An approach to the management of patients with residual Cushing’s disease

The evaluation and management of patients with residual Cushing’s disease is one of the more complex issues facing neurosurgeons and neuroendocrinologists in clinical practice. There is considerable controversy over several relevant issues such as the timing of the assessment of whether a patient is in remission, what biochemical parameters define remission, the most appropriate course of action to take after residual disease has been defined, etc. As a consequence of the controversies, treating physicians develop notions and fall into certain practice patterns based on evidence of varying levels, their anecdotal experiences, and information gleaned from scientific meetings. This practice pattern, we believe, constitutes the “art of medicine.” We conducted a PubMed literature search to identify manuscripts containing data relevant to Cushing’s disease, outcomes of various therapeutic modalities, and recurrences. Reference lists were used to identify additional relevant manuscripts. We focused our review on manuscripts that included reasonably large series of patients, those reflecting the experience of pituitary centers and physicians recognized as experts in the field, and those papers felt to represent seminal contributions to the literature. Furthermore, trends in the evaluation and management of relevant patients have been incorporated by the senior author who has seen and evaluated over 750 patients with documented Cushing’s syndrome over the past 18 years in clinical practice. An analysis of current evidence indicated that, despite advances in neurosurgical techniques and recent developments in adjuvant therapies, patients with residual Cushing’s disease present significant management challenges to treating physicians. In this era, however, it is indeed possible to gain control of the hypercortisolism in most patients. Despite the wide variability in research methodology designed to collect relevant data, a step-wise approach to the management of these patients can be achieved. A logical step-wise approach to the evaluation of postoperative patients with Cushing’s disease is essential. Patients with residual disease require the development of an individualized plan of management that takes into account numerous factors pertaining to status of disease, the experience of treating physicians, and available therapeutic modalities

Coping with Illness: Insight from the Bhagavad Gita

The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. It uses the conversation between Lord Krishna and Arjuna to highlight initial negative coping mechanisms exhibited by the latter. It goes on to showcase positive coping skills suggested by Lord Krishna and implemented by Arjuna. The Bhagavad Gita, through this case-based methodology, teaches us how to cope with a demanding situation. Diabetes is a lifestyle disease, which warrants a thorough change in one\u27s lifestyle, including changes in basic activities such as diet and exercise. This brief communication utilizes the teachings of Bhagavad Gita to help in coping with illness, especially chronic illness such as diabetes. The article cites verses from the Bhagavad Gita to show how one may cope with the stress of illness such as diabetes

The overlap of accessory virulence factors and multidrug resistance among clinical and surveillance Klebsiella pneumoniae isolates from a neonatal intensive care unit in Nepal: a single-centre experience in a resource-limited setting

Background: There is a lack of data on the characteristics of overlap between acquired antimicrobial resistance and virulence factors in Klebsiella pneumoniae in high-risk settings, especially with the inclusion of surveillance isolates along with the clinical. We investigated K. pneumoniae isolates, from a neonatal intensive care unit (NICU) in Nepal, for the presence of both accessory virulence factors and acquired antimicrobial resistance. Methods: Thirty-eight clinical and nineteen surveillance K. pneumoniae isolates obtained between January 2017 and August 2022 in the NICU of Siddhi Memorial Hospital, Bhaktapur, Nepal were investigated with antimicrobial susceptibility testing, PCR-based detection of β-lactamases and virulence factors, and genetic similarity by ERIC–PCR. Results: K. pneumoniae was found positive in 37/85 (43.5%) blood culture-positive neonatal bloodstream infections, 34/954 (3.6%) patient surveillance cultures, and 15/451 (3.3%) environmental surveillance samples. Among 57 isolates analyzed in this study, we detected multidrug resistance in 37/57 (64.9%), which was combined with at least one accessory virulence factor in 21/37 (56.8%). This overlap was mostly among β-lactamase producing isolates with accessory mechanisms of iron acquisition. These isolates displayed heterogenous ERIC–PCR patterns suggesting genetic diversity. Conclusions: The clinical significance of this overlap between acquired antimicrobial resistance and accessory virulence genes in K. pneumoniae needs further investigation. Better resource allocation is necessary to strengthen infection prevention and control interventions in resource-limited settings

Effect of imaging and catheter characteristics on clinical outcome for patients in the PRECISE study

The PRECISE study used convection enhanced delivery (CED) to infuse IL13-PE38QQR in patients with recurrent glioblastoma multiforme (GBM) and compared survival to Gliadel Wafers (GW). The objectives of this retrospective evaluation were to assess: (1) catheter positioning in relation to imaging features and (2) to examine the potential impact of catheter positioning, overall catheter placement and imaging features on long term clinical outcome in the PRECISE study. Catheter positioning and overall catheter placement were scored and used as a surrogate of adequate placement. Imaging studies obtained on day 43 and day 71 after resection were each retrospectively reviewed. Catheter positioning scores, catheter overall placement scores, local tumor control and imaging change scores were reviewed and correlated using Generalized Linear Mixed Models. Cox PH regression analysis was used to examine whether these imaging based variables predicted overall survival (OS) and progression free survival (PFS) after adjusting for age and KPS. Of 180 patients in the CED group, 20 patients did not undergo gross total resection. Of the remaining 160 patients only 53% of patients had fully conforming catheters in respect to overall placement and 51% had adequate catheter positioning scores. Better catheter positioning scores were not correlated with local tumor control (P = 0.61) or imaging change score (P = 0.86). OS and PFS were not correlated with catheter positioning score (OS: P = 0.53; PFS: P = 0.72 respectively), overall placement score (OS: P = 0.55; PFS: P = 0.35) or imaging changes on day 43 MRI (P = 0.88). Catheter positioning scores and overall catheter placement scores were not associated with clinical outcome in this large prospective trial

Electronic Resource Management (ERM): Procurement Policies, Issues and Challenges in Indian Libraries

This paper provides an overview of electronic resources and its management prevailed in Indian libraries. Also analyses the procurement policies, current trends, issues and challenges faced by the library professionals to provide an effective electronic resource collection to its users in a better way. One of the challenges faced by the librarians to get access to electronic recourses is the availability of the required funds for purchasing it. However, up to some extent consortium for electronic journals help to acquire more resources. This paper would help the librarians to understand the challenges in procuring and managing electronic resources and to take appropriate measures to avoid the issues related

Calcifying pseudoneoplasm of the neuraxis within the sellar region: illustrative case

BACKGROUND: There are numerous atypical lesions of the sellar and suprasellar region that are often mistaken for pituitary adenomas. It is important to consider rare mimics of more common pathologies in this region. OBSERVATIONS: The authors detail the case of a 37-year-old woman with hypopituitarism who was found to have an atypical sellar mass with slow growth on interval imaging. The lesion was debulked via a microscopic endonasal transsphenoidal approach and found to be a calcifying pseudoneoplasm of the neuraxis (CAPNON). LESSONS: CAPNON is a rare disease entity that may affect the sellar region. CAPNON should be on the differential diagnosis for sellar masses that are associated with T1 and T2 hypointensity on magnetic resonance imaging with minimal enhancement. Although CAPNON is not at risk for malignant progression, these benign lesions can continue to grow after a subtotal resection and require follow-up

The yo-yo technique to prevent cerebrospinal fluid rhinorrhea after anterior clinoidectomy for proximal internal carotid artery aneurysms

OBJECTIVE: Resection of the anterior clinoid process is important for the exposure of aneurysms on clinoidal and supraclinoidal segments of the internal carotid artery. Cerebrospinal fluid (CSF) rhinorrhea can complicate anterior clinoidectomy when the optic strut is pneumatized and its removal communicates the subarachnoid space with the sphenoid sinus. We present a technique for repairing this defect and preventing CSF rhinorrhea. METHODS: A suture is secured around a strip of temporalis muscle, which is then pushed through the opening in the optic strut completely into the sphenoid sinus. The ends of suture that trail the muscle are used to retract the muscle from the sphenoid sinus back into the optic strut. The suture is trimmed and the repair is covered with sealant or fibrin glue. RESULTS: During an 8-year period in which 127 patients with proximal internal carotid artery aneurysms that required anterior clinoidectomy were treated, pneumatized optic struts were encountered in 14 patients (11%). Four patients were treated with the yo-yo technique, none of whom experienced CSF rhinorrhea. Before using this technique, 10 patients were managed with standard packing techniques (wax, muscle, and gel foam) and four of these patients subsequently experienced CSF rhinorrhea (40%). In these four patients, all required reoperation with either craniotomy and packing with pericranium (one patient), Couldwell-Luc procedure (one patient), or endoscopic transnasal obliteration of the sphenoid sinus with fat (two patients). CONCLUSION: The yo-yo technique of tightly wedging a muscle plug into the optic strut proved to be simple, fast, and effective, preventing CSF rhinorrhea in all patients in whom it was applied. Although experience with this technique is limited, reversing the direction of packing and pulling muscle from the sphenoid sinus into the optic strut eliminated a complication that occurred in 40% of patients with standard packing techniques. Copyright © Congress of Neurological Surgeons

Food Waste to Energy: An Overview of Sustainable Approaches for Food Waste Management and Nutrient Recycling

Food wastage and its accumulation are becoming a critical problem around the globe due to continuous increase of the world population. The exponential growth in food waste is imposing serious threats to our society like environmental pollution, health risk, and scarcity of dumping land. There is an urgent need to take appropriate measures to reduce food waste burden by adopting standard management practices. Currently, various kinds of approaches are investigated in waste food processing and management for societal benefits and applications. Anaerobic digestion approach has appeared as one of the most ecofriendly and promising solutions for food wastes management, energy, and nutrient production, which can contribute to world’s ever-increasing energy requirements. Here, we have briefly described and explored the different aspects of anaerobic biodegrading approaches for food waste, effects of cosubstrates, effect of environmental factors, contribution of microbial population, and available computational resources for food waste management researches