Introduction

Most frequent sites of metastasis from lung cancer are the liver, brain and adrenal. Pancreas is an infrequent site of solitary metastasis from the lung primary with limited treatment options. There is insufficient data on the prognosis and optimal management of such cases.

Case Description

We report a case of 44-year-old gentleman diagnosed with locally advanced lung adenocarcinoma Stage T4N3 who was treated radically with chemoradiation therapy, followed by a relapse of solitary pancreatic metastasis, which was treated with targeted therapy, erlotinib, due to the presence of epidermal growth factor receptor (EGFR) mutation.

Practical Implications

This case reports an excellent radiological and symptomatic response in a patient who received erlotinib for advanced non-small-cell lung cancer (NSCLC). The use of EGFR-tyrosine kinase inhibitors has led to better prognosis and longer progression-free survival for patients with advanced NSCLC. However, the long-term survival of patients with metastatic NSCLC is limited.

Long-Term Disease Control of Locally Invasive Epithelial-Myoepithelial Carcinoma of Parapharyngeal Salivary Glands With Definitive Radiotherapy

Epithelial-myoepithelial carcinoma (EMC) is a rare clinical entity that affects glandular tissues, most commonly salivary glands. EMC of parapharyngeal space is exceedingly rare. Surgery is the mainstay of treatment with or without chemotherapy, radiotherapy, or both. Due to the rarity of the disease, select cases where surgery is not possible present a management conundrum. We present a case of locally advanced, stage IVa EMC of parapharyngeal space that was treated with upfront definitive radiotherapy. Radiotherapy treatment alone led to long-term disease control in both clinical and radiological follow-ups. The patient was followed for more than eight years posttreatment with no disease recurrence, enjoying the normal activities of life with no late toxicities including xerostomia. This case report highlights the role of radiotherapy in the management of such patients, and more studies are required in this context for surgical candidates with positive disease margins.

Anticancer genes (NOXA, PAR-4, TRAIL) are de-regulated in breast cancer patients and can be targeted by using a ribosomal inactivating plant protein (riproximin)

BACKGROUND

Anticancer genes are an endogenous defense against transformed cells as they impose antineoplastic effects upon ectopic expression. Profiling the expression of these genes is fundamental for exploring their prognostic and therapeutic relevance in cancers. Natural compounds can upregulate anticancer genes in malignant cells and thus be useful for therapeutic purposes. In this study, we identified the expression levels of anticancer genes in breast cancer clinical isolates. In addition, the purified and sequenced plant protein (riproximin) was evaluated for its potential to induce anticancer genes in two breast cancer cell lines.

METHODOLOGY

Expression profiles of three anticancer genes (NOXA, PAR-4, TRAIL) were identified by immunohistochemistry in 45 breast cancer clinical isolates. Breast cancer cells were exposed to riproximin and expression of the anticancer genes was determined by microarray, real-time PCR and western blot methodologies. Lastly, a bioinformatic approach was adopted to highlight the molecular/functional significance of the anticancer genes.

RESULTS

NOXA expression was evenly de-regulated among the clinical isolates, while PAR-4 was significantly down-regulated in majority of the breast cancer tissues. In contrast, TRAIL expression was increased in most of the clinical samples. Expression levels of the anticancer genes followed a distinct trend in accordance with the disease severity. Riproximin showed a substantial potential of inducing expression of the anticancer genes in breast cancer cells at transcriptomic and protein levels. The bioinformatic approach revealed involvement of anticancer genes in multiple cellular functions and signaling cascades.

CONCLUSION

Anticancer genes were de-regulated and showed discrete expression patterns in breast cancer patient samples. Riproximin effectively induced the expression of selected anticancer genes in breast cancer cells.

Molecular Characterization of Extensively Drug Resistant Salmonella Enterica Serovar Typhi Clinical Isolates from Lahore, Pakistan

Background

The emergence of extensively drug-resistant (XDR) typhoid in Pakistan has endangered the treatment options available to manage this infection. Third generation cephalosporin were the empiric choice to treat typhoid fever in Pakistan, but acquisition of ESBLs have knocked them out of the arsenal. The current empiric choice is azithromycin which is vulnerable to resistance too. This study aimed to assess the burden of XDR typhoid and the frequency of resistance determinants in blood culture samples collected from different hospitals in Lahore, Pakistan.

Methods

A total of 835 blood cultures were collected from different tertiary care hospitals in Lahore during January 2019 to December 2021. Among 835 blood cultures, 389 Salmonella Typhi were identified, and 150 were XDR S. Typhi (resistant to all recommended antibiotics). Antibiotics resistance genes of the first-line drugs (bla_TEM-1, catA1, sul1, and dhfR7) and second line drugs (gyrB, gyrA, qnrS, ParC and ParE) were investigated among XDR S. Typhi. There were different CTX-M genes isolated using the specific primers, bla_CTX-M-U, bla_CTX-M-1, bla_CTX-M-15, bla_CTX-M-2, bla_CTX-M-8 and bla_CTX-M-9.

Results

Antibiotic resistant genes of the first-line drugs were isolated with different frequency, bla_TEM-1 (72.6%), catA1 (86.6%), sul1 (70%), and dhfR7 (56%). Antibiotics resistance genes of second-line drugs were isolated as: gyrB (60%), gyrA (49.3%), qnrS (32.6%), parC (44%) and parE (28%). Among CTX-M genes, bla_CTX-M-U (63.3%) was the most frequent followed by bla_CTX-M-15 (39.3%) and bla_CTX-M-1 (26%).

Conclusion

Our study concluded that XDR isolates circulating in Pakistan have acquired first-line and second-line antibiotic resistant genes quite successfully along with CTX-M genes (ESBLs) rendering them resistant to the third generation cephalosporins as well. Emergence of azithromycin resistance in XDR S. Typhi which is currently used as an empiric treatment option is worrisome and needs to be monitored carefully in endemic countries like Pakistan.

Expression profiling of anticancer genes in colorectal cancer patients and their in vitro induction by riproximin, a ribosomal inactivating plant protein

BACKGROUND

Ectopic expression of anticancer genes (ACGs) imposes antineoplastic effects on transformed cells. Clinically, reduced expression of these genes has been linked with poor prognosis, metastasis and chemo/radiotherapy resistance in cancers. Identifying expression pattern of ACGs is crucial to establish their prognostic and therapeutic relevance in colorectal cancer (CRC). In addition to the clinical perspective, naturally occurring compounds can be explored in parallel for inducing ACGs to achieve cancer cell-specific death.

METHODOLOGY

Expression profiles of three ACGs (NOXA, PAR-4, TRAIL) were identified via real-time PCR in CRC clinical isolates. Time lapse-based expression modifications in ACGs were studied in a CRC liver metastasis animal model using microarray methodology. Effects of a purified plant protein (riproximin) on selected ACGs were identified in three primary and metastatic CRC cell lines by real-time PCR. Lastly, importance of the ACGs in a cellular environment was highlighted via bioinformatic analysis.

RESULTS

ACGs (except NOXA) were persistently downregulated in clinical isolates when comparing the overall mean expression values with normal mucosa levels. In vivo studies showed a prominent inhibition of NOXA and PAR-4 genes in implanted CRC cells during rat liver colonization. TRAIL showed deviation from this theme while showing marked induction during the early period of liver colonization (days 3 and 6 after CRC cell implantation). Riproximin exhibited substantial potential of inducing ACGs at transcriptome levels in selected CRC cell lines. Bioinformatic analysis showed that vital molecular/functional aspects of a cell are associated with the presence of ACGs.

CONCLUSION

ACGs are downregulated in primary and metastatic phase of CRC. Riproximin effectively induces ACGs in CRC cells and can be exploited for clinical investigations over time.

Epidemiology of young breast cancer patients at Gujranwala: A single institution based study

The objective of this study was to illustrate the statistical and medical characteristics of females younger than 40 years presenting with breast cancer at GINUM. A descriptive case series in which 235 patients who fulfilled the inclusion and exclusion criteria were included. The majority of the patients had advanced disease at presentation. Family history was positive in 59 (25.11%) patients. Patients having grade III and II disease were 142(60.42%) and 89 (37.87%) respectively. Thirteen (5.5%) patients had Right-sided breast cancers in our series. No significant association of null parity with breast cancer was found. Receptor status studies revealed only 2.55% increased oestrogen receptor/progesterone receptor (ER/PR) positive patients as compared to oestrogen receptor/progesterone receptor (ER/PR) negative patients. Our population shares slightly different features as compared to Western population because there were slightly increased right-sided tumours and majority of our patients were parous.

Blood-based gene expression profile of oxidative stress and antioxidant genes for identifying surrogate markers of liver tissue injury in chronic hepatitis C patients

Oxidative stress is the process by which reactive molecules and free radicals are formed in cells. In this study, we report the blood-based gene expression profile of oxidative stress and antioxidant genes for identifying surrogate markers of liver tissue in chronic hepatitis C (CHC) patients by using real-time PCR. A total of 144 untreated patients diagnosed with CHC having genotype 3a and 20 healthy controls were selected for the present study. Liver biopsy staging and grading of CHC patients were performed using the METAVIR score. Total RNA was extracted from liver tissue and blood samples, followed by cDNA synthesis and real-time PCR. The relative expression of genes was calculated using the ΔΔCt method. The expression profile of 84 genes associated with oxidative stress and antioxidants was determined in liver tissue and blood samples. In liver tissue, 46 differentially expressed genes (upregulated, 27; downregulated, 19) were identified in CHC patients compared to normal samples. In blood, 61 genes (upregulated, 51; downregulated; 10) were significantly expressed in CHC patients. A comparison of gene expression in liver and whole blood showed that 20 genes were expressed in a similar manner in the liver and blood. The expression levels of commonly expressed liver and blood-based genes were also correlated with clinical factors in CHC patients. A receiver operating curve (ROC) analysis of oxidative stress genes (ALB, CAT, DHCR24, GPX7, PRDX5, and MBL2) showed that infections in patients with CHC can be distinguished from healthy controls. In conclusion, blood-based gene expression can reflect the behavior of oxidative stress genes in liver tissue, and this blood-based gene expression study in CHC patients explores new blood-based non-invasive biomarkers that represent liver damage.

Current Status of Direct Acting Antiviral Agents against Hepatitis C Virus Infection in Pakistan

In Pakistan, the burden of the hepatitis C virus (HCV) infection is the second highest in the world with the development of chronic hepatitis. Interferon-based combination therapy with ribavirin was the only available treatment until a few years back, with severe side-effects and high failure rates against different genotypes of HCV. Interferon-free all-oral direct-acting antiviral agents (DAAs) approved by the FDA have revolutionized the HCV therapeutic landscape due to their efficiency in targeting different genotypes in different categories of patients, including treatment naïve, treatment failure and relapsing patients, as well as patients with compensated and decompensated cirrhosis. The availability and use of these DAAs is limited in the developing world. Sofosbuvir (SOF), a uridine nucleotide analogue and inhibitor of HCV encoded NS5B polymerase, is now a widely available and in-use DAA in Pakistan; whereas daclatasvir was recently added in the list. According to the documented results, there is hope that this disease can be effectively cured in Pakistan, although a few concerns still remain. The aim of this article is to review the effectiveness of DAAs and the current status of this treatment against HCV genotype 3 infection in Pakistan; various factors associated with SVR; its limitations as an effective treatment regime; and future implications.

Primary Mammary Small Cell Carcinoma

Neuroendocrine breast cancer was defined in 2003 by WHO as a separate and unique breast cancer subtype. Primary small cell carcinoma of the breast, an exceptionally uncommon and aggressive tumor, is frequently characterised by early progression and worse outcome. Moreover, it is essential to distinguish between small cell carcinoma arising primarily in the breast and the metastatic disease to the breast. We had a patient of primary small cell carcinoma of breast. As her initial metastatic workup was negative for disease elsewhere, so she was started on neoadjuvant chemotherapy to which she responded well. Her modified radical mastectomy (MRM) was done followed by completion of chemotherapy up to 6 cycles and local radiotherapy of chest wall. However, the disease behaved aggressively afterwards as she developed recurrence twice at 9 and 19 months interval, respectively, for which she was considered for second and third line chemotherapy. An accurate management of the primary small cell carcinoma of the breast still lacks a consensus. Relevant studies were also reviewed to enhance knowledge and expertise in diagnosis, clinicopathologic features, management, and outcome of this tumor.

Distribution of IL28B and IL10 polymorphisms as genetic predictors of treatment response in Pakistani HCV genotype 3 patients

There are over 10 million hepatitis C virus (HCV)-infected patients in Pakistan. For these patients, a combination of interferon with ribavirin is the most economical and easily available treatment. Single-nucleotide polymorphisms in interleukin genes have been reported to be associated with the pathogenesis and clearance of HCV, and sustained virologic response (SVR). An interleukin 28B (IL28B) gene polymorphism has been shown to modify treatment outcomes, but the effects of interleukin 10 (IL10) polymorphisms have not been previously assessed in the Pakistani population. The present study was conducted with 302 subjects categorized into two groups: 100 healthy volunteers (Group I) and 202 patients with chronic HCV (Group II). Patients within Group II were further divided into two subgroups according to therapeutic response: SVR (responders = 132) and NR (non-responders/relapsers = 70). IL28B (rs8099917, rs12979860) and IL10 (rs1800872, rs1800871, rs1800896) gene polymorphisms were studied in all subjects. A significant difference in the distribution of IL28B rs12979860C/T genotypes between the two groups (p<0.05) was observed, while of the three IL10 polymorphisms, a significant difference was only shown for rs1800896 A/G. Haplotype analysis (IL28B and IL10) showed a significant association of TTGTC and TTGTA when comparing the groups. There was a strong association of the favorable alleles rs8099917T and rs12979860C in the SVR group as compared with the NR group (p<0.05), and rs1800896 also showed an association with the SVR group as compared to the NR group (p<0.004). Haplotype analysis showed significant associations when comparing the SVR and NR subgroups, i.e. TCATC (p=0.009), TTGTA (p=0.005), TCATA (p<0.0005), TCACA (p=0.002), GTGCC (p=0.002) and TCGTC (p=0.005). IL28B (rs8099917 and rs12979860) and IL10 (rs1800896) polymorphisms alone, or in combination, are good predictors of therapeutic response in HCV-3a patients.

Association of TP53 codon 72 polymorphism in women suffering from endometriosis from Lahore, Pakistan

OBJECTIVE

To investigate TP53 gene codon 72 polymorphism in women with endometriosis and compare it with healthy samples.

METHODS

This case-control study was carried out at Jinnah Hospital, Services Hospital and Sheikh Zayed Hospital, Lahore, Pakistan, from 2014 to 2016, and comprised patients with endometriosis and healthy controls. SPSS 21 was used for statistical analysis.

RESULTS

Of the 176 participants, 88(50%) were healthy controls and 88(50%) were endometriosis patients. The observed genotype frequencies for controls and patients were 14(15.9%) and 31(35.3%) for proline/proline, 46(52.3%) and 35(39.8%) for proline/arginine, and 28(31.8%) and 22(25%) for arginine/arginine, respectively. The association of different genotypes was not significant in patients with moderate-to-severe endometriosis (p=0.574). The presence of pro/pro genotype enhanced the chances/odds of getting the disease (p<0.05). However, the risk further increased with the advancement of age, particularly in the 27-46 age group (p<0.05).

CONCLUSIONS

In Pakistani women the association of TP53 gene codon 72 arginine/proline polymorphism was present..

SOCS3 mRNA expression and polymorphisms as pretreatment predictor of response to HCV genotype 3a IFN-based treatment

Aim

Suppressor of Cytokine Signaling 3 (SOCS3) gene belongs to SOCS family as one of the negative regulators of cytokine signaling and IFN response that function via the JAK-STAT pathway in antiviral response. SOCS3 expression and genetic polymorphism influences the pathogenesis and outcome of antiviral treatment in hepatitis C virus (HCV) infected patients. This study was designed for analysis of SOCS3 gene expression and polymorphism in Pakistani HCV patients.

Methods

This descriptive study was conducted on 250 diagnosed HCV genotype 3a infected subjects. The study population was divided into two major groups on the basis of therapeutic response i.e. sustained virological response (SVR) and non-responders/relapsers (NR). SOCS3 gene mRNA expression analysis was done by using Real time PCR technique, whereas ARMS PCR technique was used for analysis of SOCS3 gene polymorphisms i.e. 8464 A/C (rs12952093), −4874 A/G (rs4969170) and −1383 A/G, (rs4969168).

Results

Gene expression analysis of SOCS3 showed that there was statistically significant increase of 2.275-fold and 3.72-fold in relative gene expression for SVR and NR as compared to normal healthy samples (p < 0.001). The distribution of rs4969168, rs4969170 and rs12952093 genotype frequencies between SVR versus NR group were not statistically significant, only the allelic frequency of rs4969170 was statistically significant (p ≤ 0.0001) with therapeutic response.

Conclusion

The gene expression analysis of SOCS3 showed a clear difference in mRNA expression of SOCS3 as a possible indicator of therapeutic response rather than polymorphism of SOCS3 gene in our studied population.

Association of FcγRIIa Polymorphism with Clinical Outcome of Dengue Infection: First Insight from Pakistan

Dengue illness has been a major health concern in Pakistan during the last decade. Dengue infection can result in a spectrum of clinically distinct outcomes, ranging from asymptomatic infection to potentially life-threatening forms of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). A single-nucleotide polymorphism in FcγRIIa (rs1801274) results in altered affinity of the receptor for different subclasses of immunoglobulin G, and is a key player in determining the susceptibility to or protection from severe clinical infection of dengue. In this study, we analyzed the allelic and genotypic distribution of rs1801274 in subjects of Pakistani origin with subclinical dengue infection (n = 40), dengue fever (DF) (n = 40), and DHF/DSS (n = 30). We found that HH homozygotes and heterozygotes were significantly more likely to develop clinical dengue (odds ratio [OR] = 3.21, 95% confidence interval [CI] = 1.29-7.97, P = 0.009), either DF (OR = 2.82, 95% CI = 1.00-7.97, P = 0.045) or DHF/DSS (OR = 3.90, 95% CI = 1.13-13.07, P = 0.024) than the asymptomatic dengue infection. Results of allelic distribution comparisons and logistic regression analysis also supported the same relationship. The results suggest complex nature of interacting factors in determining the course for severe dengue illness.

Coexisting Tertiary Hyperparathyroidism and Severe Hypothyroidism in an End-Stage Renal Disease Patient on Hemodialysis

Introduction:

Case Presentation:

Conclusions:

Pilot study: association of traditional and genetic risk factors and new-onset diabetes mellitus following kidney transplantation

INTRODUCTION

New-onset diabetes mellitus, which occurs after kidney transplant and type 2 diabetes mellitus (T2DM), shares common risk factors and antecedents in impaired insulin secretion and action. Several genetic polymorphisms have been shown to be associated with T2DM. We hypothesized that transplant recipients who carry risk alleles for T2DM are "tipped over" to develop diabetes mellitus in the posttransplant milieu.

METHODS

We investigated the association of genetic and traditional risk factors present before transplantation and the development of new-onset diabetes mellitus after kidney transplantation (NODAT). Markers in 8 known T2DM-linked genes were genotyped using either the iPLEX assay or allelic discrimination (AD)-PCR in the study cohort testing for association with NODAT. We used univariate and multivariate logistic regression models for the association of pretransplant nongenetic and genetic variables with the development of NODAT.

RESULTS

The study cohort included 91 kidney transplant recipients with at least 1 year posttransplant follow-up, including 22 who developed NODAT. We observed that increased age, family history of T2DM, pretransplant obesity, and triglyceridemia were associated with NODAT development. In addition, we observed positive trends, although statistically not significant, for association between T2DM-associated genes and NODAT.

CONCLUSIONS

These findings demonstrated an increased NODAT risk among patient with a positive family history for T2DM, which, in conjunction with the observed positive predictive trends of known T2DM-associated genetic polymorphisms with NODAT, was suggestive of a genetic predisposition to NODAT.

The supraorbital craniotomy for access to the skull base and intraaxial lesions: a technique in evolution

INTRODUCTION

The supraorbital craniotomy was initially described as a minimally invasive means to target extra-axial lesions in the anterior cranial fossa and sellar/parasellar region. Since its initial description, various modifications have been described. We report our recent experience with this approach (and its modifications) for not only extra-axial but also intra-axial neoplastic pathology.

METHODS

Based on patient pathology and anatomic considerations, one of two approaches was performed: supraorbital craniotomy through an eyebrow incision or a combined orbital osteotomy and supraorbital craniotomy through an eyelid incision.

RESULTS

This technique was performed on twenty-eight consecutive patients. Intra-axial pathology ranged from anaplastic astrocytoma to metastasis while extra-axial lesions included meningiomas and skull-based metastases. Excellent lesion resection was achieved in the majority of patients. Complications were infection (2 patients) and CSF leak.

DISCUSSION

The supraorbital craniotomy and its modifications provide an ideal anterior subfrontal approach through which a wide variety of pathology can be approached. This technique has particular considerations in comparison to traditional cranial base approaches that must be taken into account before it is utilized.

Nematicidal natural products from the aerial parts of Lantana camara Linn

Lantanilic acid, camaric acid and oleanolic acid possessing nematicidal activity were isolated from the methanolic extract of the aerial parts of Lantana camara Linn. through bio-assay guided fractionation. These compounds exhibited 98%, 95% and 70% mortality respectively against root-knot nematode Meloidogyne incognita at 0.5% concentration. Conventional nematicide furadan showed 100% mortality at this concentration.

Early posttransplant lymphoproliferative disorder presenting with ureteric obstruction in en bloc kidneys

We describe a female patient who received double pediatric (en bloc) kidney transplants. She presented initially with fever of unknown origin 3 months after transplantation; 5 months after surgery, she presented with obstruction of one ureter followed by obstruction of the other. After 9 months she developed posttransplant lymphoproliferative disorder in both kidneys. To our knowledge, this is the first case report of this disorder occurring in en bloc kidneys and presenting with bilateral ureteric obstruction.

Addition of bicarbonate to plain bupivacaine does not significantly alter the onset or duration of plexus anesthesia

BACKGROUND AND OBJECTIVES

In an effort to elucidate further the effect of alkalinization of bupivacaine on its anesthetic effect, a study was undertaken using alkalinized and non-alkalinized bupivacaine for lumbar plexus block and comparing the results with those obtained previously with brachial plexus block.

METHODS

Thirty consenting adult patients about to undergo lower extremity surgery under regional anesthesia were selected for the study. All of the patients received an inguinal paravascular lumbar plexus block ("3-in-1 block"), along with a sciatic block to allow the anticipated surgery to be carried out. The patients were divided into two groups, one receiving plain "alkalinized" 0.5% bupivacaine; the other receiving plain "non-alkalinized" 0.5% bupivacaine. After each lumbar plexus block, the onset and duration of analgesia and anesthesia of the nerves derived from the lumbar plexus were determined by an independent investigator who was unaware of which solution had been administered.

RESULTS

There was no statistically significant difference between the two groups with respect to the onset or duration of anesthesia and analgesia.

CONCLUSIONS

The data obtained in the present study indicate that alkalinization of non-epinephrine-containing bupivacaine does not reduce the latency or increase the duration of analgesia or anesthesia after lumbar plexus block. Since most of the studies that do show such an effect of alkalinization were carried out using epinephrine-containing bupivacaine, it is postulated that in those studies alkalinization contributed to the decrease in latency and increase in duration, not so much by providing an increased amount of local anesthetic in the free base form, but by reactivating epinephrine's vasoconstrictor activity, which is inactivated by a low pH.

A complete regional anesthesia technique for cardiac pacemaker insertion

Sixteen consecutive adult patients scheduled for permanent transvenous cardiac pacemaker insertion received as their total anesthetic the combination of a cervical plexus block and blocks of the second, third, and fourth intercostal nerves using a combination of 1% mepivacaine and 0.2% tetracaine with epinephrine, 1:200,000. This technique consistently provided complete surgical anesthesia of the third cervical (C3) through the fourth thoracic (T4) dermatomes, without anesthesia of the brachial plexus. Anesthesia was adequate for the surgical procedure without the need for supplemental analgesia or anesthesia in all cases. Because fluoroscopy was used routinely for the surgical procedure, it was possible to document that there were no instances of diaphragmatic paralysis or pneumothorax. In contrast to other reports, this technique provides surgical anesthesia that is adequate for all of the approaches used for transvenous pacemaker implantation, except for placement of a battery in an abdominal pouch. There were no serious complications and/or side effects in any of the patients studied.

Brachial plexus block with a new local anaesthetic: 0.5 per cent ropivacaine

A new local anaesthetic, ropivacaine hydrochloride, was used in a concentration of 0.5 per cent in 32 patients receiving a subclavian perivascular block for upper extremity surgery. One group (n = 15) received 0.5 per cent ropivacaine without epinephrine and a second group (n = 17) received 0.5 per cent ropivacaine with epinephrine in a concentration of 1:200,000. Anaesthesia was achieved in 87 per cent of the patients in both groups in all of the C5 through T1 brachial plexus dermatomes. Motor block was profound with 100 per cent of patients in both groups developing paresis at both the shoulder and hand and 100 per cent developing paralysis at the shoulder. There was a rapid initial onset of sensory block (a mean of less than four minutes for analgesia) with a prolonged duration (a mean of greater than 13 hr of analgesia). The addition of epinephrine did not significantly affect the quality or onset of sensory or motor block. The duration of sensory block was reduced by epinephrine at T1 for analgesia and at C7, C8, and T1 for anaesthesia. The duration of sensory block in the remaining brachial plexus dermatomes as well as the duration of motor block was not effected by epinephrine. There was no evidence of cardiovascular or central nervous system toxicity in either group with a mean dose of 2.5-2.6 mg.kg-1 ropivacaine.

Protection from stress of tracheal intubation with midazolam-sufentanil neuroleptanalgesia

Although diazepam has been shown to reduce the stress response, the protective effect of midazolam, a newer benzodiazepine from a stressful event, tracheal intubation, has not been studied as yet by catecholamine assays in patients undergoing coronary artery bypass surgery, who also receive intravenous sufentanil as a component of the neuroleptanalgesic technique. Therefore, we evaluated the influence of midazolam in combination with sufentanil on the plasma free catecholamines before and after midazolam, after sufentanil and pancuronium and before and after intubation in 15 adult patients undergoing coronary artery surgery. After routine premedication, midazolam 0.14 +/- 0.01 mg.kg-1 i.v. was given over 1 min followed 5 min later by sufentanil in incremental i.v. doses of 1.5 micrograms.kg-1 to a total pre-intubation dose of 4.0-5.0 micrograms.kg-1 injected in 10 min. The incremental doses of sufentanil were given when a greater than 15 per cent increase in rate-pressure product occurred. One min after the initial dose of sufentanil, pancuronium 0.1 mg.kg-1 i.v. was given to provide muscle relaxation. Midazolam administration per se caused a significant decrease in systolic and diastolic blood pressures with a concomitant reduction in systemic vascular resistance. Sufentanil reduced the left ventricular stroke-work index. Tracheal intubation, a strong stressor during anesthesia, elicited no increase in catecholamines and/or adverse hemodynamic responses in contrast to a marked increase in plasma catecholamines routinely observed in patients anesthetized by the commonly used technique of intravenous barbiturates in combination with succinylcholine.

Haemodynamic stability with midazolam-ketamine-sufentanil analgesia in cardiac surgical patients

Although sufentanil in high doses may result in deep coma sufficient to conduct coronary-bypass surgery painlessly in patients, its side effects, e.g., bradycardia and hypotension, may lead to complications in some patients. Since ketamine causes central sympathetic stimulation, we attempted to counteract the vagomimetic effects of sufentanil by ketamine. Anaesthesia was induced in patients, (n = 15), for elective coronary artery-bypass surgery with 0.12 mg.kg-1 midazolam IV, followed by 1 mg.kg-1 ketamine and 0.6 micrograms.kg-1 sufentanil IV eight minutes later. Subsequently, pancuronium 0.1 mg.kg-1 was given to facilitate tracheal intubation. Three minutes later, the trachea was intubated, and ketamine 1 mg.kg-1.hr-1 IV infusion was started. Incremental doses of 0.6 micrograms.kg-1 sufentanil were given whenever a greater than 15 per cent increase in rate-pressure product was observed. The mean +/- S.E.M. dose of sufentanil before cardiopulmonary bypass was 6.5 +/- 0.6 micrograms.kg and 9.1 +/- 0.9 micrograms.kg for the entire procedure. Although midazolam alone caused reductions in systolic BP, SVR and LVSWI, other haemodynamic variables were not altered. The administration of this anaesthetic technique caused no clinically important adverse haemodynamic changes and/or ST-segment changes and prevented the adverse haemodynamic changes caused by intubation, skin incision, sternotomy and periaortic dissection. Adequate analgesia, complete amnesia and early recovery of wakefulness were observed.

pH adjustment schedule for the amide local anesthetics

Several studies have indicated that the addition of sodium bicarbonate to solutions of local anesthetics to raise the pH closer to the pKa shortens the latency, increases the intensity, and prolongs the duration of the resultant neural blockade. However, the addition of too much bicarbonate will cause precipitation, and this may result in the injection of particulate free base along with the solution. The present study was carried out to determine the maximal amount of sodium bicarbonate that can be added to each of the amide local anesthetics without the formation of a precipitate, and, thus, to construct a pH adjustment schedule to simplify the alkalinization of local anesthetics in clinical practice.

Comparison of the hemodynamic effects of midazolam and diazepam in patients with coronary occlusion

Midazolam is gradually replacing diazepam in neuroleptanalgesia with fentanyl and sufentanil because of its greater water solubility, greater hypnotic potency, shorter half-life, lack of pharmacologically active metabolites and low incidence of thrombophlebitis. In order to substantiate midazolam as being as safe and effective as diazepam in cardiac patients with severe coronary occlusion, hemodynamic measurements were made before and 10 min after completion of intravenous injection of 0.2 mg/kg i.v. midazolam (n = 45) and 0.4 mg/kg i.v. diazepam (n = 30), the doses which are identical to those used in patients undergoing cardiac catheterization. All 75 patients were spontaneously breathing 40% O2 in air. No positional changes or stimulation of patients were allowed before and during the study. Of hemodynamic variables, systemic systolic blood pressure was significantly reduced by both midazolam and diazepam. Midazolam also caused significant reduction in systemic vascular resistance with reduction in diastolic pressure and left ventricular stroke work index. No changes in heart rate, systolic and diastolic pulmonary artery pressures, cardiac output and index, stroke volume and index, pulmonary vascular resistance, right ventricular stroke work index and rate pressure product were observed following either midazolam or diazepam. No statistically significant differences were observed in any hemodynamic variable between those patients receiving midazolam or diazepam. It is concluded that midazolam is as safe as diazepam in cardiac patients with coronary obstruction.

Haemodynamic stability with midazolam-sufentanil analgesia in cardiac surgical patients

Since the administration of both diazepam and midazolam are claimed to cause adverse haemodynamic effects following fentanyl or sufentanil intravenous injection, we evaluated the effectiveness and safety of the reverse sequence, (midazolam-sufentanil) on haemodynamic variables, adequacy of analgesia, amnesia and recovery in 15 adult patients undergoing coronary artery surgery (with a mean +/- SEM ejection fraction of 0.41 +/- 0.03). After routine premedication, midazolam 0.14 +/- 0.01 mg.kg-1 IV was given over one min followed 5 min later by sufentanil in incremental IV doses of 1.5 micrograms.kg-1 to a total pre-intubation dose of 4.0-5.0 micrograms.kg-1 injected in 10 min. One minute after the initial dose of sufentanil, pancuronium 0.1 mg.kg-1 IV was given in 30 seconds. The incremental doses of sufentanil were based on a greater than 15 per cent increase in rate-pressure product. The mean dose of sufentanil before cardiopulmonary bypass was 9.6 +/- 2.1 micrograms.kg-1 and 13.9 +/- 1.3 micrograms.kg-1 for the entire procedure. A significant decrease in systolic and diastolic blood pressures occurred after midazolam administration which was sustained until sternotomy. A significant reduction in systemic vascular resistance occurred following midazolam. Sufentanil reduced the left ventricular stroke-work index. Tracheal intubation, skin incision and sternotomy elicited no adverse haemodynamic responses. Adequate analgesia, complete amnesia and early recovery of wakefulness were observed.

Nalbuphine as an analgesic component in balanced anesthesia for cardiac surgery

The efficacy and safety of nalbuphine hydrochloride as an IV analgesic used in combination with pretreatment and supplemental doses of diazepam with and without N2O were assessed in 15 patients scheduled to undergo aortocoronary bypass (n = 11) or valve replacement surgery (n = 4). The loading infusion of 3.0 mg/kg nalbuphine given in 20 min 5 min after conclusion of IV injection of 0.4 mg/kg/5 min diazepam caused no significant changes in systolic or diastolic systemic and pulmonary arterial blood pressures or in heart rate, cardiac index, stroke index, systemic and pulmonary vascular resistance, or right and left ventricular stroke work index. After the initial 1-hr loading infusion of 6.66 +/- 0.89 mg/kg nalbuphine (mean +/- SE), additional nalbuphine infusion maintenance doses of 4.73 +/- 0.77, 1.87 +/- 0.31, 2.16 +/- 0.23, 1.65 +/- 0.22, and 2.35 +/- 0.44 were used in the subsequent hourly periods to maintain a pain-free state throughout surgery. Hemodynamic changes during the three most stressful periods, tracheal intubation, skin incision, and sternotomy, were not statistically significant. Normal plasma catecholamine and cortisol levels indicate that these patients experienced neither stress nor pain during the maintenance of anesthesia. Nalbuphine caused no significant histamine release. All patients had uncomplicated maintenance of and emergence from anesthesia.