Hypokalaemia in Type-4 Renal Tubular Acidosis: A Rare Presentation

Proximal/Type-2 Renal Tubular Acidosis (RTA) occurs due to impairment of bicarbonate absorption in the proximal tubule and is mainly characterised by hypokalaemia and metabolic acidosis. There are various causes of proximal RTA like genetic, cystinosis, Wilson’s disease, drugs and toxins, vitamin D deficiency, hyperparathyroidism, amyloidosis. Vitamin D deficiency is one of the uncommon causes and is more common in elderly. Hereby, authors present a case report of a diabetic and hypothyroid 30-year-old female, who presented with chronic limb weakness, myalgia and bilateral leg swelling. After detailed history taking, clinical examination and laboratory investigations, she was diagnosed with nephrotic syndrome and proximal RTA associated with vitamin D deficiency. She had hypokalaemia with acidosis initially and was managed with diuretics, Angiotensin Converting Enzyme (ACE) inhibitors, vitamin D and potassium supplementation, after which, she developed hyperkalaemia with acidosis. She was evaluated for hyperkalaemic RTA and its common causes and was diagnosed with hyperkalaemic RTA associated with diabetes. Thus, treatment of type-2 RTA due to vitamin D deficiency, led to unmasking of underlying type-4 RTA due to diabetic nephropathy.

Minimally invasive lateral transpsoas approach for lumbar corpectomy and stabilization

Background

Here, we present our experience with the minimally invasive (MI) transpsoas approach for lumbar corpectomy and stabilization. Transpsoas approach accesses the lumbar spine and includes both the direct lateral interbody fusion and extreme lateral interbody fusion techniques. Both procedures utilize a tubular retractor system which facilitates adequate retraction and direct visualization of the target, while supposedly reducing soft tissue trauma.

Case Description

We evaluated two patients, one with a traumatic L2 wedge compression fracture and the other with an L3 pathological compression fracture due to multiple myeloma. Both patients underwent MI transpsoas lumbar corpectomy, anterior column reconstruction with an expandable cage, and posterior pedicle screw instrumentation to correct a kyphotic deformity. Both patients were mobilized on the 1^st postoperative day and experienced significant postoperative pain relief.

Conclusion

In two cases involving L2 and L3 compression fractures, MI transpsoas lumbar corpectomy was safely performed, with reduced perioperative and postoperative morbidity. Here, the transpsoas approach also allowed for early mobilization, adequate postoperative biomechanical stability, and resulted in immediate good outcomes.

Optimal technique of radiotherapy for carcinoma cervix in developing countries: Dosimetric and logistic comparison

Purpose

Carcinoma cervix is the most common malignancy affecting women in developing countries. Radical radiotherapy is the mainstay of treatment in more than 90% of patients. The present study is a dosimetric and logistic comparison of various techniques of radiotherapy, namely two-dimensional conventional radiotherapy (2DCRT), three-dimensional conformal radiotherapy (3DCRT), and intensity-modulated radiotherapy (IMRT).

Methods

All the patients underwent contrast-enhanced computed tomography (CT) scans for simulation. 2DCRT, 3DCRT, and IMRT plans were generated in 24 patients and dosimetrically compared. Radiotherapy treatment time involved in each technique was analyzed in 27 treated patients.

Results

The planning target volume (PTV) coverage was best in 3DCRT technique with a median coverage of 99.9% as compared to IMRT (99.3%) and 2DCRT (82.2%). There was progressive sparing of all the organs at risk in IMRT as compared to 3DCRT. The total planning time was longest in IMRT (332.1 min) and shortest in 2DCRT (11.7 min). The mean treatment time for the delivery of each fraction of 2DCRT, 3DCRT, and IMRT were 14.3, 13.6, and 24.7 min, respectively.

Conclusion

3DCRT technique is the most optimal technique for radical radiotherapy of cervical cancers with optimum PTV coverage, acceptable planning time, and minimal treatment time as compared to IMRT. 2DCRT technique should be limited to the setting where CT simulation is unavailable.

Early Competing Deaths in Locally Advanced Head-and-Neck Cancer

Introduction:

The competing (noncancer) deaths have increased with aggressive treatment approach and better disease control in locally advanced head-and-neck cancer.

Aim:

The aim of this study is to find incidence, cause and predictors of early competing mortality in locally advanced head-and-neck cancer patients undergoing combined modality therapy.

Subjects and Methods:

In this retrospective study, a total of 125 locally advanced head-and-neck patients treated from January 2013 to June 2017 were analyzed. The total number of deaths, cause, and the time of death from the start of therapy was recorded. To study the risk factors of competing deaths, univariate and multivariate logistic regression was applied. Data were analyzed using SPSS v. 24 software.

Results:

A total of 51 deaths (31 cancer deaths and 20 competing deaths) recorded at a median follow-up of 16 months (1–62 months). The incidence of early competing mortality was 12% (n = 15) with a median time of 2.7 months from treatment initiation. Sepsis was major cause of early competing death (n = 13). On univariate and multivariate logistic regression analysis, competing death was significantly associated with pharyngeal (oropharynx, hypopharynx, and larynx) site primary (odds ratio [OR] = 3.562; 95% confidential interval [CI] = 1.207–10.517; P = 0.016), and Stage IVA/IVB disease (OR = 5.104; 95% CI = 1.123–23.202; P = 0.021).

Conclusion:

Competing deaths is one of the multifaceted problems in locally advanced head-and-neck cancer patients. Sepsis being single most cause of early competing deaths in Stage IVA/IVB pharyngeal and laryngeal cancer.

Analgesic and Opioid Use in Pain Associated with Head-and-Neck Radiation Therapy

Aim

The aim of the study is to find the incidence of analgesic and opioid use in pain associated in HNC patient undergoing radiation therapy.

Background

Radiation therapy with concurrent chemotherapy has become the standard of care in head and neck cancer. Acute toxicity like mucositis and dysphagia has increased with aggressive therapy. Pain is an invariable accompaniment of oropharyngeal mucositis, which leads to decreased quality of life and treatment break.

Materials and Methods

This is a retrospective review of radiation charts of head and neck patients treated from January 2013 to June 2017 at St. John's Medical college and Hospital, Bengaluru.

Results

A total of 138 (92%) patients required analgesia during the radiation course. The analgesic consumption started increasing from week 2, peaked at week 5, persist for 6 weeks and started declining after week 10. 52% patients required opioids, especially from week 4 to week 8. 15% of patients required Morphine, the maximum use in week 6 to week 8. The use of chemotherapy (P = 0.031), presence of grade 3 mucositis (P = 0.010) and grade 3 dysphagia (P = 0.001) were significantly associated with severe pain (use of strong opioids). All 80 (100%) patients receiving concurrent chemotherapy required analgesia. More than 80% patients required opioids and one fourth required strong analgesic in concurrent chemotherapy group.

Conclusion

More than 90% of all head and neck cancer patient undergoing radiation therapy experience therapy related pain for more than 6 weeks. 53% of the patients require opioids and 15% require strong opioids. The use of concurrent chemotherapy was significantly associated with severe pain.

Screening of flavonoid "quercetin" from the rhizome of Smilax china Linn. for anti-psoriatic activity

OBJECTIVE

To assess anti-psoriatic activity of the methanol extract and the isolated flavonoid quercetin from the rhizome of Smilax china (S. china) Linn.

METHODS

Mouse tail test was used for the evaluation of anti-psoriatic activity. Methanol extract (100 and 200 mg/kg b.w.) and isolated flavonoid quercetin (25 and 50 mg/kg b.w.) were tested in Swiss albino mice. Parameters studied in the mouse tail test were changes in epidermal thickness and percentage orthokeratotic values. The anti-inflammatory role of the methanol extract and isolated flavonoid quercetin was evaluated using carrageenan-induced pleurisy in rats. In vitro antiproliferant assay on HaCaT cell lines was also carried out.

RESULTS

The isolated flavonoid quercetin from the rhizome of S. china produced significant orthokeratosis (P<0.01) in the mouse tail test. In epidermal thickness, a significant reduction with respect to control was observed in groups treated with retinoic acid and isolated flavonoid quercetin. The methanol extract (200 mg/kg) and isolated flavonoid quercetin (50 mg/kg) showed anti-inflammatory effect in terms of significant inhibition (P<0.001) in leukocyte migration. Maximum antiproliferant activity was shown by isolated flavonoid quercetin (IC50, 62.42±10.20 µg/mL).

CONCLUSIONS

From the above data, the flavonoid quercetin shows significant orthokeratosis, anti-inflammatory and maximum antiproliferant activities. To our knowledge, this is the first report on the anti-psoriatic effect of the flavonoid quercetin which is promising for further investigations to prove its anti-psoriatic activity.

Entropy-based straight kernel filter for echocardiography image denoising

A new filter has been proposed with the aim of eliminating speckle noise from 2D echocardiography images. This speckle noise has to be eliminated to avoid the pseudo prediction of the underlying anatomical facts. The proposed filter uses entropy parameter to measure the disorganized occurrence of noise pixel in each row and column and to increase the image visibility. Straight kernels with 3 pixels each are chosen for the filtering process, and the filter is slided over the image to eliminate speckle. The peak signal-to-noise ratio (PSNR) is obtained in the range of 147 dB, and the root mean square error (RMSE) is very low of approximately 0.15. The proposed filter is implemented on 36 echocardiography images, and the filter has the competence to illuminate the actual anatomical facts without degrading the edges.

Occipital dermal sinus with a vermian dermoid

Congenital occipital dermal sinus with an underlying dermoid is a rare, benign lesion of embryological origin and may occur anywhere along the neuraxis. We present a case of a 15-year-old girl with a vermian dermoid and an occipital dermal sinus. Gross total resection of the lesion was done and post-operative period was uneventful. A detailed review of the literature is also covered.

Role of palliative radiotherapy in brain metastases

Background:

Brain metastases are a common manifestation of systemic cancer and exceed primary brain tumors in number and are a significant cause of neurologic problems. They affect 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases.

AIM:

The aim of the study was to know the outcome of palliative radiotherapy in symptomatic brain metastases in terms of improvement in their performance status.

Materials and Methods:

This is a retrospective study of 63 patients diagnosed to have brain metastases and treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks between June 1998 and June 2007. Diagnosis was done in most of the cases with computed tomography scan and in a few with magnetic resonance imaging. Improvement in presenting symptoms has been assessed in terms of improvement in their performance status by using the ECOG scale.

Results:

Fifty-four patients completed the planned treatment. Eight patients received concurrent Temozolamide; 88% of patients had symptom relief at one month follow-up; 39/54 patients had a follow-up of just one to three months. Hence survival could not be assessed in this study.

Conclusion:

External beam radiotherapy in the dose of 30 Gy over two weeks achieved good palliation in terms improvement in their performance status in 88% of patients. Addition of concurrent and adjuvant Timozolamide may improve the results.

Aggressive approach in a case of cancer cervix with uremia

Carcinoma of cervix is the most common cancer in developing countries. Majority of them present in locally advanced stages. A 36-year-old lady presented with bleeding and white discharge per vagina since four months, vomiting and reduced urine output since two weeks. Patient had an exophytic cervical growth. Investigation revealed elevated serum creatinine. Patient received single fraction radiation and underwent percutaneous nephrostomy. At one month follow-up, serum creatinine returned to almost normal level. Patient underwent bilateral ante grade stenting and completed concurrent chemoradiotherapy. In selected subsets of patients, aggressive management offered longer palliation and good quality of life.

Magnitude of fatigue in cancer patients receiving radiotherapy and its short term effect on quality of life

BACKGROUND

Fatigue is one of the most common, ongoing symptoms reported by patients undergoing radiotherapy and has profound effects on the quality of life.

AIMS

This study attempts to identify the magnitude of fatigue and its implication on the quality of life during radiotherapy.

METHODS AND MATERIALS

A prospective study was conducted from March 2004 to September 2005, on 90 patients with histologically proven cancer, receiving radiotherapy. Pretreatment and weekly assessment of fatigue and QOL was done during radiation treatment using Brief Fatigue Inventory Scale and EORTC QLQ C30 respectively and repeated one month after completion of radiotherapy. All the scores were measured in the 0 to 100 scale. STATISTICAL METHODS USED: Trimean, SPSS 11.0 and Sysstat 8.0 were used for statistical analysis.

RESULTS

Fatigue was present in 87.8% of patients initially and increased gradually over the course of radiotherapy and peaked in the last week. However at follow up it was nearing the pretreatment level. There was significant reduction in the functional scores ( P < 0.001) of QOL (physical, role and emotional function), which returned to pretreatment level at follow up. In the seventh week impairment of cognitive function (P=0.059) was noted. Significant reduction of social function (P < 0.001) at second week and global health status (P < 0.001) at fifth week was noted while financial difficulty was seen from second week onwards.

CONCLUSION

Fatigue is transiently increased by radiotherapy before reaching pretreatment level after few weeks of completion of radiotherapy. QOL is also affected by fatigue which follows the same pattern.

Morphometric analysis of the thoracic pedicle: an anatomico-radiological study

BACKGROUND

Knowledge of the morphometric anatomy of the pedicles in thoracic spine is essential for the surgeon attempting thoracic pedicle screw placement.

AIM

To study the morphometry of the pedicles in the thoracic spine in Indian subjects and note the anatomical landmarks required for safe and accurate pedicle screw placement.

SETTINGS AND DESIGN

An anatomico-radiological study with cadaveric confirmation was conducted in a medical college and tertiary care center.

MATERIALS AND METHODS

Morphometric anatomy of 720 pedicles from T1-T12 was studied. The study consisted of 15 separated thoracic vertebral cadavers and 15 computed tomographic scans of undiseased thoracic spine. Transverse and sagittal pedicle diameters, transverse pedicle angle, chord length and the pedicle entry point landmarks were studied. Using the results, accuracy of the pedicle screw placement was confirmed in 120 pedicles from five unseparated cadavers.

RESULTS

Transverse pedicle diameter was narrowest at T4 and gradually increased craniocaudally. Twenty-two percent of the pedicles from T4 to T6 were less than 4.5 mm, but none were less than 3.5 mm. The transverse pedicle angle was widest at T1 (26.50) and decreased caudally to T12 (8.10). The chord length gradually increased caudally from a minimum of 30.4 mm at T1 to a maximum of 43.3 mm at T12. Landmarks (transverse and vertical distance) for the pedicle entry point were measured from the reference point taken as the center of the junction of lamina and the transverse process. The pedicle entry point was always superolateral to this reference point.

CONCLUSION

Knowledge of the pedicle diameter and chord length is essential for choosing the appropriate pedicle screw, whereas the pedicle angle and the entry point are important for accurate screw placement.

Methyl 5-phenyl-1,2,3,4,4a,5,5a,13c-octahydro-6H-benzo[f]chromeno[3,4-b]indolizine-5a-carboxylate

In the title compound, C₂₇H₂₇NO₃, the pyrrolidine ring exhibits a twist conformation and the piperidine ring exhibits a chair conformation. The pyrrolidine ring makes dihedral angles of 54.47 (5), 51.50 (5) and 73.37 (6)° with the napthalene ring system and the tetra­hydro­pyran and phenyl rings, respectively. The structure is stabilized by intra­molecular C—H⋯O and C—H⋯N inter­actions.

Methyl 3-(4-bromophenyl)-1-methyl-1,2,3,3a,4,9b-hexahydrobenzo[f]chromeno[4,3-b]pyrrole-3a-carboxylate

In the title compound, C₂₄H₂₂BrNO₃, the dihydro­pyran ring adopts a half-chair conformation, whereas the pyrrolidine ring is in an envelope conformation. The bromo­phenyl group is oriented at an angle of 66.44 (4)° with respect to the naphthalene ring system. In the crystal structure, mol­ecules are linked into centrosymmetric dimers by C—H⋯π inter­actions and the dimers are connected via C—H⋯Br hydrogen bonds. The crystal structure is further stabilized by π–π inter­actions [centroid–centroid distance = 3.453 (1) Å].

Methyl 4-(4-methoxy-phen-yl)-1,2,3,3a,4,4a,5,12c-octa-hydro-benzo[f]chromeno[3,4-b]pyrrolizine-4a-carboxyl-ate

In the title compound, C₂₇H₂₇NO₄, both the pyrrolidine rings in the pyrrolizine ring system adopt envelope conformations, whereas the dihydro­pyran ring adopts a half-chair conformation. The methoxy­phenyl group is oriented at an angle of 53.72 (4)° with respect to the naphthalene ring system. Intra­molecular C—H⋯O hydrogen bonds are observed. The crystal structure is stabilized by weak inter­molecular C—H⋯π inter­actions.

Methyl 1-methyl-3-p-tolyl-1,2,3,3a,4,11c-hexa-hydro-benzo[f]chromeno[4,3-b]pyrrole-3a-carboxyl-ate

In the title compound, C(25)H(25)NO(3), the dihydro-pyran ring adopts a half-chair conformation, whereas the pyrrolidine ring is in a twist conformation. The tolyl group is oriented at an angle of 82.92 (7)° with respect to the napthalene ring system. In the crystal structure, mol-ecules are linked into centrosymmetric dimers by C-H⋯π inter-actions involving the benzene ring of the tolyl group.

Chloridobis(ethyl-enediamine-κN,N')(n-pentyl-amine-κN)cobalt(III) dichloride monhydrate

The title complex, [CoCl(C₅H₁₃N)(C₂H₈N₂)₂]Cl₂·H₂O, comprises one chloridobis(ethyl­enediamine)(n-pentyl­amine)cobalt(III) cation, two chloride counter-anions and a water mol­ecule. The Co^III atom of the complex is hexa­coordinated by five N and one Cl atoms. The five N atoms are from two chelating ethyl­enediamine and one n-pentyl­amine ligands. Neighbouring cations and anions are connected by N—H⋯Cl and N—H⋯O hydrogen bonds to each other and also to the water mol­ecule.

4'-(4-Methoxy-phen-yl)-1,1',1''-trimethyl-dispiro-[indoline-3,2'-pyrrolidine-3',3''-pyrrolidine]-2,2'',5''-trione

In the title compound, C(24)H(25)N(3)O(4), the pyrrolidine ring adopts an envelope conformation while the pyrrolidine-2'',5''-dione ring adopts a twist conformation. The indoline unit is planar [maximum deviation of -0.050 (9) Å] and forms a dihedral angle of 40.36 (4)° with the methoxy-phenyl ring. Intra-molecular C-H⋯O hydrogen bonds are observed. In the crystal, mol-ecules are linked into a two-dimensional network parallel to the ab plane by inter-molecular C-H⋯O hydrogen bonds and C-H⋯π inter-actions.

Methyl 5-ferrocenyl-5a-hydr-oxy-1-methyl-10-oxo-2,3,3a,4,5a,10-hexa-hydro-1H-indeno[1,2:2',3']furo[3',4'-b]pyrrole-3a-carboxyl-ate

In the title compound, [Fe(C(5)H(5))(C(21)H(20)NO(5))], the pyrrolidine and cyclo-penta-none rings exhibit a twist conformation. The pyrrolidine ring is almost perpendicular to the cyclo-penta-none ring, making a dihedral angle of 81.91 (6)°. The mol-ecular conformation is stabilized by an intra-molecular O-H⋯N hydrogen bond and C-H⋯O inter-actions. The crystal structure is stabilized by inter-molecular C-H⋯O inter-actions.

Methyl 3-[ferrocen-yl(hydr-oxy)meth-yl]-1-methyl-2'-oxospiro-[pyrrolidine-2,3'-indoline]-3-carboxyl-ate

In the title compound, [Fe(C(5)H(5))(C(20)H(21)N(2)O(4))], the pyrrolidine ring exhibits an envelope conformation with the spiro-C atom deviating from the plane of the remaining four atoms. The pyrrolidine ring is almost perpendicular to the indolinone ring [dihedral angle = 87.52 (7)°]. The structure is stabilized by an intra-molecular O-H⋯N hydrogen bond and by inter-molecular C-H⋯O and N-H⋯O inter-actions.

Unilateral solitary choroid metastasis from breast cancer: rewarding results of external radiotherapy

Intraocular metastatic tumor is the commonest intraocular malignancy in adults, with uveal tract the commonest site. In nearly 85% of cases the choroid is the afflicted site due to its vascularity. Breast and lung are the common primaries. In breast primaries, this could be the first metastatic disease. This condition should always be kept in mind in patients with visual symptoms. Fundus examination, ultrasonography and CT/MRI of the orbit help in diagnosis. Early recognition and timely treatment can save the visual function thus imparting good quality of life to the patient. External beam radiotherapy is a good local form of treatment. Hormone therapy in hormone receptor positive tumors can have additional benefits. Here we report a case of unilateral solitary choroid metastasis in a case of breast cancer treated with external beam radiotherapy.

Ethyl 2-[4-(benzyloxy)anilino]-4-oxo-4,5-dihydro-furan-3-carboxyl-ate

In the title compound, C(20)H(19)NO(5), the dihydro-furan ring is almost planar [maximum deviation of 0.021 (2)°] and makes dihedral angles of 28.1 (7) and 54.5 (5)° with the benzyl and phenyl-amino rings, respectively. The mol-ecular packing is stabilized by intra-molecular N-H⋯O hydrogen bonds and inter-molecular C-H⋯O inter-actions.

(1'S)-4-(3,4-Dichlorophenyl)-1'-(3,5-dimethoxyphenyl)-1,2,3,4-tetrahydronaphthalene-2-spiro-2'-pyrrolizidine-3'-spiro-3''-indoline-1,2''-dione

In the title compound C(37)H(32)Cl(2)N(2)O(4), the unsubstituted pyrrolidine ring shows a twist conformation whereas the substituted pyrrolidine ring shows an envelope conformation. The dimeth-oxy benzene ring is perpendicular to the tetra-lone ring, making a dihedral angle of 89.94 (5)°. Mol-ecules are linked into centrosymmetric dimers by N-H⋯O hydrogen bonds and the crystal structure is stabilized by C-H⋯π inter-actions and C-H⋯O hydrogen bonds. One meth-oxy group is disordered over two positions with the site occupancy factors of 0.84 (2) and 0.16 (2).

Ethyl 1'-[1-(4-methoxyphenyl)-3-phenoxy-4-phenylazetidin-1-yl]-1,3-dioxo-2′,3′,5′,6′,7′,7a′-hexahydroindan-2-spiro-3′-1′H-pyrrolizine-2′-carboxylate

In the title compound, C₃₄H₃₂N₂O₇, the methyl group and methylene H atoms of the ethoxycarbonyl substituent are disordered over two positions with site occupancy factors for the major and minor conformers of 0.594 (8) and 0.406 (8), respectively. The unsubstituted ring of the pyrrolizine ring system exhibits a twist conformation, the other an envelope conformation. In the crystal structure, mol­ecules are linked through C—H⋯O hydrogen bonds; intramolecular C—H⋯O interactions are also observed.

1-[2-Oxo-1'-phenyl-2',3',5',6',7',7a'-hexa-hydroindoline-3-spiro-3'-1'H-pyrrolizin-2'-yl]-3-phenyl-prop-2-en-1-one

In the title compound, C(29)H(26)N(2)O(2), one of the pyrrolidine rings in the pyrrolizine system is disordered, with site occupancies of ca 0.55 and 0.45. Both components of the disordered pyrrolidine ring adopt envelope conformations, whereas the other pyrrolidine ring adopts a twist conformation. The mol-ecules are linked into centrosymmetric dimers by N-H⋯O hydrogen bonds and the dimers are connected via C-H⋯π inter-actions.

3-(4-Fluoro-phenyl)-1-[1'-(4-fluoro-phenyl)-2-oxo-5',6',7',7a'-tetra-hydro-1H-indole-3(2H)-spiro-3'(2'H)-1H'-pyrrol-izin-2'-yl]prop-2-en-1-one

In the title compound, C(29)H(24)F(2)N(2)O(2), one of the pyrrolidine rings of the pyrrolizine system is disordered over two sites, with occupancy factors 0.734:0.266 (12). Both components of the disordered pyrrolidine ring adopt envelope conformations, whereas the other pyrrolidine ring adopts a twist conformation. The mol-ecules are linked into centrosymmetric dimers by N-H⋯O hydrogen bonds and the dimers are connected via C-H⋯π inter-actions. The crystal structure is also stabilized by inter-molecular C-H⋯F hydrogen bonds.

Methyl 3-(4-bromo-phen-yl)-2-(1H-indol-3-ylmeth-yl)-5-[1-(4-methoxy-phen-yl)-4-oxo-2-phenyl-azetidin-2-yl]-4-nitro-pyrrolidine-2-carboxyl-ate

In the title compound, C(37)H(33)BrN(4)O(6), the pyrrolidine ring adopts an envelope conformation. The β-lactam ring is planar and makes dihedral angles of 70.16 (13) and 28.32 (13)° with the phenyl and 4-methoxy-phenyl rings, respectively. The mol-ecular packing is stabilized by intra-molecular C-H⋯O inter-actions and the crystal packing is determined by inter-molecular N-H⋯O hydrogen bonds, and C-H⋯O and C-H⋯π inter-actions.

Methyl 3-(2-chlorophenyl)-2-(1H-indol-3-ylmethyl)-5-[1-(4-methoxyphenyl)-4-oxo-3-phenylazetidin-2-yl]-4-nitropyr-rolidine-2-carboxylate

In the mol-ecule of the title compound, C(37)H(33)ClN(4)O(6), the four-membered β-lactam ring is essentially planar and is oriented at dihedral angles of 30.0 (1), 76.3 (1) and 30.9 (1)° with respect to the methoxy-phenyl ring, the phenyl ring and the indole unit, respectively. The pyrrolidine ring adopts a twist conformation. Intra-molecular C-H⋯Cl and C-H⋯O hydrogen bonds result in the formation of two five- and one six-membered rings. In the crystal structure, inter-molecular C-H⋯O and N-H⋯O hydrogen bonds link the mol-ecules. A weak π⋯π inter-action between the pyrrole rings further stabilizes the structure, with a centroid-centroid distance of 3.806 (2) Å.

Ethyl 1-(4-methoxy-phen-yl)-2-nitro-3-[4-oxo-3-phenyl-1-(4-methoxy-phen-yl)azetidin-2-yl]-2,3,10,10a-tetra-hydro-1H,5H-pyrrolo[1,2-b]isoquinoline-10a-carboxyl-ate

In the mol-ecule of the title compound, C(38)H(37)N(3)O(7), the pyrrolidine ring adopts a twist conformation and the six-membered heterocyclic ring has a boat conformation. In the crystal structure, mol-ecules are linked into a three-dimensional framework through inter-molecular C-H⋯O hydrogen bonds. One ethyl group is disordered over two positions with occupancies 0.67 (2)/0.33 (2).

1-Allyl-3,3-di-p-tolyl-indolin-2-one

In the title compound, C(25)H(23)NO, the indoline system is essentially planar. The mol-ecular structure is stabilized by weak intra-molecular C-H⋯N inter-actions and the crystal packing is determined by inter-molecular C-H⋯π inter-actions.

1-(4-Methoxy-phen-yl)-7-phenyl-3-(phenyl-selenylmeth-yl)perhydro-isoxazolo[2',3':1,2]pyrrolo[3,4-b]azetidine-6-spiro-2'-chroman-2,4'-dione

In the title compound, C(35)H(30)N(2)O(5)Se, the pyrrolidine ring adopts an envelope conformation and the oxazolidine ring is in a twist conformation. The tetra-hydro-pyran ring adopts a half-chair conformation. The methoxy-phenyl ring is twisted away from the attached azetidinone ring by 15.7 (1)°. In the crystal structure, inter-molecular C-H⋯O inter-actions link the mol-ecules into a two-dimensional network.

1-Allyl-3,3-diphenyl-indolin-2-one

In the title compound, C₂₃H₁₉NO, the oxindole residue is essentially planar and is almost perpendicular to the phenyl rings [dihedral angles = 72.1 (6) and 77.6 (6)°]. The mol­ecular packing is stabilized by C—H⋯O hydrogen bonds and C—H⋯N inter­actions.

3-(4-Chloro-phen-yl)-4-(4-methoxyphen-yl)-6-(phenyl-selenylmeth-yl)-2,3,3a,3b,4,5,5a,6,1'',2'',3'',4''-do-deca-hydro-azeto[2',3':3,4]pyrrolo[1,2-b]isoxazole-2-spiro-2''-naphthalene-5,1''-dione

In the title compound, C₃₆H₃₁ClN₂O₄Se, the four-membered β-lactam ring is fused to a pyrrolidine ring. The central five-membered ring of the fused tricyclic system exhibits an envelope conformation with the N atom as the flap, while the other five-membered ring exhibits a twist conformation. The chloro­phenyl ring is almost perpendicular to the pyrrolidine ring, making a dihedral angle of 73.45 (1)°. The crystal structure is stabilized by weak inter­molecular C—H⋯O inter­actions and the packing is further enhanced by C—H ⋯N inter­actions and π–π inter­actions between benzene rings of tetra­lone groups in mol­ecules related by an inversion center, with a centroid–centroid separation of 3.8923 (2) Å.

(3aS,9bR)-Methyl 1-methyl-3-phenyl-1,2,3,3a,4,9b-hexa-hydro-chromeno[4,3-b]pyrrole-3a-carboxyl-ate

In the title compound, C(20)H(21)NO(3), the heterocyclic six-membered ring adopts a half-chair conformation and the pyrrolidine ring adopts an envelope conformation. The mol-ecular conformation is stabilized by C-H⋯O and C-H⋯N inter-actions.

Nasopharyngeal angiofibroma treated with radiotherapy

Nasopharyngeal angiofibroma is a rare, highly vascular, benign, locally aggressive tumor, affecting boys of adolescent age. The aggressiveness and high vascularity makes surgery and even a biopsy difficult in majority of cases. Although surgery is the treatment of choice in early cases, considerable debate exists regarding the treatment of advanced disease with intracranial extension. Radiotherapy provides a good response and also avoids surgery-associated morbidity. We are herewith reporting a case of nasopharyngeal angiofibroma who showed complete hemostasis and improvement in vision to radiotherapy.

cis-3-Methyl-1-phenyl-8a,9,10,11,12,12a,12b-hexa-hydro-1H,3bH-pyrazolo[3,4:2',3']pyrano[4',5',6'-kl]xanthene

The asymmetric unit of the title compound, C₂₃H₂₂N₂O₂, contains two independent mol­ecules, A and B. The cyclo­hexane ring of mol­ecule B is disordered, with occupancies for the major and minor conformers of 0.570 (9) and 0.430 (9), respectively. The cyclo­hexane ring adopts a boat conformation in mol­ecule A and in the major conformer of mol­ecule B, and a chair conformation in the minor conformer of mol­ecule B. In both independent mol­ecules, one of the dihydro­pyran rings adopts a boat conformation while the other is in a half-chair conformation. The dihedral angle between the pyrazole and phenyl rings is 16.0 (1)° in mol­ecule A and 12.9 (1)° in mol­ecule B. The crystal packing is stabilized by C—H⋯O and C—H⋯N inter­molecular hydrogen bonds.

(3aRS,9bSR)-3-(4-Chloro-phen-yl)-1-methyl-1,2,3,3a,4,9b-hexa-hydro-chromeno[4,3-b]pyrrole-3a-carbonitrile

In the mol-ecule of the title compound, C(19)H(17)ClN(2)O, the heterocyclic six-membered ring adopts a half-chair conformation, while the pyrrolidine ring has an envelope conformation. In the crystal structure, C-Cl⋯π [Cl⋯centroid = 3.680 (2) Å] inter-actions and van der Waals forces are present.

Microsurgical anatomy of the posterior circulation

CONTEXT

The microsurgical anatomy of the posterior circulation is very complex and variable. Surgical approaches to this area are considered risky due to the presence of the various important blood vessels and neural structures.

AIMS

To document the microsurgical anatomy of the posterior circulation along with variations in the Indian population.

MATERIALS AND METHODS

The authors studied 25 cadaveric brain specimens. Microsurgical dissection was carried out from the vertebral arteries to the basilar artery and its branches, the basilar artery bifurcation, posterior cerebral artery and its various branches. Measurements of the outer diameters of the vertebral artery, basilar artery and posterior cerebral artery and their lengths were taken.

RESULTS

The mean diameter of the vertebral artery was 3.4 mm on the left and 2.9 mm on the right. The diameter of the basilar artery varied from 3-7 mm (mean of 4.3 mm). The length varied from 24-35 mm (mean of 24.9 mm). The basilar artery gave off paramedian and circumferential perforating arteries. The origin of the anterior inferior cerebellar artery (AICA) varied from 0-21 mm (mean 10.0 mm) from the vertebrobasilar junction. The diameter of the AICA varied from being hypoplastic i.e.,

CONCLUSIONS

The authors have documented the various anomalies as well as the differences of the anatomy in this area in the Indian population as compared to the Western literature.

Treatment outcomes in locally advanced colorectal carcinoma

BACKGROUND: Locally advanced colorectal cancers form a distinct subgroup where contiguous organs could be involved without distant metastases and so may be amenable to curative surgical resection. It was our objective to report our experience in treating six such patients with operable locally advanced colorectal carcinomas. METHODS: We retrospectively reviewed the case notes of 47 patients who were diagnosed with colorectal cancers at M S Ramaiah Medical Teaching Hospital between the years 1996 - 2001. Six patients were identified with T4 lesions, adjacent organ involvement and with no nodal involvement. The treatments and outcomes for these patients were then reviewed. RESULTS: Two of three patients with rectal malignancies who underwent pelvic exenteration succumbed to disease recurrence within the first 18 months. One of the three patients with colonic cancers died of non malignant causes. The other two are disease free till date. CONCLUSIONS: Aggressive multivisceral resections for locally advanced colonic cancers might be appropriate. Rectal cancers when locally advanced may be considered for pelvic exenteration, but a more guarded prognosis may apply.