An alternative technique for pituitary tumour removal: Sequential endoscopic-microscopic pituitary procedure (SEMPP).

Several authors have reported advantages of the purely endoscopic (PE) approach over traditional purely microscopic (PM) techniques for many sinus and anterior skull base procedures. However, in pituitary surgery, the PE approach carries a number of limitations. Experienced microscopically-trained neurosurgeons are required to master the endoscopic technique which has a steep learning curve due to its one-handed nature and optically-distorted 2-dimensional view. We describe our novel technique, the sequential endoscopic and microscopic pituitary procedure (SEMPP) which does not require microscopically-trained neurosurgeons to alter their technique. We compare SEMPP with the PE approach in terms of outcome and safety. Retrospective chart review of consecutive SEMPP cases performed at our institution between January 2010 and December 2013 was conducted. Operative time, gross total resection rate, resolution of endocrine and visual dysfunction, hospital length of stay, cerebrospinal fluid (CSF) leak rate and revision rates were recorded. 32 patients were identified (50% female, mean age 53.0 years), and 33 SEMPP cases. Mean operating time was 132 min (range 90-200). 69% of patients experienced gross total resection. Most patients (81.3%) with preoperative visual deficit either experienced complete resolution or improved symptoms. The remainder experienced no change in vision. 12.5% (n = 4) of patients experienced intraoperative CSF leaks. All were repaired intraoperatively or with conservative management. Two patients (6.3%) experienced epistaxis managed with conservative measures. The SEMPP technique demonstrates comparable outcomes, complication rates and operative time to PE and PM techniques described in the literature.

Nasolacrimal Sac Diverticulum: A Case Series and Literature Review.

PURPOSE: To describe the demographics, presentation, treatment, and outcome in 10 cases of lacrimal sac diverticulum and to review the literature on this topic, and to determine the incidence of diverticula from a series of dacryocystograms. METHODS: Data were collected for all consecutive patients with lacrimal sac diverticulum seen between 2003 and 2015, including patient demographics, clinical presentation, imaging findings, treatment, and follow-up. A systematic literature review was performed for cases of lacrimal sac diverticulum. A retrospective review of 400 consecutive dacryocystograms was performed to determine the incidence of lacrimal sac diverticulum. RESULTS: Ten cases (9 patients) of lacrimal sac diverticulum are described, and a further 36 cases were discovered through a literature review. Epiphora, swelling, and dacryocystitis and/or diverticulitis were the most common presenting complaints. When all 46 cases are combined, lacrimal patency was demonstrated in 50% of cases. Dacryocystography diagnosed only 57% of patients with diverticulum, not helped by the addition of ultrasound or CT. The incidence of diverticulum was 3.2% on review of 400 consecutive dacryocystograms (1.6% per lacrimal system). Surgical management with dacryocystorhinostomy and/or diverticulum excision was effective in all 34 operated cases at resolving symptoms in the case series and literature review. CONCLUSIONS: Lacrimal sac diverticula present with epiphora, medial canthal swelling, dacryocystitis, and/or diverticulitis. Dacryocystography, despite being the most sensitive radiologic test, is only 59% sensitive, and adjunctive CT and ultrasound have limited use. Surgical management is recommended because conservative management often fails. Dacryocystorhinostomy, diverticulum excision, or a combination thereof appears to be equivalent in achieving resolution of symptoms.

"Silent Sinus Syndrome" Following Orbital Trauma: A Case Series and Review of the Literature.

PURPOSE: To describe the demographics, presentation, and treatment of "silent sinus syndrome" (SSS) diagnosed following orbital trauma and review the literature on this topic. METHODS: A retrospective review of 6 consecutive cases of SSS following trauma seen by the authors from 2004 to 2015. Data collected included patient demographics, details of previous trauma, clinical presentation, imaging findings, surgery performed, outcome, and follow up. RESULTS: Six patients were identified presenting with SSS following orbital floor fracture. All cases developed progressive enophthalmos due to maxillary sinus atelectasis on average 8 months after their initial trauma (range, 3-16 months). The appearance of the maxillary sinus on CT was indistinguishable from the changes seen in spontaneous SSS. All 6 patients had surgical repair, which included maxillary sinus reventilation and surgery to build up the orbital floor and correct the enophthalmos in 4 patients, maxillary sinus reventilation surgery only in 1 patient and surgery to build up the orbital floor only in 1 patient. There was a reduction of enophthalmos and globe dystopia in all cases with no significant complications. CONCLUSIONS: Changes in the maxillary sinus after orbital floor fracture may occur in the months following the initial trauma and the changes are indistinguishable from those seen in spontaneous SSS. The mechanism is presumed to be obstruction of the natural ostium of the maxillary sinus, accumulation of secretions and the development of negative pressure within the sinus leading to its collapse.

Ethmoid Silent Sinus Syndrome Following Orbital Trauma.

A 55-year-old man presented with progressive "enophthalmos" of his ocular prosthesis, 12 years after secondary orbital implant placement following evisceration of a severe traumatic globe rupture. The medial orbital wall was found to be displaced inwards, associated with ethmoid sinus opacification, and consistent with post traumatic silent sinus syndrome affecting the ethmoid paranasal sinuses. The authors present the clinical and radiological findings, review the literature on silent sinus syndrome of nonmaxillary sinuses, and discuss the possible mechanisms for his presentation.

Spatial learning deficits in Parkinson's disease with and without mild cognitive impairment.

BACKGROUND: Several MRI studies have demonstrated hippocampal atrophy in Parkinson's disease (PD), a structure considered a key element in spatial learning. Despite this, no study has been undertaken to investigate spatial navigation in PD using a virtual version of the Morris water maze, which is the gold standard for testing hippocampal function in rodents. METHODS: We studied 17 cognitively unimpaired PD patients, 12 PD patients with mild cognitive impairment (MCI) and 15 controls in a virtual water maze procedure. RESULTS: Measured by the main outcome parameters latency to locate the target and heading error (average difference between direction of movement toward anticipated target and real direction toward the target), controls performed significantly better on the virtual water maze task than cognitively unimpaired PD patients or PD patients with MCI, while there was no significant difference between latter two groups. CONCLUSIONS: The virtual water maze test differentiates PD patients from controls, but does not distinguish between cognitively normal and cognitively impaired PD patients, indicating a possible dopamine dependent component in spatial learning. Spatial performance deficits might thus constitute very early signs of dopamine depletion independent of the presence of MCI in Parkinson's disease.

Four-dimensional computed tomography for parathyroid localization: a new imaging modality.

INTRODUCTION: Four-dimensional computed tomography (4DCT) is a new parathyroid localization technique not previously reported in Australia. It provides both functional and anatomical imaging in a single test, with superior sensitivity compared with sestamibi scintigraphy (SeS). This study examines the utility of 4DCT in defined clinical situations. METHODS: This is a retrospective cohort study in a tertiary referral hospital setting. One hundred consecutive operative cases of primary hyperparathyroidism (99 patients) undergoing both preoperative 4DCT and SeS. Localization studies were correlated with operative findings, histopathology and clinical outcomes. The utility of 4DCT was analysed in three common clinical settings: primary cases with positive SeS (Group A, n = 68), primary cases with negative SeS (Group B, n = 21) and re-operative cases (Group C, n = 11). RESULTS: The overall sensitivity of 4DCT was 92% compared with 70% for SeS. The sensitivity of 4DCT was superior to SeS in Groups B and C (76% versus 0% and 91% versus 46%, respectively). The overall cure rate was 98%, with 94% of cases completed as minimally invasive procedures. Up to 62% of Group B cases potentially avoided a bilateral neck exploration owing to a positive 4DCT. CONCLUSIONS: 4DCT is an accurate technique providing both functional and anatomical localization of abnormal parathyroid glands. However, the advantage of speed and simplicity in image acquisition needs to be balanced against the small risk of increased radiation exposure in the younger patient group.

Levodopa therapy in Parkinson's disease: influence on liquid chromatographic tandem mass spectrometric-based measurements of plasma and urinary normetanephrine, metanephrine and methoxytyramine.

BACKGROUND: Medication-related interferences with measurements of catecholamines and their metabolites represent important causes of false-positive results during diagnosis of phaeochromocytomas and paragangliomas (PPGLs). Such interferences are less troublesome with measurements by liquid chromatography with tandem mass-spectrometry (LC-MS/MS) than by other methods, but can still present problems for some drugs. Levodopa, the precursor for dopamine used in the treatment of Parkinson's disease, represents one potentially interfering medication. METHODS: Plasma and urine samples, obtained from 20 Parkinsonian patients receiving levodopa, were analysed for concentrations of catecholamines and their O-methylated metabolites by LC-MS/MS. Results were compared with those from a group of 120 age-matched subjects and 18 patients with PPGLs. RESULTS: Plasma and urinary free and deconjugated (free + conjugated) methoxytyramine, as well as urinary dopamine, showed 22- to 148-fold higher (P < 0.0001) concentrations in patients receiving levodopa than in the reference group. In contrast, plasma normetanephrine, urinary noradrenaline and urinary free and deconjugated normetanephrine concentrations were unaffected. Plasma free metanephrine, urinary adrenaline and urinary free and deconjugated metanephrine all showed higher (P < 0.05) concentrations in Parkinsonian patients than the reference group, but this was only a problem for adrenaline. Similar to normetanephrine, plasma and urinary metanephrine remained below the 97.5 percentiles of the reference group in almost all Parkinsonian patients. CONCLUSIONS: These data establish that although levodopa treatment confounds identification of PPGLs that produce dopamine, the therapy is not a problem for use of LC-MS/MS measurements of plasma and urinary normetanephrine and metanephrine to diagnose more commonly encountered PPGLs that produce noradrenaline or adrenaline.

WHO IS 'BEHAVIORAL'? COGNITIVE ABILITY AND ANOMALOUS PREFERENCES.

In this paper, we ask whether variation in preference anomalies is related to variation in cognitive ability. Evidence from a new laboratory study of Chilean high-school students with similar schooling backgrounds shows that small-stakes risk aversion and short-run discounting are less common among those with higher standardized test scores. The relationship with test scores survives controls for parental education and wealth. We find some evidence that elementary-school GPA is predictive of preferences measured at the end of high school. Two laboratory interventions provide suggestive evidence of a possible causal impact of cognitive resources on expressed preferences. (JEL: J24, D14, C91).

A molecular assay for sensitive detection of pathogen-specific T-cells.

Here we describe the development and validation of a highly sensitive assay of antigen-specific IFN-γ production using real time quantitative PCR (qPCR) for two reporters--monokine-induced by IFN-γ (MIG) and the IFN-γ inducible protein-10 (IP10). We developed and validated the assay and applied it to the detection of CMV, HIV and Mycobacterium tuberculosis (MTB) specific responses, in a cohort of HIV co-infected patients. We compared the sensitivity of this assay to that of the ex vivo RD1 (ESAT-6 and CFP-10)-specific IFN-γ Elispot assay. We observed a clear quantitative correlation between the two assays (P<0.001). Our assay proved to be a sensitive assay for the detection of MTB-specific T cells, could be performed on whole blood samples of fingerprick (50 uL) volumes, and was not affected by HIV-mediated immunosuppression. This assay platform is potentially of utility in diagnosis of infection in this and other clinical settings.

Repulsive guidance molecule-A (RGM-A) inhibits leukocyte migration and mitigates inflammation.

Directed cell migration is a prerequisite not only for the development of the central nervous system, but also for topically restricted, appropriate immune responses. This is crucial for host defense and immune surveillance. Attracting environmental cues guiding leukocyte cell traffic are likely to be complemented by repulsive cues, which actively abolish cell migration. One such a paradigm exists in the developing nervous system, where neuronal migration and axonal path finding is balanced by chemoattractive and chemorepulsive cues, such as the neuronal repulsive guidance molecule-A (RGM-A). As expressed at the inflammatory site, the role of RGM-A within the immune response remains unclear. Here we report that RGM-A (i) is expressed by epithelium and leukocytes (granulocytes, monocytes, and T/B lymphocytes); (ii) inhibits leukocyte migration by contact repulsion and chemorepulsion, depending on dosage, through its receptor neogenin; and (iii) suppresses the inflammatory response in a model of zymosan-A-induced peritonitis. Systemic application of RGM-A attenuates the humoral proinflammatory response (TNF-α, IL-6, and macrophage inflammatory protein 1α), infiltration of inflammatory cell traffic, and edema formation. In contrast, the demonstrated anti-inflammatory effect of RGM-A is absent in mice homozygous for a gene trap mutation in the neo1 locus (encoding neogenin). Thus, our results suggest that RGM-A is a unique endogenous inhibitor of leukocyte chemotaxis that limits inflammatory leukocyte traffic and creates opportunities to better understand and treat pathologies caused by exacerbated or misdirected inflammatory responses.

Parathyroid carcinoma: increasing incidence and changing presentation.

BACKGROUND: Parathyroid carcinoma has been regarded as an exceedingly rare disease worldwide, responsible for less than 1% of cases of primary hyperparathyroidism. However, there have been anecdotal reports recently of an increasing number of patients presenting with parathyroid carcinoma. The aim of this study was to examine the changing incidence and presentation of parathyroid cancer within a single centre. PATIENTS AND METHODS: This is a retrospective case series. Data were obtained from the University of Sydney Endocrine Surgical Unit database, as well as a review of hospital records. All pathology was independently reviewed. RESULTS: Over the 52-year period of the study from 1958 to 2010, there were 21 cases of confirmed parathyroid cancer. Only three cases were reported in the first 30 years of the study with the majority of cases (n = 11) presenting in the last 5 years. Despite the exponential increase in presentations, no significant differences in demographics or mode of presentation were found. CONCLUSION: Possible reasons for the dramatic increase in parathyroid cancer include increased screening, an increase in referrals for parathyroid surgery overall associated with the availability of minimally invasive techniques, changes in diagnostic techniques with immunohistochemistry for parafibromin and protein gene product 9.5 (PGP9.5) or possibly a true increase in the incidence of the disease.

Effects of temperature-induced variation in anuran larval growth rate on head width and leg length at metamorphosis.

We tested whether temperature-induced variation in the growth rate of Rana cascadae tadpoles caused any variation in head width or leg length at metamorphosis, independent of the effects of temperature on body size. Body-size-adjusted head width appears to be insensitive to even large variations in tadpole growth rate. This result mirrors previous observations on the effects of variation in food level and temperature on metric shape in frogs and other ectothermic vertebrates. Leg length, on the other hand, showed a small but statistically significant response to the temperature treatment. Fast-growing tadpoles attained slightly longer legs than slowly growing tadpoles at a common metamorphic body size. This example is the first to show that variation in growth rate per se can influence metric shape (i.e., the rate at which individuals reach a common body size determines their shape at that size). Nevertheless, the induced effects were small, and our results taken together with those of previous studies suggest that environmentally induced variation in growth rate is not a major source of variation in metric shape of skeletal characters in ectothermic vertebrates.