Clinical and therapeutic outcomes of pediatric pituitary adenomas: a single pituitary center experience

PURPOSE

Pediatric pituitary adenomas (PPA) are rare. Although PPAs are mostly benign, they can be challenging to manage. Most studies evaluating PPA are based on surgical series. We aimed to present the clinical features, hormonal status and treatment outcomes of children with PPA managed in a joint neuroendocrine setting.

METHODS

In this single-center study, demographic, clinical and endocrinological data of patients under 19 years old who were followed up with the diagnosis of PPA between 2002-2022 were retrospectively reviewed. A total of 21 studies published in the past 20 years were also systematically reviewed.

RESULTS

There were 79 patients (52 girls, 27 boys) with a median age of 15.8 years. Median follow-up time was 30 months. The most common adenoma subtype was non-functioning adenoma (NFA) (35.5%), followed by prolactinoma (29.1%), corticotropinoma (21.5%), and somatotropinoma (13.9%), respectively. The frequency of micro and macroadenomas was almost equal while 38% of all adenomas were invasive. Headache, visual impairment and menstrual irregularity were the most common complaints, while the most common hormonal deficiency at diagnosis was central hypothyroidism (31.6%), followed by hypogonadotropic hypogonadism (22.7%), growth hormone deficiency (15.2%) and central adrenal insufficiency (11.4%), respectively. Fifty patients (63.2%) underwent endoscopic endonasal transsphenoidal surgery (EETS). Following the surgery, impaired endocrine functions recovered at a rate of 62% while permanent central diabetes insipidus was observed in 6%, and new onset hypopituitarism developed in 4%.

CONCLUSION

NFA was more common in this cohort than in previous reports, which is one of the largest PPA series in the literature. Hormonal disorders, which were common at the time of diagnosis, were largely resolved with appropriate endocrinological and surgical approaches, while the rate of pituitary hormonal deficiencies after EETS was relatively low. Therefore, we recommend that children with PPA be managed in the setting of a high-volume pituitary center to provide long-term low morbidity.

A reference center study in thyrotropin-secreting pituitary adenomas: clinicopathological, therapeutic and long-term follow-up outcomes

PURPOSE

This study aims to analyze the clinicopathological features, diagnostic steps, and therapeutic results of TSHomas and to reveal the effective factors on remission.

METHODS

The clinical, radiological, and pathological features and surgical and endocrinological results of 41 TSHoma cases followed between 2005 and 2022 were retrospectively analyzed. The factors affecting the surgical cure were investigated by comparing the groups with and without remission.

RESULTS

A total of 41 patients (23 male,18 female) were included in the study and the mean age was 42 (31.5-49). Palpitation and headache were the most common complaints. The time from the onset of symptoms to diagnosis was 8 (3-20) months. There were 8 patients with a preoperative clinical and biochemical diagnosis of TSH + GH co-secretion. In the TRH stimulation test, a blunted TSH response was obtained in 18 patients (90.0%). Complete suppression could not be obtained in any of the patients who underwent the T3 suppression test. The median maximum tumor diameter was 19.0 mm (6.8-41). There was microadenoma in 4 (9.8%) patients and macroadenoma in 37 patients (92.8%). Remission was achieved in 31 (75.6%) of 40 patients who underwent endoscopic transsphenoidal surgery (eTSS). The Ki-67 labeling index was 2% (1.00-4.00) in the entire patient group. Preoperative use of antithyroid drugs appears to be significantly associated with surgical cure.

CONCLUSION

Diagnosis of TSHoma is still full of challenges and dynamic tests remain important. Recognition and good management of inappropriate TSH secretion states affect subsequent surgical outcomes.

Far-infrared treatment of experimental sinusitis in rabbits: a pilot study

OBJECTIVE

Thermal therapy has existed for thousands of years and dates back to ancient civilizations such as the Finns, Romans, ancient Chinese, American Indians, and Egyptians. Sun therapy is a form of natural Far Infrared Rays (FIR) thermal therapy. Far infrared rays are invisible rays with the longest wavelength of natural sunlight. However, sunbathing should only be done in moderation, as sunlight contains ultraviolet rays that can burn and damage the skin. More than 30 million people in Asia, Europe, and Australia receive Far Infrared Therapy with FIR lamps. They emit 2-25-micron wavebands. We aimed to investigate whether FIR therapy that uses a similar waveband improves sinusitis symptoms.

MATERIALS AND METHODS

This study was conducted on 10 New Zealand rabbits of both sexes, 7-8 months old, with an average weight of 1.8-2.4 kg. They were divided into four study groups. Sinusitis was induced in rabbits by blocking the sinus ostium, whereas some were left as control. Far infrared treatment with an infra-sin device was given with or without antibiotics. Mucosal samples were evaluated microscopically regarding epithelial eruption, epithelial vacuolization, interstitial edema, vascular congestion, leukocyte infiltration, and mucosal thickening.

RESULTS

We found clinical and histopathological improvements in rabbits with sinusitis on the right side of the nose, to which we applied FIR treatment with the device Infra-Sin.

CONCLUSIONS

Our findings in this animal study led us to conclude that it would be beneficial to study the effects of FIR treatment on people with allergic rhinitis and sinusitis and to identify the optimal dosing, treatment duration, and intensity. To add to our findings, looking into whether FIR therapy can be used as an alternative to antibiotic treatment for human sinusitis is essential.

Recurrent Cushing's Disease in Adults: Predictors and Long-Term Follow-Up

Cushing's disease (CD) is characterized by endogenous hypercortisolism that is associated with increased mortality and morbidity. Due to high recurrence rates in CD, the determination of high-risk patients is of paramount importance. In this study, we aimed to determine recurrence rates and clinical, laboratory, and histological predictors of recurrence in a high volume single-center. This retrospective study included 273 CD patients operated in a single pituitary center between 1997 and 2020. The patients with early postoperative remission were further grouped according to recurrence status (recurrent and sustained remission groups). Demographic, radiologic, laboratory, pathologic, and follow-up clinical data of the patients were analyzed and compared between groups. The recurrence rate was 9.6% in the first 5 years; however, the overall recurrence rate was 14.2% in this study. Higher preoperative basal ACTH levels were significantly correlated with CD recurrence even with ACTH levels adjusted for tumor size, Ki-67 levels, and tumoral invasion. Recurrence rates were significantly higher in patients with ACTH levels higher than 55 pg/ml, tumor diameter>9.5 mm, and if adrenal axis recovery was before 6 months. The severity of hypercortisolism, morbidities, and demographic factors except age were not predictive factors of recurrence. Based on our study data, younger age at diagnosis, a diagnosis of osteoporosis, higher preoperative ACTH levels, larger tumor size, invasive behavior, higher Ki 67 index, and early recovery of the adrenal axis during the postoperative period attracted attention as potential predictors of recurrent disease.

Endoscopically operated 15 ventral skull-base dermoid and epidermoid cysts: Outcomes of a case series and technical note

BACKGROUND

Epidermoid and dermoid tumors in the sellar region are rare. These cystic lesions are a surgical challenge, as the thin capsule adheres firmly to nearby structures. A case series of 15 patients is presented.

METHODS

The patients were operated on in our clinic between April 2009 and November 2021. The endoscopic transnasal approach (ETA) was used. Lesions were located in the ventral skull base. In addition, the literature was reviewed to compare clinical features and outcomes of ventral skull-base epidermoid/dermoid tumors operated on via ETA.

RESULTS

In our series, removal of cystic contents and tumor capsule (gross total resection: GTR) was achieved in 3 patients (20%). GTR was not possible for the others, because of adhesions to vital structures. Near total resection (NTR) was achieved in 11 patients (73.4%), and subtotal resection (STR) in 1 (6.6%). At a mean follow-up of 55±26.27 months, there were no cases of recurrence requiring surgery.

CONCLUSION

Our series demonstrates that ETA is suitable for resection of epidermoid and dermoid cysts in the ventral skull base. GTR cannot always be the absolute clinical aim, because of inherent risks. In patients with expected long-term survival, the aggressiveness of surgery should be weighed on an individual risk/benefit basis.

The association of bone mineral density Z-score with the early postoperative remission and characteristics of bone mineral loss in patients with Cushing's disease: a retrospective study

AIM

To investigate the association of bone mineral density (BMD) Z-scores with early-postoperative remission rate and clinical parameters in patients with Cushing's disease (CD).

METHODS

We retrospectively evaluated the records of patients diagnosed with CD. After the exclusion of 230 patients, 87 CD patients were finally enrolled. BMD was determined by dual-energy x-ray absorptiometry (DXA) at the lumbar spine 1-4 (L1-4) and left femur. Early-postoperative remission was defined as a morning cortisol concentration on the first day after surgery of less than 5 μg/dL. The diagnosis of BMD "below the expected range for age" was defined as a Z-score≤-2.00 standard deviations.

RESULTS

DXA results were not significantly associated with early postoperative remission. They also did not significantly differ between eugonadal and menopausal groups. Preoperative morning cortisol significantly negatively but weakly correlated with Z-score of the total femur, while preoperative adrenocorticotropic hormone/cortisol ratio positively but weakly correlated with DXA results of L1-4.

CONCLUSION

The severity of bone loss was not significantly related to the failure of transsphenoidal surgery for Cushing's disease.

The association of bone mineral density Z-score with the early postoperative remission and characteristics of bone mineral loss in patients with Cushing's disease: a retrospective study

AIM

To investigate the association of bone mineral density (BMD) Z-scores with early-postoperative remission rate and clinical parameters in patients with Cushing's disease (CD).

METHODS

We retrospectively evaluated the records of patients diagnosed with CD. After the exclusion of 230 patients, 87 CD patients were finally enrolled. BMD was determined by dual-energy x-ray absorptiometry (DXA) at the lumbar spine 1-4 (L1-4) and left femur. Early-postoperative remission was defined as a morning cortisol concentration on the first day after surgery of less than 5 μg/dL. The diagnosis of BMD "below the expected range for age" was defined as a Z-score≤-2.00 standard deviations.

RESULTS

DXA results were not significantly associated with early postoperative remission. They also did not significantly differ between eugonadal and menopausal groups. Preoperative morning cortisol significantly negatively but weakly correlated with Z-score of the total femur, while preoperative adrenocorticotropic hormone/cortisol ratio positively but weakly correlated with DXA results of L1-4.

CONCLUSION

The severity of bone loss was not significantly related to the failure of transsphenoidal surgery for Cushing's disease.

Surface waves and crustal structure on Mars

We detected surface waves from two meteorite impacts on Mars. By measuring group velocity dispersion along the impact-lander path, we obtained a direct constraint on crustal structure away from the InSight lander. The crust north of the equatorial dichotomy had a shear wave velocity of approximately 3.2 kilometers per second in the 5- to 30-kilometer depth range, with little depth variation. This implies a higher crustal density than inferred beneath the lander, suggesting either compositional differences or reduced porosity in the volcanic areas traversed by the surface waves. The lower velocities and the crustal layering observed beneath the landing site down to a 10-kilometer depth are not a global feature. Structural variations revealed by surface waves hold implications for models of the formation and thickness of the martian crust.

Largest recent impact craters on Mars: Orbital imaging and surface seismic co-investigation

Two >130-meter-diameter impact craters formed on Mars during the later half of 2021. These are the two largest fresh impact craters discovered by the Mars Reconnaissance Orbiter since operations started 16 years ago. The impacts created two of the largest seismic events (magnitudes greater than 4) recorded by InSight during its 3-year mission. The combination of orbital imagery and seismic ground motion enables the investigation of subsurface and atmospheric energy partitioning of the impact process on a planet with a thin atmosphere and the first direct test of martian deep-interior seismic models with known event distances. The impact at 35°N excavated blocks of water ice, which is the lowest latitude at which ice has been directly observed on Mars.

May the SAGIT® instrument be used as a preoperative prognostic tool in patients with acromegaly?

BACKGROUND

The SAGIT® instrument has been developed for acromegaly to assist clinicians in staging the disease accurately, assessing the response to therapy, and adjusting the treatment. We aimed to evaluate the preoperative utility of the SAGIT® instrument and to discover a cut-off value for predicting the surgery outcome and long-term prognosis of patients with acromegaly.

METHODS

A total of 832 patients with acromegaly were identified from the medical record system. Acromegaly diagnosis was confirmed by elevated IGF-1 levels according to the age-adjusted upper limit of normal, lack of suppression of GH concentration to <0.4 μg/L following a 75 g oral glucose tolerance test, and the existence of a pituitary adenoma demonstrated by MRI. The SAGIT® instrument comprises five key components of acromegaly: signs and symptoms (S), associated comorbidities (A), GH levels (G), IGF-1 levels (I), and the features of the tumor (T). The initial postoperative remission was evaluated 3 months after surgery.

RESULTS

A final cohort of 132 patients has been included in our study. Median preoperative SAGIT scores were significantly different (10.00 [9.00 - 11.00] to 11.00 [10.00 - 13.00], [p = 0.002]) between patients who achieved initial remission at 3 months and those who were not in remission. The threshold SAGIT score distinguishing between initial remission and nonremission groups was 10 with an AUC of 0.660 (p < 0.001).

CONCLUSIONS

In our retrospective cohort study, the findings suggested that the SAGIT® instrument may be a beneficial preoperative tool to predict the initial remission postoperatively and long-term prognosis of the patients with acromegaly.

Improving Constraints on Planetary Interiors With PPs Receiver Functions

Seismological constraints obtained from receiver function (RF) analysis provide important information about the crust and mantle structure. Here, we explore the utility of the free-surface multiple of the P-wave (PP) and the corresponding conversions in RF analysis. Using earthquake records, we demonstrate the efficacy of PPs-RFs before illustrating how they become especially useful when limited data is available in typical planetary missions. Using a transdimensional hierarchical Bayesian deconvolution approach, we compute robust P-to-S (Ps)- and PPs-RFs with InSight recordings of five marsquakes. Our Ps-RF results verify the direct Ps converted phases reported by previous RF analyses with increased coherence and reveal other phases including the primary multiple reverberating within the uppermost layer of the Martian crust. Unlike the Ps-RFs, our PPs-RFs lack an arrival at 7.2 s lag time. Whereas Ps-RFs on Mars could be equally well fit by a two- or three-layer crust, synthetic modeling shows that the disappearance of the 7.2 s phase requires a three-layer crust, and is highly sensitive to velocity and thickness of intra-crustal layers. We show that a three-layer crust is also preferred by S-to-P (Sp)-RFs. While the deepest interface of the three-layer crust represents the crust-mantle interface beneath the InSight landing site, the other two interfaces at shallower depths could represent a sharp transition between either fractured and unfractured materials or thick basaltic flows and pre-existing crustal materials. PPs-RFs can provide complementary constraints and maximize the extraction of information about crustal structure in data-constrained circumstances such as planetary missions.

A single-center experience with giant cell tumors of sphenoid bone and clivus

OBJECTIVE

To present pathologic, clinical, and treatment findings for giant cell tumors (GCTs) of sphenoid bone and clivus.

METHODS

We describe the optimal treatment algorithm in patients with a histopathologic diagnosis of bone GCT by presenting the effects of denosumab treatment in both pediatric and adult patients with GCT undergoing endoscopic transnasal surgery. Clinicopathologic correlation is crucial for the differential diagnosis of GCT and the choice of treatment modality.

CONCLUSION

GCT of bone is a local aggressive tumor that accounts for about 3%-7% of all bone tumors. GCTs located in the cranium are extremely uncommon neoplasms. There are no defined guidelines for the treatment of GCTs in skull base. Following surgical resection of the tumor, the addition of denosumab treatments to radiotherapy has a significant role in preventing the recurrence of GCT and in promoting regression of residual tumor size.

The association between insulin-like growth factor 1 levels within reference range and early postoperative remission rate in patients with Cushing's disease

INTRODUCTION

The relationship between growth hormone (GH)/insulin-like growth factor 1 (IGF-1) and glucocorticoids (GC) was examined in various studies. Long-term GC treatment was shown to decrease GH concentration and, interestingly, to increase IGF-1 concentration. We performed a retrospective study in order to examine how preoperative IGF-1 concentrations vary within the reference range and if tertiles of age- and sex-adjusted normal IGF-1 are predictive for early postoperative remission in the patients with Cushing's Disease (CD).

PATIENTS AND METHODS

Patients diagnosed with CD were retrospectively evaluated. After the exclusion of 67 patients, a final cohort of 250 CD patients were included. Age- and sex-adjusted normal IGF-1 levels were divided into tertiles (T1, T2 and T3). Early postoperative remission was defined as a nadir morning cortisol concentration measured within the first 3 consecutive days following surgery of less than 5 µg/dL (138 nmol/L).

RESULTS

Early postoperative remission rate was the lowest in T1 and highest in T3; 49.1% (n = 28) versus 77.3% (n = 75), p = .001, respectively. Binary logistic regression analysis showed the remission rate in T3 was three times higher than that in T1 (p = .003). Cortisol and ACTH concentration were significantly higher and GH concentrations were significantly lower in T1 compared to those in the other two tertiles.

CONCLUSIONS

As the first study evaluating the correlation between early postoperative remission rate in patients with CD and the tertiles of normal age- and sex-adjusted IGF-1 levels, we have shown that higher IGF-1 levels could predict better outcome in CD.

Cushing's disease due to a pituitary adenoma as a component of collision tumor: A case report and review of the literature

Background

The coexistence of two morphologically different tumors attached to each other creates a very rare type of tumor called a collision tumor. Collision tumors containing pituitary adenoma–sellar meningioma have only been described in four cases to date; we discuss a fifth case harboring a collision tumor comprising a pituitary corticotroph adenoma and a sellar meningioma in the same anatomic position.

Case presentation

A 34-year-old Caucasian woman presented with menstrual irregularity, severe weakness of the proximal muscles, and 10–15 kg weight gain within a year. Basal plasma cortisol and adrenocorticotrophic hormone levels were 17.7 mg/dL and 58 pg/mL, respectively. Her diurnal cortisol rhythm was impaired (plasma cortisol at 23:00, 18.2 mg/dL) and after a 48-hour, 2-mg dexamethasone suppression test, plasma cortisol level was 13.6 mg/dL. The results were consistent with a diagnosis of Cushing’s syndrome. We then performed a nocturnal 8-mg dexamethasone suppression test and the suppression of cortisol was not greater than 50% (21.4 to 19.3). A pituitary magnetic resonance imaging revealed a tuberculum sellae meningioma arising from within the sellar region. An operation was chosen in order to examine whether the tumor was an adrenocorticotrophic hormone/corticotropin-releasing hormone-secreting lesion or if there were any microadenomas that could be observed during the operation. Via an extended endoscopic endonasal approach the meningioma was resected successfully. Unexpectedly, our patient complained of nausea and vomiting postoperatively. Plasma cortisol was 2.6 mg/dL and orally administered hydrocortisone treatment was initiated immediately. Histopathological examination revealed that the tumor generally consisted of a pituitary corticotroph adenoma infiltrated by meningioma. Our patient maintained hydrocortisone treatment for 11 months. At the latest visit, she had lost 12 kg, and her hypertension, menstrual irregularity, and weakness of the proximal muscles had disappeared. Her mental and physical wellbeing were restored.

Conclusions

To the best of our knowledge, this is the first report of Cushing’s disease due to a pituitary corticotroph adenoma adjacent to a meningioma. Even if a high-dose dexamethasone suppression test fails to suppress basal cortisol level, the importance of considering a suprasellar/sellar meningioma a possible component of a collision tumor presenting as adrenocorticotrophic hormone-dependent Cushing’s syndrome is highlighted here.

The effect of somatostatin analogues on Ki-67 levels in GH-secreting adenomas

PURPOSE

Somatostatin analogues (SSAs) can slow down the growth of neuroendocrine tumors. However, the mechanism remains unclear. Recent studies on patients with acromegaly suggest that SSAs may induce apoptosis, increase autophagy, and decrease cell proliferation of pituitary adenoma. Ki-67-labeling index is a marker of cellular proliferation; therefore, decreased levels are associated with inhibition of proliferation. The aim of this study was to evaluate and compare the Ki-67-labeling index of GH-secreting pituitary adenoma tissues in patients who had undergone pituitary surgery twice due to residual or recurrent tumors and had received SSA treatment between the two surgeries.

METHOD

Thirty acromegaly patients who met the above criteria were identified and evaluated for the demographic, clinical and radiological features retrospectively. Surgical pathology samples of each operation were stained for Ki-67 and evaluated blindly by a staff pathologist specialized in pituitary diseases.

RESULTS

Among patients who received SSA treatment between the first and second operations, the Ki-67 index of the adenoma at the second operation was significantly lower than the Ki-67 index at the first operation. There were no differences in clinical and radiological prognostic markers between the groups with decreased and unchanged Ki-67 index.

CONCLUSION

We concluded that SSA treatment appears to decrease Ki-67 proliferation index independent of tumor features, SSA type, dose and treatment duration. This result suggests that SSA treatment may decrease cellular proliferation, supporting the previous studies.

SEIS: Insight's Seismic Experiment for Internal Structure of Mars

By the end of 2018, 42 years after the landing of the two Viking seismometers on Mars, InSight will deploy onto Mars' surface the SEIS (Seismic Experiment for Internal Structure) instrument; a six-axes seismometer equipped with both a long-period three-axes Very Broad Band (VBB) instrument and a three-axes short-period (SP) instrument. These six sensors will cover a broad range of the seismic bandwidth, from 0.01 Hz to 50 Hz, with possible extension to longer periods. Data will be transmitted in the form of three continuous VBB components at 2 sample per second (sps), an estimation of the short period energy content from the SP at 1 sps and a continuous compound VBB/SP vertical axis at 10 sps. The continuous streams will be augmented by requested event data with sample rates from 20 to 100 sps. SEIS will improve upon the existing resolution of Viking's Mars seismic monitoring by a factor of ∼ 2500 at 1 Hz and ∼ 200 000 at 0.1 Hz. An additional major improvement is that, contrary to Viking, the seismometers will be deployed via a robotic arm directly onto Mars' surface and will be protected against temperature and wind by highly efficient thermal and wind shielding. Based on existing knowledge of Mars, it is reasonable to infer a moment magnitude detection threshold of M w ∼ 3 at 40 ∘ epicentral distance and a potential to detect several tens of quakes and about five impacts per year. In this paper, we first describe the science goals of the experiment and the rationale used to define its requirements. We then provide a detailed description of the hardware, from the sensors to the deployment system and associated performance, including transfer functions of the seismic sensors and temperature sensors. We conclude by describing the experiment ground segment, including data processing services, outreach and education networks and provide a description of the format to be used for future data distribution.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11214-018-0574-6) contains supplementary material, which is available to authorized users.

Annular Pancreas, Severe Tracheomalacia and Bronchomalacia in a Preterm Boy with Vacterl Association

VACTERL association includes vertebral anomalies, anal atresia, cardiac defects, tracheao-esophageal fistula, renal anomalies, and limb abnormalities. It is defined by the presence of at least three of these congenital malformations. The incidence has been estimated to be 1/10.000-1/40.000 live births. We report on a preterm infant with VACTERL presentin with respiratory complicatons due to the presence of severe tracheomalacia and bronchomalacia. He also had an annular pancreas.

Morinda citrifolia L. (noni) and memantine attenuate periventricular tissue injury of the fourth ventricle in hydrocephalic rabbits

This study was designed to evaluate the neuroprotective effects of Morinda citrifolia L. (Rubiaceae), commonly known as noni, and memantine (a N-methy-D-aspartate receptor inhibitor) on hydrocephalus-induced neurodegenerative disorders. Kaolin was injected into the cistern magna of male adult New Zealand rabbits to establish a hydrocephalus animal model. Memantine (20 mg/kg, intraperitoneally; memantine-treated group) or noni (5 mL/kg, intragastrically; noni-treated group) was administered daily for 2 weeks. Microtubule-associated protein-2 and caspase-3 immunohistochemistry were performed to detect neuronal degeneration and apoptosis in the periventricular tissue of the fourth ventricle of rabbits. Microtubule-associated protein-2 staining density was significantly decreased in the hydrocephalic group, while the staining density was significantly increased in the memantine- and noni-treated groups, especially in the noni-treated group. Noni treatment decreased the number of caspase-3-positive cells in rabbits with hydrocephalus, while memantine had no effect. These findings suggest that noni exhibits more obvious inhibitory effects on hydrocephalus-induced neurodegenerative disorders than memantine in periventricular tissue of the fourth ventricle.

Effects of various agro-industrial residues on soil fertility and yield and quality of potatoes

Nine combinations of production residues of agro-industries, urban wastes and mineral fertilizers were applied to potatoes (Solanum tuberosum var. Marabel) in a field experiment, and the effect of these combinations on soil characteristics, on yield and on various quality parameters of tubers were determined. The applications significantly affected soil pH, CaCO3 and organic matter content. Total N and available P and K levels of soils showed significant differences between the applications. The content of available Zn and Mn in the soil differed significantly between the applications. Sufficient levels of N, P and K were not attained in leaves in any application. Significant differences were observed between the P content of the leaves of the control and of the other applications. Potassium and Na content of the leaves showed significant variations between the applications. Manganese was at a statistically higher level in the leaves of some combinations. The nitrogen, P and Mn contents of tubers differed significantly between the applications. Phosphorus, K, Mg and Cu levels were found to be sufficient, but Fe, Zn and Mn were low in tubers. Tuber yield was statistically highest in the Wastes P + Mineral NK combination. Reduced sugar and protein content of the tubers was affected significantly by the applications. Significant correlations were found between soil, leaf and tubers.

Initial mini-mental state and cerebral perfusion in Alzheimer's disease

PURPOSE

The relationship between the initial mini-mental state examination (MMSE) score and cerebral perfusion was evaluated in patients with Alzheimer's disease (AD).

METHODS

In the study single photon emission computed tomography (SPECT) images of the brains of 40 AD patients were compared with the brain scans of 10 healthy controls. Each patient underwent MMSE analysis at initial evaluation as well as Tc-99 m hexamethylpropyleneamine oxine (HMPAO) brain SPECT. The patients were followed up for at least 42 months.

RESULTS

The regional cerebral blood flow (rCBF) values for patients were found to be significantly decreased for all cerebral lobes compared to the control subjects and p-values were calculated to be less than 0.001 except for occipital lobes. The most statistically significant correlation between the MMSE scores and rCBF values was determined for the left temporal lobe (p < 0.0001). A significant correlation was also found for the right temporal lobe (p < 0.005). A minimal statistically significant correlation was found for the frontal lobes and the left parietal lobe (p < 0.05).

CONCLUSIONS

The overall cerebral perfusion was decreased except in the occipital lobes in AD cases with low initial MMSE scores and there was a significant relationship between the decrease in perfusion of the temporal/frontal lobes and the left parietal lobe with the decrease in the initial MMSE scores. The most significant relationship between the decrease in the initial MMSE scores and the rCBF values was determined for the temporal lobes (especially for the left temporal lobe). It was also found that the left frontal lobe was affected from the beginning of the disease.

Membranous structures affecting the success of endoscopic third ventriculostomy in adult aqueductus sylvii stenosis

BACKGROUND

The purpose of the present study was to observe Liliequist's membrane (LM) and membranous structures located in the prepontine cistern via 3-Tesla magnetic resonance imaging (MRI) with 3D driven equilibrium radio frequency reset pulse (DRIVE) sequence and multiplanar reformat (MPR) images and to evaluate the success of endoscopic third ventriculostomy (ETV) by assessing these membranes in adult aqueduct stenosis.

PATIENTS

29 patients (17 female, 12 male) with primary aqueductus sylvii stenosis were included in the study. 19 patients were diagnosed as long-standing overt ventriculomegaly in adults (LOVA) and patients had severe ventriculomegaly, macrocephalus, and aqueduct stenosis on MR imaging. 10 patients were diagnosed as aqueduct stenosis presented with acute onset of hydrocephalus with symptoms of raised ICP. All patients in the study group were analyzed with conventional and cine MRI before and after treatment. We performed 3D DRIVE sequence and MPR at 3-T MR equipment to determine the membranous structures in 3 dimensions. We correlated the success of the procedure considering the preoperative, postoperative MRI and intraoperative images.

RESULTS

5 patients (26.3%) with LOVA and 2 patients (20%) with aqueduct stenosis, in total 7 patients (24.1%), did not respond to ETV. Cerebrospinal fluid (CSF) flow was blocked by membranous structures located in the prepontine cistern in 4 of 8 patients. In 2 patients, CSF through the stoma was blocked either by the LM or closed tuber cinerum. In 1 patient insufficient CSF flow was observed through the stoma and the LM accompanying prepontine membranes.Totally closed membranes were observed in the prepontine cistern in 5 patients (17.24%) according to the postoperative MRI. LM was verified in all patients intraoperatively that were also demonstrated in the preoperative MRI.

CONCLUSION

3D sequences with MPR may help to observe not only the LM but also other membranes located through the prepontine cistern, which may be the reason of failed ETV.

Diagnostic value of liquid-based (Liqui-PREP) preparations and interobserver reproducibility in fine needle aspiration cytology of the nodular thyroid lesions

The aim of this study is to define the diagnostic role of Liqui-Prep (LP) technique for the diagnosis of thyroid lesions and to assess interobserver variabilities. In all, 98 thyroid FNA (fine needle aspiration) cytology samples from 83 patients for preoperative evaluation of thyroid nodules, prepared by the LP, were examined. The LP slides were independently evaluated by three pathologists and they were classified into the five categories according to the Bethesda system. The histopathologic diagnoses were grouped as follows: benign, follicular neoplasm, and malignant. Agreements between LP and histopathologic diagnoses were investigated using kappa values. Marginal homogenity and kappa tests were used for statistical analysis for the evaluation of the agreement between the pathologists and the interobserver variability of the thyroid aspiration cytology results. The presence of nucleoli, nuclear grooving, overlapping, intranuclear inclusion, and nuclear irregularity were recorded and scored on each case based on LP slide review. Concurrences between LP and the histologic diagnoses for the three pathologists were almost perfect (k = 0.798; k = 0.826; k = 0.880). When the observers were paired there was no significant difference from the diagnostic point of view. Interobserver agreement among the three pathologists was moderate. Initially diagnostic difficulties may occur because of the inadequate experience of the pathologists concerning the evaluation of the cytologic changes associated with this new technique. Liqui-Prep technique is useful for the cytologic diagnosis of the thyroid nodules. The nuclear irregularity was the most essential feature for the differentiation of malignant lesions from follicular neoplasm by the LP method.

Massive intracerebral haemorrage due to developmental venous anomaly

In cases of intracerebral haematoma associated with developmental venous anomalies (DVAs), there is usually an associated cavernoma, which is thought to be the source of haemorrhage. Only a few cases have been reported in the literature where an intracerebral haemotoma has been caused by a DVA without an associated cavernoma. In this report we describe a case with a massive haematoma due to venous angioma alone.

Endoscopic optic nerve decompression for idiopathic intracranial hypertension in two cases: case report

Pseudotumor cerebri is a syndrome with headaches and visual loss that sometimes cannot be treated with medication. In spite of medical treatment, the clinical course in some patients can approach extreme dysfunction with severe impairment in visual field and acuity as well as incapacitating headache. Patients with progressive or persistent symptoms require surgical treatment and decompression of the optic nerve is the preferred surgical procedure. We report on two cases of bilateral decompression of the optic nerves performed through an endonasal endoscopic approach.

Fluorescein sodium-guided surgery in glioblastoma multiforme: a prospective evaluation

We have evaluated the influence of fluorescein-guided resection on gross total resection (GTR) and survival in a series of patients with GBM. Group 1 consisted of 47 patients given fluorescein and group 2 comprised 33 patients, on whom fluorescein was not used. Median survival time was 43.9 weeks in the patients given fluorescein and was 41.8 weeks in the non-fluorescein group. There was no statistically significant difference in survival between the two groups. However, the extent of resection had a powerful influence on the median survival time. Survival was 34.3 weeks after partial resection and 46.5 after GTR. Our data shows that the use of fluorescein injection is a simple procedure, which allows a significant increase in the number of patients having GTR (83 vs. 55%). Our findings are similar to a recently published multicentre Phase III randomized trial in which 5-aminolevulinic acid was used to facilitate resection of malignant glioma.

[Antimicrobial resistance profiles of community-acquired uropathogenic Escherichia coli isolates during 2004-2006 in a training hospital in Istanbul]

In order to reveal the antimicrobial resistance profiles against first-line antimicrobial agents in community-acquired acute uncomplicated urinary tract infections (UTIs), resistance patterns were determined for 1664 Escherichia coli strains collected between 2004 and 2006 in GATA Haydarpasa Training Hospital, Istanbul, Turkey. Of the isolates 38.2% were found to be susceptible to all of the tested antimicrobial agents, while the resistance rate to single antibiotic was 13.5%. Highest prevalence of antimicrobial resistance was observed for ampicillin (AMP) (49%), followed by amoxycillin-clavulanic acid (AMC) (34%), sulphamethoxazole/trimethoprim (SXT) (34%) and ciprofloxacin (CIP) (18%). The rate of multidrug resistant isolates was 33.5% and 48.4% of them were co-resistant. Resistance against two antimicrobials was identified in 244, against three antimicrobials in 205, against four antimicrobials in 160, against five antimicrobials in 63 and against six antimicrobials in 23 strains. Most frequent phenotypes indicating resistance against two, three and four antimicrobial agents were AMP/AMC (5.7%), AMP/AMC/SXT (5.4%) and AMP/AMC/cephazolin/SXT (2.6%), respectively. Extended spectrum beta-lactamase (ESBL) activity was detected in 40 (2.4%) of the isolates. Most prominent increases in resistance prevalence during the study period were observed for AMP (from 52% to 63%), AMC (from 33% to 45%) and CIP (from 15% to 22%). These results show that resistance to AMP, AMC and SXT are frequent in community-acquired E. coli strains and empirical initial treatment with these agents will most probably be inappropriate in our region.

Arteriovenous malformation associated with multiple aneurysms including anterior communicating artery aneurysm located in the third ventricle: a case report

Following the significant advances in neuroradiology, it has been now recognized that an intracranial arteriovenous malformation (AVM) lesion and vascular aneurysm(s) might coexist more often than estimated before. A58-yearold female seen due to a subarachnoid hemorrhage (SAH) was subsequently shown to have an AVM lesion fed by the pericallosal frontopolar, M1 segment of the middle cerebral artery along with three cerebral aneurysms. The AVM lesion was totally excised and the coexisting aneurysms were successfully clipped. As a very rare finding, one of the aneurysms originating from the Anterior Communicating Artery was localized in the 3rd ventricle penetrating the lamina terminalis.

Familial syringomyelia in two siblings: case report

We report on syringomyelia of the thoracic spinal cord in two sisters without a Chiari or any other malformation. In both cases syringomyelia was determined by magnetic resonance imaging (MRI). Spinal MRI showed a syringomyelia between T6-T8 levels in the first sibling and between T7- T9 in the second sibling. The cranio-cervical junction was normal and tonsiller ectopia was not present. Neurological examination of both sisters was normal. They did not undergo surgery as they had mild symptoms without neurological deficit and the size of the syrinx was small. Familial syringomyelia is a very rare finding and extremely rare at only the thoracic level. Genetic and environmental factors seem to be involved in familial syringomyelia.

Chiari 1 malformation with syringomyelia: correlation of phase-contrast cine MR imaging and outcome

AIM

This study was designed to determine the hemodynamics of cerebrospinal fluid flow in syringomyelia patients associated with Chiari I malformation using phase-contrast velocity-encoded-cine MRI and also to find out whether treatment outcomes may be predicted by these flow measurements.

MATERIAL AND METHODS

Eighteen consecutive symptomatic patients with syringomyelia associated with Chiari 1 malformation were included. The PC VEC MRI was performed at the level of foramen magnum and syrinx cavity both preoperatively and 6 months postoperatively. Following surgery, the modified Asgari score was calculated, and the association between CSF flow pattern and clinical outcome was assessed.

RESULTS

Evaluation of clinical symptoms at postoperative 6th month revealed improvement in 11 (61%) patients and stabilization in 5 (28%) patients whereas results were poor in 2 (11%) patients. Preoperative cine MRI flow studies showed a heterogeneous pattern at the foramen magnum level in all of the patients. Postoperative cine MR flow studies demonstrated the change from heterogeneous pattern to sinusoidal pattern in 11 patients and a decrease in heterogeneity in 7 patients.

CONCLUSION

Our results indicate that CSF flow measurements using PC VEC MRI can give important information regarding the prognosis and follow-up of the patients with Chiari I malformation.

Primary Cranial Vault Lymphoma Presenting As a Traumatic Subdural Hematoma

OBJECTIVE AND IMPORTANCE

The authors present a rare case of a primary cranial vault lymphoma, mimicking a subacute subdural hematoma after head trauma.

CLINICAL PRESENTATION

A 78-year-old woman was admitted to the hospital with progressive left hemiparesis, headache and a gradually increasing soft lump over the right parietal region 1 week after head trauma due to falling from a high place. A computed tomography (CT) scan demonstrated a hyperdense parieto-occipital subdural and subgaleal lesion together with marked midline shift and white matter edema.

INTERVENTION

Considering her trauma story and clinical progression, the patient underwent an emergency operation with the diagnosis of subdural hematoma. However, the lesion was found to be of a tumors nature and the histopathological diagnosis was high-grade malignant non-Hodgkin's lymphoma.

CONCLUSION

The authors emphasize the rarity of primary cranial vault lymphoma and its importance in the differential diagnosis of cranial vault mass lesions extending either intra- or extracranially. This case may be considered as another example where magnetic resonance imaging (MRI) is the ultimate definitive test in the emergency ward whenever CT demonstrates any findings which are unclear.

Abnormal bony protuberance of anterior atlas causing dysphagia. A rare congenital anomaly

STUDY DESIGN

A Case report.

OBJECTIVE

To report an exceedingly rare case of dysphagia caused by abnormal bony protuberance of anterior atlas.

SETTING

Kocaeli University Faculty of Medicine, Departments of Neurosurgery and Otorhinolaryngology.

METHOD

Radiological examinations revealed a large anterior abnormal bony tuberance of atlas in an 11-year-old boy who complained of dysphagia of 5 years donation.

RESULT

The anterior bony tuberance of the atlas was resected by a transoral approach. Histopathological examination of the surgical specimens showed normal bone tissue. Resection resulted in complete resolution of the dysphagia.

CONCLUSIONS

Dysphagia can be caused by disorders of the cervical spine. These disorders are usually seen in elderly adults. In the pediatric population, spinal abnormality is an exceedingly rare cause of dysphagia. Abnormal inductive signals from the adjacent notocord and ventral neural tube may play role in the pathogenesis of this abnormal bony protuberance.

Association of spondylocostal dysostosis and type I split cord malformation

In reports on children with congenital segmental costovertebral malformations who showed neural tube defects, cases with type I split cord malformation are quite rare. Up to now such association has been reported only in two cases with Jarcho-Levin syndrome. Here, a 7-year-old girl presenting with spondylocostal dysostosis and type I split cord malformation is reported. To the best of our knowledge, this is the first case documented in the literature. The association of segmental costovertebral malformations and neural tube defects is discussed. Genetic and embryological studies are also briefly reviewed.

Comparison of skin tests to aeroallergens in Ankara and Seoul

BACKGROUND

The environment contains many allergenic proteins, and skin test reactivity to aeroallergens may be different among people living in different regions.

OBJECTIVE

To compare skin test results of Turkish and Korean patients with respiratory allergies.

METHODS

The charts of 304 (160 male, 144 female) patients from Ankara, Turkey, and 208 (111 male, 97 female) patients' charts from Seoul, Korea, who had undergone skin prick tests were reviewed. Skin tests were classified as positive when the allergen-induced wheal size was the same size or larger than that caused by histamine.

RESULTS

Grass pollens were found to be major allergens more often in Ankara than in Seoul (74.34% vs. 15.87%, p < 0.001). Skin test reactivities in Ankara were significantly lower (p < 0.001) than in Seoul to weed (6.91% vs. 37.50%) and tree pollens (4.61% vs. 39.42%). Allergic reactions to indoor allergens were significantly higher (p < 0.001) in Seoul than in Ankara: house dust mites (HDM) (83.17% vs. 32.90%), cockroaches (45.67% vs. 1.97%), and cats (17.79% vs. 1.65%).

CONCLUSION

Due to the different aeroallergen environment, the positive skin test results were different in both cities: grass pollens were the most common allergens in Ankara, while patients from Seoul reacted more commonly to indoor allergens, especially to HDMs and cockroaches.