Treatment of Nonfunctional Pituitary Adenoma Postoperative Remnants: Adjuvant or Delayed Gamma Knife Radiosurgery?

OBJECTIVE: It is still not clear whether Gamma Knife radiosurgery (GKRS) for nonfunctional pituitary adenomas should be used as a standard adjuvant postoperative therapy or applied when there is documented progression of the remnant on follow-up magnetic resonance imaging. METHODS: We performed a retrospective study of patients with nonfunctional pituitary adenomas who underwent primary surgery and GKRS between 2002 and 2015. Patients were divided into 2 groups on the basis of the GKRS indication: adjuvant treatment (GKRS ≤6 months postoperatively) or delayed treatment (GKRS if documented progression occurred on the follow-up magnetic resonance imaging). RESULTS: Fifty patients were included and grouped based on adjuvant (n = 13) or delayed (n = 37) GKRS following primary surgery. The adjuvant and delayed groups had 10-year actuarial tumor control rates of 92% and 96% (P = 0.408), respectively. The 10-year actuarial endocrinologic control rate was 82% for the adjuvant group and 49% for the delayed group (P = 0.597). None of the patients developed any new neurologic deficit post-GKRS. GKRS-induced complications (intratumoral bleeding and tumoral tissue inflammation) occurred in 6% of the patients, of whom 4% were in the delayed group and 2% in the adjuvant group. CONCLUSION: Adjuvant treatment with GKRS yields the same high long-term tumor control as delayed GKRS. Neither adjuvant nor delayed GKRS induced additional neurologic complications. There is a trend that adjuvant GKRS induces less additional endocrinologic deficits compared with delayed GKRS.

[Diagnostic image (278). A confused man with a cough]. / Diagnose in beeld (278). Een verwarde man met hoestklachten.

A 69-year-old man with confusion and a subdural haematoma presented with a cough and a radiopaque lesion was visible on chest X-ray. Bronchoscopy revealed a push pin, which was removed successfully using a rigid bronchoscope.

The ventral striatum in off-line processing: ensemble reactivation during sleep and modulation by hippocampal ripples.

Previously it has been shown that the hippocampus and neocortex can spontaneously reactivate ensemble activity patterns during post-behavioral sleep and rest periods. Here we examined whether such reactivation also occurs in a subcortical structure, the ventral striatum, which receives a direct input from the hippocampal formation and has been implicated in guidance of consummatory and conditioned behaviors. During a reward-searching task on a T-maze, flanked by sleep and rest periods, parallel recordings were made from ventral striatal ensembles while EEG signals were derived from the hippocampus. Statistical measures indicated a significant amount of reactivation in the ventral striatum. In line with hippocampal data, reactivation was especially prominent during post-behavioral slow-wave sleep, but unlike the hippocampus, no decay in pattern recurrence was visible in the ventral striatum across the first 40 min of post-behavioral rest. We next studied the relationship between ensemble firing patterns in ventral striatum and hippocampal ripples-sharp waves, which have been implicated in pattern replay. Firing rates were significantly modulated in close temporal association with hippocampal ripples in 25% of the units, showing a marked transient enhancement in the average response profile. Strikingly, ripple-modulated neurons in ventral striatum showed a clear reactivation, whereas nonmodulated cells did not. These data suggest, first, the occurrence of pattern replay in a subcortical structure implied in the processing and prediction of reward and, second, a functional linkage between ventral striatal reactivation and a specific type of high-frequency population activity associated with hippocampal replay.

Applicability of surface-enhanced resonance Raman scattering for the direct discrimination of ballpoint pen inks.

In situ surface-enhanced resonance Raman spectroscopy (SERRS) with excitation at 685 nm is suitable for the direct discrimination of blue and black ballpoint pen inks on paper. For black inks, shorter excitation wavelengths can also be used. For blue inks, SERRS at 514.5 and 457.9 nm does not provide adequate discriminative power. At these excitation wavelengths, the SERRS signals of the Methyl Violet derivatives present in inks easily dominate the overall spectrum because of resonance enhancement and preferential interaction with silver sol particles. At 685 nm, this problem is not encountered as the Methyl Violet derivatives do not show resonance enhancement, while other components may still exhibit resonance. Thirteen blue and thirteen black ink lines were examined. For the blue and black inks, on the basis of the 685 nm SERR spectra, eight and six groups of spectra, respectively, could be distinguished. This discrimination largely agrees with information from thin layer chromatography (TLC) experiments, although some differences in group compositions are found. The in situ SERR spectra show good repeatability with regard to the Raman frequencies, band shapes and relative intensities of the spectral bands. However, absolute intensities cannot be used for discrimination purposes.

Ultrastructure of the endolymphatic sac in two-phase endolymphatic hydrops in the guinea pig.

Two-phase endolymphatic hydrops is a subtle experimental model for Meniere's disease. Chronic dysfunction of the endolymphatic sac, induced by dissection of the most distal part without causing damage to the intermediate part, is combined with increased endolymph production induced by administration of aldosterone which stimulates the N/K-ATPase in the stria vascularis. A transmission electron microscopic study was performed on the endolymphatic sacs of four groups of guinea pig cochleas: controls: non-operated aldosterone-treated cochleas; operated (dissection of the endolymphatic sac) cochleas; operated and aldosterone-treated cochleas. Light and electron microscopy showed a normal morphology in the controls. Aldosterone treatment had no visible effect. Dissected ears revealed severe deviations. The epithelium of the intermediate sac was low, showed dilated lateral intercellular spaces indicating elevated fluid transport and displayed serious degenerative processes. Distally, the endolymphatic sac was completely blocked by newly formed bone. Additional aldosterone treatment had no cumulative effect on the dissected ears.

Regeneration of full-thickness wounds using collagen split grafts.

Collagen-based skin substitutes are among the most promising materials to improve regeneration of full-thickness wounds. However, additional meshed grafts or cultured epidermal grafts are still required to create epidermal regeneration. To avoid this, we substituted collagen-based split grafts, i.e., grafts with a separated top and bottom layer, in a rat full-thickness wound model and compared regeneration with nontreated, open control wounds. We hypothesized that epidermal regeneration would occur in the split in between the two layers, with the top layer functioning as a clot/scab and the bottom layer as a dermal substitute. Two types of dermal sheep collagen (DSC) split grafts were tested: one with a top layer of noncrosslinked DSC (NDSC) and bottom layer of hexamethylenediisocyanate crosslinked DSC (HDSC), further called N/HDSC; and the second with both a top and bottom layer of HDSC (H/HDSC). With the N/HDSC split graft NDSC did not function as a sponge for formed exudate and as a consequence the split was not longer available to facilitate epidermal regeneration. In contrast, with the H/HDSC graft the split facilitated proliferation and differentiation of the epidermal cells in the proper way. With this graft, clot formation was restricted to the top layer, which was rejected after 8 weeks, while the bottom layer functioned during gradual degradation as a temporary matrix for the formation of autologous dermal tissue. H/HDSC strongly inhibited infiltration of myofibroblasts, resulting in a 30% wound contraction, while a 100% contraction was found with the open control wound. The results show that H/HDSC split-grafts function conforms to the hypothesis in regeneration of large, full-thickness wounds without further addition of seeded cells or use of meshed autografts.

Early evolution and recovery from excitotoxic injury in the neonatal rat brain: a study combining magnetic resonance imaging, electrical impedance, and histology.

We explored the therapeutic potentials of two N-methyl-D-aspartate (NMDA) receptor antagonists in vivo using different techniques. NMDA injected into the striatum of neonatal rats (20 nmol/0.5 microliters) induced a rapid increase in the diffusion-weighted (DW) image intensity, spreading over a large part of the ipsilateral hemisphere. Subcutaneous injection of the NMDA receptor antagonist MK-801 (1 mg/kg) or D-(E)-4-(3-phosphono-2-prop-enyl)-2-piperazine-carboxylic acid (D-CPPene; 1.5 mg/kg) reversed both the volume and the grading of the NMDA-induced hyperintensity of DW images, the reversal by MK-801 being more rapid than that by D-CPPene. In the cerebral cortex, there was an inverse relationship between changes in DW image intensity and the size of the extracellular space, assessed by electrical impedance measurements. The reduction of the hyperintense volume in DW images 1 or 2 h after MK-801 or D-CPPene treatment of NMDA-injected animals depended on the type of antagonist used and on the interval between intrastriatal NMDA injection and antagonist treatment. The reduction was 95% when MK-801 was given with a delay of 90 min and decreased to 20% when it was given at 360 min. With D-CPPene, the reduction was 80% after a delay of 30 min and virtually absent when it was administered at 360 min. Quantitative analysis showed significant correlations between the residual hyperintense volume 1 or 2 h after MK-801 or D-CPPene treatment and the final lesion volume, assessed from either T2-weighted images (R = 0.89, p < 0.001) or histology (R = 0.80, p < 0.001) 5 days after the insult. This study illustrates the sensitivity of DW magnetic resonance imaging to monitor in vivo early events after an excitotoxic insult and the effect of putative protective drugs that may counteract the resulting damage.

The congenital bicuspid aortic valve with post-inflammatory disease--a neglected pathological diagnosis of clinical relevance.

It is unusual to find surgically excised congenital bicuspid aortic valves with post-inflammatory disease. We have analysed retrospectively all surgically excised aortic valves over a 6-year period for this particular diseased state in relation to relevant clinical data. There were 181 congenital bicuspid aortic valves, and the characteristic gross pathology of the tricuspid aortic valve with post-inflammatory disease served as reference. Twelve of the 181 congenital bicuspid aortic valves were identified as post-inflammatory (6.6%); one with clinically established rheumatic disease. The mean age at operation of these 12 patients was significantly lower compared to 'other' aortic valves. The study indicates that post-inflammatory involvement of a congenital bicuspid aortic valve can be identified, which is of clinical relevance since these patients have a significantly younger age at operation.

Stress urinary incontinence: effect of pelvic muscle exercise.

Twenty women with stress urinary incontinence diagnosed by urodynamic testing participated in a 6-week pelvic muscle exercise program. The aim of the study was to evaluate the effectiveness of the exercise program, with or without an intravaginal balloon, on urinary leakage as determined by a 30-minute and a 24-hour pad test. Relative strength of the pelvic muscles was evaluated using an intravaginal device that measures the pressure generated during a muscle contraction. After completion of the exercise program, 18 of the 20 subjects had an increase in strength of the pelvic floor muscles, as demonstrated by increased intravaginal pressure or a decrease in urinary loss on the 24-hour pad test. The use of an intravaginal balloon did not improve performance of the pelvic muscles or decrease urinary loss as compared with the subjects who exercised without an intravaginal balloon. Twelve months after the completion of the exercise program, 19 of the participants responded to a questionnaire about their urinary loss and performance of pelvic muscle exercises. None of the subjects stated that her urinary loss was worse, three had undergone surgical intervention, and ten had not continued to exercise. Seven subjects still exercised, with subjective improvement of urinary loss. It appears that pelvic muscle exercises may be successful in improving the condition of stress urinary incontinence; however, half of the subjects did not continue to exercise independently.

[Balloon valvuloplasty of the aortic valve: short-term and medium-term results in 50 patients]. / Ballonvalvuloplastiek van de aortaklep: resultaten op korte en middellange termijn bij 50 patiënten.

Fifty patients with severe symptomatic aortic stenosis underwent a balloon valvuloplasty of the aortic valve with acceptable initial haemodynamic results. Follow-up at one month showed clinical improvement in 66% of the patients. Long-term follow-up (clinical, Doppler echocardiography and repeat cardiac catheterization) was disappointing. The intervention-free rates at one and two years were 44% and 26%, respectively. Aortic balloon valvuloplasty should be limited to patients with a severe aortic stenosis and short life expectancy because of non-cardiac disease and to patients with severely depressed left ventricular function as a bridge to valve replacement.