Ishwar Singh

Antioxidant enzymes and lipid peroxidation in Type 2 diabetes mellitus patients with and without nephropathy

Background: Oxidative stress has been considered to be a pathogenic factor of diabetic complications including nephropathy. There are many controversies and limited studies regarding the antioxidant enzymes in diabetic nephropathy. Aim: This study was to evaluate the levels of antioxidant enzymes and lipid peroxidation in Type-2 Diabetes Mellitus (DM) patients with and without nephropathy. Materials and Methods: The study included 90 age and sex matched subjects. Blood samples of all subjects were analyzed for all biochemical and oxidative stress parameters. Results: The malondialdehyde (MDA) levels and catalase (CAT) activity were significantly increased and reduced glutathione (GSH) levels and activities of glutathione peroxidase (GPx) and glutathione reductase (GR) were significantly decreased in Type-2 DM with and without nephropathy as compared to controls and also in Type-2 DM with nephropathy as compared to Type-2 DM without nephropathy. There were an excellent positive correlation of glycohemoglobin (HbA1c) with MDA and a good negative correlation of GPx with GSH in controls. There were positive correlations of GR, CAT, and superoxide dismutase (SOD) with MDA in Type-2 diabetes patients with nephropathy. Conclusions: Intensity of oxidative stress in Type-2 diabetic patients with nephropathy is greater when compared with Type-2 diabetic patients without nephropathy as compared to the controls.

Spinal dorsal dermal sinus tract: An experience of 21 cases

Background: Spinal dorsal dermal sinus is a rare entity, which usually comes to clinical attention by cutaneous abnormalities, neurologic deficit, and/or infection. The present study was undertaken to know the clinical profile of these patients, to study associated anomalies and to assess the results of surgical intervention. Methods: Medical records of 21 patients treated for spinal dorsal dermal sinus from September 2007 to December 2013 were reviewed. Results: We had 21 patients with male: female ratio of 13:8. Only 2 patients were below 1-year of age, and most cases (15) were between 2 and 15 years (mean age = 8.2 years). Lumbar region (11 cases) was most frequently involved, followed by thoracic (4 cases), lumbosacral, and cervical region in 3 patients each. All of our patients presented with neurological deficits. Three patients were admitted with acute meningitis with acute onset paraplegia and had intraspinal abscess. The motor, sensory, and autonomic deficits were seen in 14, 6, and 8 patients, respectively. Scoliosis and congenital talipes equinovarus were the common associated anomalies. All patients underwent surgical exploration and repair of dysraphic state and excision of the sinus. Overall, 20 patients improved or neurological status stabilized and only 1 patient deteriorated. Postoperative wound infection was seen in 2 cases. Conclusions: All patients with spinal dorsal dermal sinuses should be offered aggressive surgical treatment in the form of total excision of sinus tract and correction of spinal malformation, as soon as diagnosed.

Growing skull fractures: guidelines for early diagnosis and surgical management

BackgroundGrowing skull fracture (GSF) is a rare complication of pediatric head trauma and causes delayed onset neurological deficits and cranial defect. GSF usually develops following linear fracture with underlying dural tear resulting in herniation of the brain. Early diagnosis and treatment are essential to avoid complications. However, there are no clear-cut guidelines for the early diagnosis of GSF. The present study was conducted to identify the criteria for the early diagnosis of GSF.Material and methodsFrom 2010 to 2015, all pediatric patients of head trauma with linear fracture were evaluated. Patients of age <5xa0years with cephalhematoma, bone diastasis of 4xa0mm or more with underlying brain contusion were subjected to contrast brain MRI to find out the dural tear and herniation of the brain matter. Patients with contrast MRI showing dural tear and herniation of the brain matter were considered high risk for the development of GSF and treated surgically within 1xa0month of trauma. Patients with contrast brain MRI not showing dural tear and herniation of the brain matter were regularly followed for any signs of GSF.ResultsA total of 20 patients were evaluated, out of which 16 showed dural defects with herniation of the brain matter and were subjected to duraplasty. Four patients in which MRI did not show dural tear and herniation of the brain matter were regularly followed-up and have not shown any sign of GSF later on follow-up.ConclusionEarly diagnosis of GSF can be made based on the four criteria, i.e., (1) age <5xa0year with cephalhematoma, (2) bone diastasis 4xa0mm or more (3) underlying brain contusion (4) contrast MRI showing dural tear and herniation of the brain matter. Dural tear with herniation of the brain matter is the main etiopathogenic factor for the development of GSF. Early diagnosis and treatment of GSF can yield a good outcome.

Decrease in Antioxidant Status of Plasma and Erythrocytes from Geriatric Population

Background: Ageing is associated with an accumulation of free radical damage, which leads to physiological and clinical modifications. The study aims to find out the status of lipid profile, antioxidant enzymes, malondialdehyde in geriatric population. Patients/methods: The study was conducted on 150 subjects (75 healthy control between the ages of 20–30 years and 75 elderly subjects between ages of 50–70 years as cases). The following parameters were analyzed using the standard reference methods: lipid profile, reduced glutathione, glutathione peroxidase, glutathione reductase, catalase, superoxide dismutase and malondialdehyde. Results: The present study was conducted to estimate the oxidative stress parameters in geriatric population. Highly significant increase in total cholesterol (TC), triglyceride (TG), LDL-cholesterol (LDL-C), VLDL-cholesterol (VLDL-C), malondialdehyde, catalase and decrease in high density lipoprotein cholesterol (HDL-C), reduced glutathione, glutathione peroxidase, glutathione reductase, superoxide dismutase was observed in geriatrics when compared with their younger counterparts. Conclusion: This study concluded that there is enhanced oxidative stress and decreased antioxidant defence in geriatrics as compared to younger subjects which could play an important role in ageing. Dyslipidemia has become one of the important risk factors for the increasing prevalence of cardiovascular diseases. There is lack of awareness on the relationship between blood lipids and the risk of cardiovascular diseases in geriatric population. The strategy of early prevention should be adopted against dyslipidemia.

Combined microsurgical and endoscopic technique for removal of extensive intracranial epidermoids

Background: Intracranial epidermoid tumors are challenging lesions because they grow along the subarachnoid spaces around delicate neurovascular structures and often extend from one compartment to another. The purpose of this study was to determine the usefulness of endoscopic assistance in the microsurgical resection of these lesions, in which total resection is therapy of choice. Methods: A total of 48 cases of intracranial epidermoids were treated by combined microscopic and endoscopic techniques. Initially, the tumor was removed under the microscope and after ensuring maximum excision, the endoscope was used to find out and excise any residual tumor. Results: Out of these 48 cases complete excision was achieved in 44 cases and subtotal excision in four patients. Postoperative complications were seen in 17 patients, but none of the complications was attributed to the use of endoscope. Overall use of endoscope benefited 79% of cases. Conclusion: We recommend combined microsurgical and endoscopic approach to achieve complete/maximum resection of extensive intracranial epidermoid tumors.

Author reply - Letter to the Editor Re: Singh I et al: Growing skull fractures: guidelines for early diagnosis and surgical management

Sir, Thank you very much for your comments and subsequent discussion regarding the article. It is unanimously accepted that skull fracture with dural tear and entrapment of the arachnoid membrane or brain tissue within the fracture margin, is the most important factor for growing skull fracture pathogenesis [1]. The present study also corroborates this pathogenesis. Before this study, radiography and CT scanning were the most common methods used to assess and diagnose these cases. Unfortunately, they are not sufficient especially in early stages after trauma. Prof. Paul Steinbok has raised the question that some patients with diastatic fracture with dural tear might heal and may not require surgery as he has observed in his practice. I slightly differ as he is not doing MRI, which has high predictive value for diagnosing dural tear which is essential for development of growing skull fracture. Moreover, if herniation of brain matter is there, which was seen in all operated cases in our study, the healing of fracture is unlikely. Diastatic fracture or brain contusion does not always cause dural tear/brain herniation which is essential for development of growing skull fracture as seen in four patients in our study. Another longterm longitudinal study in the future will answer whether diastatic fractures with dural tear heal spontaneously or always progress to growing skull fractures. Secondly, a protocol was recommended in which only clinical signs and symptoms and skull radiography done at 4 weeks for diagnosing high-risk patients for growing skull fracture with reassessment after 2–3 months in equivocal cases. I believe that the time interval between head injury and diagnosis of growing skull fracture varies from 1 day to many years, and pulsatile mass or bony defect at the site of the known diastatic fracture is not always seen in early stages. Skull radiography can diagnose growing skull fracture if there is significant widening of fracture which is unlikely to be seen at 4 weeks in most cases. In my opinion, theMRI is essential for diagnosing growing skull fracture. I agree that getting an MRI is difficult in small infants and may require general anesthesia; but with early diagnosis, one can avoid complications like delayed neurological deficit, seizure, and cranioplasty.

Comparison of total versus partial revision of primary ventriculoperitoneal shunt failures.

Background: Optimal surgical management of patients presenting with primary shunt failure in the era of neuroendoscopy remains complex. The value of replacing the entire shunt system as opposed to a single shunt component has not been assessed extensively. Methods: In a retrospective study, the records of all patients who underwent their first shunt revision due to mechanical obstruction between September 2007 and December 2011 were reviewed. Shunt revisions were classified as total (entire shunt replaced) or partial (only malfunctioning component replaced). Patients having a minimum follow-up of 1 year after primary shunt revision were included in the study. Kaplan-Meier (shunt survival curves) and log-rank analysis were used to compare failure rates between partially and totally revised shunts. Results: Records of 62 patients in whom cause of primary shunt failure was obstruction (P roximal or distal) were analyzed retrospectively. At the end of follow-up period, 26 out of 28 partial revision group and 22 out of 34 total revision group had shunt failure. The median survival of the shunt in the partial revision and total revision groups was 60 and 270 days, respectively. The method (partial/total revision) related difference in shunt survival duration was statistically significant as shown by log-rank analysis (log-rank test value = 5.94 and P < 0.05). Conclusion: Partial revision of shunt predisposes to accelerated shunt failure as compared with total revision in cases of obstructed ventriculoperitoneal shunt.

Twist Drill Aspiration of Pyogenic Brain Abscesses: Our Experience in 103 Cases

BACKGROUNDnIntracranial abscesses remain a significant health care problem in developing countries. Though potentially curable, brain abscess remains a diagnostic and therapeutic challenge. The effective treatment of intracranial abscess remains controversial. Various surgical procedures like drainage, aspiration, and excision have been advocated for the management of brain abscess with variable results. Aspiration is a rapid and safe procedure, especially with use of stereotactic techniques, intraoperative ultrasound, or computed tomography (CT) scan guidance. However, these are not readily available everywhere.nnnOBJECTIVEnTo assess the outcome in pyogenic brain abscesses treated by twist drill aspiration (a bedside procedure) in which point of aspiration is marked with the help of three-dimensional (3D) reconstructed CT images.nnnMETHODSnFrom September 2007 to September 2011, a total of 103 cases of brain abscesses over 2.5 cm in size were treated by twist drill aspiration. The point of aspiration was marked with the help of 3D reconstructed CT images using fixed bony landmarks as reference, and exact measurement were taken with the help of biopsy software.nnnRESULTSnIn the present study, 103 cases of superficial brain abscesses were treated via twist drill aspiration. Out of these, 98 patients had a single abscess and five had multiple abscesses. Out of the 103 patients, 86 (83.4%) showed good recovery, 9 (8.7%) had moderate disability, 3 (2.9%) had severe disability, and 5 (4.8%) expired.nnnCONCLUSIONnTwist drill aspiration is a rapid, safe, and very effective lifesaving procedure in the underdeveloped world where stereotaxy is not readily available.