Surgical outcome of trans-sphenoidal approach to pituitary adenoma in adult patients: 10 years experience in northwest of Iran.

Background: Pituitary adenoma (PA) is a frequent intracranial lesion, that needs surgical evacuation. In this study, we evaluated the surgical outcome of PA treated via endoscopic and microscopic trans-sphenoidal approach. Methods: In this retrospective cross-sectional study, we evaluate ten years of PA surgery experience in the northwest of Iran. 721 patients underwent trans sphenoidal surgery of PA. Complication of the surgery, extension of tumors resection, demographic and clinical findings (gender, age, tumor type,..) were reviewed in this study. SPSS version 25 and statistical tests including chi square and T-test were used. P-value ˂0.5 was considered as statistically significant. Results: 483 males (58.9%) and 336 females (41.02%) were included in this study. Mean age of patients was 47.3±1.96 years.The most common initial complaints were deterioration of vision (n=528, 64.4%) and headache (n=343, 41.88%), followed by accelerated development (n=254, 31.01%), amenorrhea and galactorrhea (n=253, 30.8%). 57 (6.95%) patients had symptoms of Cushing's disease. 105 (12.8%) patients had acromegaly. TR was achieved in 87.5% of cases and sub-TR in 103 (12.5%) cases and no patient had a partial or insufficient resection. After surgery, the endocrine function was normalized in 76 (31.7%) patients who had preoperative hyper hormonal levels. 36 (4.3%) patients developed postoperative CSF leakage; of which, 4 (0.48 %) patients did not improve by lumbar drainage and other conservative treatments and needed reoperation for reconstruction of the skull base. Conclusion: The combination of microscopic and endoscopic trans-sphenoidal approach in PA surgery can be lead to total resection of tumors.

Evaluation of the risk factors associated with emergency department boarding: A retrospective cross-sectional study.

PURPOSE: Boarding is a common problem in the emergency department (ED) and is associated with poor health care and outcome. Imam Khomeini Hospital is the main healthcare center in Urmia, a metropolis in the northwest of Iran. Due to the overcrowding and high patient load, we aim to characterize the rate, cause and consequence of boarding in the ED of this center. METHODS: All medical records of patients who presented to the ED of Imam Khomeini Hospital from August 1, 2017 to August 1, 2018 were retrospectively analyzed. Patients with uncompleted records were excluded. Boarding was defined as the inability to transfer the admitted ED patients to a downstream ward in ≥2 h after the admission order. Demographic data, boarding rate, mortality and triage levels (1-5) assessed by emergency severity index were collected and analyzed. The first present time of patients was classified into 4 ranges as 0:00-5:59, 6:00-11:59, 12:00-17:59 and 18:00-23:59. Descriptive, parametric and non-parametric statistical tests were performed and the risk of boarding was determined by Pearson Chi-square test. RESULTS: Demographic data analysis showed that 941 (58.5%) male and 667 (41.5%) female, altogether 1608 patients were included in this study. Five patients (0.3%) died. The distribution of patients with the triage levels 1-5 was respectively 79 (4.9%), 1150 (71.5%), 374 (23.3%), 4 (0.2%) and 0 (0%). Most patients were of level 2. Only 75 (4.7%) patients required intensive care. The majority of patients (84.2%) were presented at weekdays. The maximum patient load was observed between 12:00-17:59. Of the 1608 patients, 340 (21.1%) experienced boarding within a mean admission time of 13.70 h. Among the 340-boarded patients, 20.1% belonged to surgery, 12.1% to orthopedics, 10.9% to neurosurgery and 10.3% to neurology. The boarding rate was higher in females, patients requiring intensive care and those with low triage levels. Compared with the non-boarded, the boarded patients had a higher mean age. CONCLUSION: The boarding rate is higher in the older and female patients. Moreover, boarding is dependent on the downstream ward sections: patients requiring surgical management experience the maximum boarding rate.

Clinical and radiological characteristics of pediatric patients with COVID-19: focus on imaging findings.

PURPOSE: CT imaging has been a detrimental tool in the diagnosis of COVID-19, but it has not been studied thoroughly in pediatric patients and its role in diagnosing COVID-19. METHODS: 27 pediatric patients with COVID-19 pneumonia were included. CT examination and molecular assay tests were performed from all participants. A standard checklist was utilized to extract information, and two radiologists separately reviewed the CT images. RESULTS: The mean age of patients was 4.7 ± 4.16 (mean ± SD) years. Seventeen patients were female, and ten were male. The most common imaging finding was ground-glass opacities followed by consolidations. Seven patients had a single area of involvement, five patients had multiple areas of involvement, and four patients had diffuse involvement. The sensitivity of CT imaging in diagnosing infections was 66.67%. Also, some uncommon imaging findings were seen, such as a tree-in-bud and lung collapse. CONCLUSION: CT imaging shows less involvement in pediatric compared to adult patients, due to pediatric patients having a milder form of the disease. CT imaging also has a lower sensitivity in detecting abnormal lungs compared to adult patients. The most common imaging findings are ground-glass opacities and consolidations, but other non-common imaging findings also exist.

Propionibacterium acnes Infection in Disc Material and Different Antibiotic Susceptibility in Patients With Lumbar Disc Herniation.

BACKGROUND: Low back pain is an important, worldwide clinical problem from which human populations are suffering. It has been suggested that Propionibacterium acnes is associated with low back pain. The objective of this clinical study is to evaluate the P. acnes infection in the disc material and antibiotic susceptibility in patients with disc herniation. METHODS: A total of 120 patients with disc herniation surgery were enrolled in the study. The samples were excited during discectomy and then cultured in both anaerobic and aerobic incubations. Minimum inhibitory concentration (MIC) was performed for determination of antibiotic susceptibility. RESULTS: Of 120 samples, 60 (50%) samples were positive for microorganisms. Disc herniation was at the level of L4-L5 in 63 cases and L5-S1 in 57 cases. CONCLUSIONS: According to the results and presence of P. acnes in more than 35% of the cultured samples, the presence of P. acnes in lumbar disc herniation is a suspected element leading to this condition. After analysis of the antibiotics, the lowest MIC value was identified for amoxicillin, ciprofloxacin, erythromycin, rifampicin, tetracycline, vancomycin; the moderate MIC value was for fusidic acid; and the highest MIC value was for gentamicin and trimethoprim.

Riluzole Can Improve Sensory and Motor Function in Patients with Acute Spinal Cord Injury.

BACKGROUND: Spinal cord injury (SCI) causes sensory, motor function and consists of a large proportion of patients that referred to trauma centers. Riluzole blocks the sodium channels and has possible supportive effects on the central nervous system. The aim of this study was to investigate the effect of riluzole on sensory and motor improvement and pain level in patients with acute SCI. MATERIALS AND METHODS: In this clinical trial, sixty patients with acute SCI with A to C Frankel grade selected and randomly divided into two groups (each group included thirty patients). The two groups carefully matched in terms of age, sex, and Frankel class. Case group, in addition to conventional treatment, received riluzole and was evaluated after 6-week, 3-month, and 6-month periods in terms of sensory and motor status and compared with control group. RESULTS: There were sixty patients divided into case and control groups. In the 6-week follow-up period and 3-month follow-up period, there was no significant difference between the two groups based on sensory and motor function (P = 0.053). In 6-month follow-up period, the difference was significant in case group (P = 0.001). CONCLUSION: The compressions between two groups demonstrated a significant difference in sensory and motor improvement and reduce pain level in patients with SCI.

What do You Expect from Patients with Severe Head Trauma?

BACKGROUND: Head trauma is one of the most common mortality and morbidity causes in adolescent. Numerous studies have been conducted on changes in laboratory results and mortality and morbidity prognostic factors; however, the obtained results have been varied and controversial. The aim of this study is to evaluate changes in laboratory findings and arterial blood gas (ABG) analyses test at admission and investigation of the relation between these changes with outcomes in patients with traumatic brain injury. MATERIALS AND METHODS: In this study, laboratory and metabolic variables were compared in patients with severe brain trauma and normal subjects. Laboratory and metabolic variables and ABG were measured on admission in patients with severe brain trauma and then compared with normal values. At last, the correlation between these variables with the prognosis in the patients was studied. RESULTS: Of 93 studied patients, 82 were male and 11 were female with the mean age of 30.54 years. Among the studied variables, prothrombin time (PT), partial thromboplastin time, international normalized ratio (INR), creatinine (Cr), blood sugar, sodium (Na+), potassium, white blood cell, and blood urea nitrogen increased while hemoglobin and platelet decreased significantly. Regarding the ABG results, the difference in PaCO2, HCO3, and SO2 at values was significant; whereas there were no statistical significant difference between the discharged and expired patients. In contrast, PT, INR, Cr, and Na had significant difference comparing the discharged and expired patients. CONCLUSION: Laboratory variables do change in patients with severe brain trauma; these changes are influential on patient prognosis, especially in case of PT, INR, Cr, and Na.

Minimal Dose of Tranexamic Acid Is Effective in Reducing Blood Loss in Complex Spine Surgeries: A Randomized Double-Blind Placebo Controlled Study.

STUDY DESIGN: A randomized double-blind placebo controlled study. PURPOSE: In the present study, we aimed to assess the efficacy of tranexamic acid (TXA) in reducing blood loss after laminectomy and posterolateral fusion of the spine. OVERVIEW OF LITERATURE: Blood loss is the most significant complication involved with surgery, especially in spinal surgery. Multilevel laminectomy and laminectomy with instrumentation (pedicle screws and rods) are complex spine surgeries and are considered as medium-risk procedures for bleeding. Recent reports have demonstrated that the use of antifibrinolytic drugs during surgery may reduce the risk of postoperative bleeding and one of the most frequently used antifibrinolytics is TXA. METHODS: In this randomized clinical trial, 50 patients eligible for laminectomy (for ≥2 level) with postero-lateral fusion with a pedicular screw (laminectomy and posterior spinal fusion) were randomly assigned to receive preoperative single doses of intravenous TXA (15 mg/kg) or 0.9% normal saline. RESULTS: Of the 50 patients, 30 (60%) were female and 20 (40%) were male. Between-group difference with respect to the total volume of blood loss during surgery was statistically significant. CONCLUSIONS: The findings of this study suggest that TXA can reduce both intraoperative and immediate postoperative blood loss, decrease the need for packed cell transfusion, and reduce the duration of hospitalization after complex spinal surgeries. No adverse events related to the use of TXA were encountered in this study.

Meningioma in Fourth Ventricle of Brain: A Case Report and Literature Review.

Meningiomas are benign tumors origin from central nervous system. They usually involve cephalic, paravertebral soft tissues, skin and in rare cases in the ear, temporal bone, mandible, foot, lung, and mediastinum. In this case, we report an unusual case of meningioma which placed in the fourth ventricle. A 14-year-old man with seizure and headache referred to our ward. The magnetic resonance imaging reported bilateral acoustic neuroma and fourth ventricle meningioma. The patient was scheduled for total tumor resection and the histopathology revealed psammomatous type of meningioma. The patient discharged with good general status.

The roles of Wnt/ß-catenin pathway in tissue development and regenerative medicine.

Regenerative medicine is a translational field which combines tissue engineering and molecular biology to construct spare organs or help injured or defective tissues to regenerate or restore their normal functions. This is particularly important with specific organs such as heart, central nervous system, retina, or limbs which possess very limited regenerative capacity. As such, regenerative medicine has received peculiar attention in the last decade. In this regard, Wnt/ß-catenin signaling pathway has been subject to intensive research, since it plays many essential roles in the regulation of the progenitor cell fate, developmental decisions, proliferation during embryonic development, and adult tissue homeostasis. In this paper, we will briefly introduce Wnt/ß-catenin signaling pathway and discuss how it integrally contributes to both stem and cancer stem cell maintenance. Finally, we summarize the current understanding of the role of Wnt/ß-catenin signaling in the development and regeneration of heart, lung, liver, bone, and cartilage.

Cause-specific mortality among women of reproductive age: Results from a population-based study in an Iranian community.

PURPOSE OF STUDY: This study was conducted to evaluate the levels, patterns, and causes of mortality among women of reproductive age in Northwestern Iran. METHODS: Deaths were determined for females resident in West Azerbaijan Province of Iran and who died between March 2013 to February 2014 using reproductive age mortality survey (RAMOS). Causes of death were ascertained by verbal autopsy (VA) and classified based on the International Classification of Diseases, tenth revision (ICD-10). Overall and cause-specific mortality rates (MRs) per 100,000 women with 95% confidence intervals were calculated. RESULTS: A total of 510 deaths were detected, and VA interviews were conducted with the relatives of the deceased Cases; overall MR was 56.59 per 100,000 women (95% CI: 56.49-56.69). The highest MR was observed in suicide cases (MR=10.21per 100,000women, 95% CI: 10.15-10.27), accounting for 18% of all deaths. The most common method of suicide was self-inflicted burns (45.6%), followed by deaths due to breast cancer (MR=4.22per 100,000women, 95% CI: 4.18-4.26), which accounted for the most cancer-related mortality. All-cause mortality was associated with age, area of residence, marital status, level of education, and ethnic (religious) status relationship (P<0.001). CONCLUSION: Suicide, especially self-immolation, was the main cause of death among women of reproductive age, and both suicides and breast cancer are major public health problems for this group of women.

Effects of Atorvastatin in Patients with Acute Spinal Cord Injury.

STUDY DESIGN: Clinical trial study. PURPOSE: The aim of this study was to evaluate the effect of atorvastatin on sensory and motor function in patients with acute spinal cord injury. OVERVIEW OF LITERATURE: The prevalence and incidence of traumatic spinal cord injury are increasing. Statins are well established for use in hypercholesterolemia as well as during anti-inflammatory events. METHODS: This clinical trial study included 60 patients with acute spinal cord injury. These were randomly divided into two groups: the case group which received atorvastatin and also underwent surgical therapy and the control group which only underwent surgical therapy. RESULTS: The severity of spinal cord lesions was evaluated based on the Frankel grade at three periods; this showed no significant difference between the two groups. Comparisons of the levels of pain between the groups based on a Visual Analog Scale system showed no significant difference at the three periods. CONCLUSIONS: We observed no improvement at the 3- and 6-month follow-up in patients who were administered atorvastatin. However, a comparison of the two groups based on pain severity demonstrated a significant difference, suggesting that atorvastatin had a positive effect on patients with spinal cord injury.

The distribution of infection with Propionibacterium acnes is equal in patients with cervical and lumbar disc herniation.

BACKGROUND: Cervical and back pains are important clinical problems affecting human populations globally. It is suggested that Propionibacterium acnes (P. acnes) is associated with disc herniation. The aim of this study is to evaluate the distribution of P. acnes infection in the cervical and lumbar disc material obtained from patients with disc herniation. METHODS AND MATERIAL: A total of 145 patients with mean age of 45.21 ± 11.24 years who underwent micro-discectomy in cervical and lumbar regions were enrolled into the study. The samples were excited during the operation and then cultured in the anaerobic incubations. The cultured P. acnes were detected by 16S rRNA-based polymerase chain reaction. RESULTS: In this study, 145 patients including 25 cases with cervical and 120 cases with lumbar disc herniation were enrolled to the study. There was no significant difference in the age of male and female patients (p = 0.123). P. acnes infection was detected in nine patients (36%) with cervical disc herniation and 46 patients (38.3%) with lumbar disc herniation and no significant differences were reported in P. acnes presence according to the disc regions (p = 0.508.). Moreover, there was a significant difference in the presence of P. acnes infection according to the level of lumbar disc herniation (p = 0.028). CONCLUSION: According to the results, the presence of P. acnes is equal in patients with cervical and lumbar disc herniation. There was a significant difference in the distribution of P. acnes infection according to level of lumbar disc herniation. LEVEL OF EVIDENCE: II.

Modic changes in the adjacent vertebrae due to disc material infection with Propionibacterium acnes in patients with lumbar disc herniation.

INTRODUCTION: Modic changes (MCs) in vertebral bones are induced by two mechanisms of mechanical factors and infection. As Propionibacterium acnes (P. acnes) have been reported to be associated with LBP. The aim of this study is to evaluate the MCs in patients with disc herniation and positive for P. acnes. METHODS AND MATERIAL: A total of 120 patients with disc herniation surgery were enrolled into the study. The samples were excised during discectomy and then cultured in both anaerobic and aerobic incubations. Gram staining was employed for investigation of all colonies. The cultured P. acnes were detected by 16S rRNA-based polymerase chain reaction (PCR). MCs of baseline MRI were evaluated. RESULTS: In this study, 120 subjects (69 male and 51 female) with mean age of 43.15 ± 12.62 years were investigated. Sixty disc samples and eight muscle samples were positive for microorganisms. Moreover, 16S rDNA gene was identified in 46 (38.3%) disc samples. Moreover, 36/46 patients with P. acnes in their sample had MCs. CONCLUSION: According to the results and presence of 36/46 MCs in patients with lumbar disc herniation, positive for P. acnes suggests that P. acnes can lead to edema on the vertebrae endplates near to infected area.

Can Serum Glucose Level in Early Admission Predict Outcome in Patients with Severe Head Trauma?

BACKGROUND: Traumatic brain injury is a major general health concern. This study aims to evaluate a possible relationship between the serum level of glucose during admission and the outcome of patients with severe traumatic brain injury. METHODS: In this prospective study, 80 patients with severe traumatic brain injury were recruited from the emergency department of Urmia Imam Khomeini Hospital. Serum level of glucose was measured at the time of admission and its correlation was investigated with the Glasgow Coma Scale score (on admission, 24 hours, 48 hours, and 1 week later, and at discharge) and Glasgow Outcome Score. In addition, the value of admission serum glucose was compared between deceased and discharged patients. RESULTS: Eighty patients with severe head trauma, 71 men (88%) and 9 women (11.2%) with a mean age of 31.71 ± 15.66 years, were enrolled into the study. The in-hospital mortality rate was 25% (n = 20). There was no significant correlation between serum glucose level and Glasgow Coma Scale score (at different intervals) or Glasgow Outcome Score. The mean serum level of glucose was comparable between deceased and discharged patients (186.10 ± 51.36 vs. 187.98 ± 76.03 mg/dL, respectively; P = 0.91). CONCLUSIONS: Admission serum glucose is not a significant indicator of outcome in patients with severe head trauma.

Anti-fatigue mats, low back pain, and electromyography: An interventional study.

OBJECTIVES: Increasing bilateral gluteus medius co-activation has been identified as one of the most important factors in developing low back pain due to prolonged standing in healthy people. This study aims to investigate the impact of an anti-fatigue mat on the bilateral gluteus medius co-activation pattern and to report the low back pain subjectively in 2 different standing positions on the normal rigid surface and on the anti-fatigue mat. MATERIAL AND METHODS: While carrying out an easy simulated profession, 16 participants who had no low back pain background were requested to stand for 2 h in each position, with and without using the anti-fatigue floor mat, respectively. At the beginning of standing process and at every 15 min until the time of 120 min lapses, electric activities for the bilateral gluteus medius co-activation and subjective pain level in low back area were collected by the surface electromyogeraphy (EMG) and the visual analogue scale (VAS), respectively in each position. RESULTS: The obtained findings revealed that the anti-fatigue mat significantly decreased subjective pain level in low back area among 15 participants (p < 0.05). However, there was objectively no significant difference in the bilateral gluteus medius co-activation pattern among the participants between the position 1 and the position 2 (p > 0.05). The findings obtained under this study related to the impact of the anti-fatigue mat upon the low back pain based on the increase of > 10 mm on the VAS threshold, which showed that this intervention had no significant impact upon decreasing the number of patients suffering from the low back pain and also minimizing the bilateral gluteus medius co-activation in both pain developer groups (p > 0.05). However, 73% of the participants preferred to apply it. CONCLUSIONS: It seems that the anti-fatigue mat may be useful in reducing the low back pain although it objectively didn't significantly change the gluteus medius co-activation pattern related to the low back pain.

Radiosurgical retreatment for brain arteriovenous malformation.

OBJECTIVE: To analyze our experience with a second radiosurgical treatment for brain arteriovenous malformations (BAVMs) after an unsuccessful first radiosurgical treatment. METHODS: Between 1993 and 2000, 242 patients were treated by the Toronto Sunnybrook Regional Cancer Center using a LINAC system. Fifteen of these patients required a second radiosurgical intervention due to the failure of the first procedure. Data was collected on baseline patient characteristics, BAVM features, radiosurgery treatment plan and outcomes. Brain arteriovenous malformation obliteration was determined by follow-up MRI and angiography and the obliteration prediction index (OPI) calculated according to a previously established formula. RESULTS: The median interval between the first and second treatment was 46 months (range 39-109). The median follow-up after the second procedure was 39 months (range 26 to 72). The mean BAVM volume before the first treatment was 8.9cm3 (range 0.3-21) and before the second treatment was 3.6cm3 (range 0.2-11.6). The mean marginal dose during the first treatment was 18Gy (range 12-25) and during the second treatment was 16Gy (range 12-20). After the second treatment, nine patients had obliteration of their BAVM confirmed by angiography and one patient had obliteration confirmed by MRI, resulting in an obliteration rate of 66.6%, which is very comparable to that predicted by the OPI (65%). After the second treatment two patients had a radiation-induced complication (13.3%). CONCLUSION: Retreatment of BAVM using a second radiosurgery procedure is a safe and effective option that offers the same rate of success as the initial radiosurgery and an acceptable risk of radiation-induced complication.

Immunotherapy of prolactinoma with a T helper 1 activator adjuvant and autoantigens: a case report.

OBJECTIVE: To date, efforts to reliably manipulate the immune system to promote tumor regression in the brain have been disappointing. We report a unique experience of successful immunotherapy to treat a pituitary macroprolactinoma. METHODS: A 31-year-old woman with an established history of pituitary macroprolactinoma who had undergone tumor resection followed by radiation was admitted to our clinic. The diagnosis had been made due to the patient's symptoms, a serum prolactin (PRL) level of 29,600 mIU/l, a brain MRI revealing a 23 x 19 x 18 mm pituitary mass and a positive PRL immunohistochemistry of the mass. Six months following surgery, she reexperienced headache, excessive sweating and a serum PRL concentration of 2,960 mIU/l despite receiving 30 mg/day bromocriptine. Brain MRI revealed a pituitary mass (3 x 6 x 8 mm) compatible with a pituitary adenoma. Twenty micrograms per milliliter of G2 (as a T helper 1 activator adjuvant) was inoculated intradermally once per week for 24 consecutive weeks (each injection contained 10 mug of G2). The autoantigens were inoculated at the same time with G2. RESULTS: After immunotherapy, serum PRL concentration decreased to 82 mIU/l, the patient's symptoms disappeared, skin thickness increased to normal and bromocriptine dosage was tapered to 20 mg per week. A follow-up brain MRI revealed almost complete disappearance of the tumor. The patient does not complain of any problems at 1-year follow-up. CONCLUSION: Activation of both nonspecific (natural killer cells) and specific (cytotoxic T lymphocytes) immunity in relation to the T helper 1 cytokine network is a promising strategy for the treatment of tumors of the central nervous system in humans, especially pituitary macroprolactinomas.