Minimally Invasive Posterolateral Transcavernous Transtentorial Approach: 2-Dimensional Operative Video.

INDICATIONS CORRIDOR AND EXPOSURE: MIPLATTA uses a "key-exposure" concept aligning a small minipterional craniotomy with variations of extradural transcavernous transtentorial corridors to access the skull base. ANATOMIC ESSENTIALS FOR PREOPERATIVE PLANNING: Safety and efficiency depend on mastery of the anterior clinoid process (ACP) and cavernous sinus (CS). Preoperative planning includes assessment of ACP pneumatization; tumor epicenter relative to the CS, ACP, and tentorium; and pattern of venous drainage (role of vein of Labbé). ESSENTIAL SURGICAL STEPS: 1. Interfascial flap for facial nerve preservation.2. Minipterional craniotomy with extradural anterior clinoidectomy.3. Variable Transcavernous dissection according to the Hakuba method4. Dural opening parallel to the Sylvian fissure.5. Transtentorial with possible Kawase.6. Closure with autologous graft into the clinoidal triangle and water-tight dural closure. PITFALLS: Incomplete release of the optic and oculomotor nerves during anterior clinoidectomy may lead to deficits. Insufficient caudal extent of the craniotomy may cause undue retraction on Labbé and a temporal lobe infarct. Thorough anatomic knowledge of the CS is a key for catastrophe prevention. VARIANTS AND THEIR INDICATIONS: 1. Basic MIPLATTA with minipterional and extradural anterior clinoidectomy (Hakuba approach) for optic nerve decompression and parasellar lesions.2. Extended MIPLATTA adds oculomotor nerve transposition and cavernous sinus peeling for middle fossa, sphenoid ridge, and giant clinoid tumors.3. Full MIPLATTA adds Kawase and internal auditory canal exposure with endoscopic-assisted microsurgery for tumors invading the posterior fossa.The patients consented to both surgery and publication of their images. Permission was obtained appropriately for the publication of the cadaveric images. The anatomic images and animations in the surgical anatomy section of the video are sole property of www.neurosurgicalanatomy.com and Neurosurgical Anatomy by Arnau Benet, MD, who shall retain copyright, and used with permission.

One year weight loss in the TRAMOMTANA study. A randomized controlled trial.

BACKGROUND: Morbid obesity is a major health problem and bariatric surgery is currently the most effective therapy available to induce weight loss in these patients. This report describes 1-year changes in weight and metabolic parameters, in a trial designed to examine the effects of a nonsurgical approach, Intensive Life style Intervention (ILI) on the therapy of morbid obesity. METHODS: The primary outcome was change in body weight. Patients were randomized to ILI (n = 60) or conventional obesity therapy (COT) (n = 46). The ILI group received behavioural therapy and nutritional/physical activity counselling. The COT group received the standard medical treatment available for these patients. A third group consisted of the patients already included in our bariatric surgery waiting list (n = 37). FINDINGS: We present here 1-year data showing that patients who received ILI with no restrictions in calorie intake had a greater percentage of weight loss than patients receiving COT (-11·58% vs -0·4%; P < 0·001). Importantly, 31·4% of patients included in the ILI group were not morbidly obese after 6 months of intervention. This number increased to 42·8% after 12 months of intervention. INTERPRETATION: ILI was associated with significant weight loss compared with COT in a group of morbidly obese patients. The weight loss effect was already obtained after 6 months of ILI intervention. These results seriously question the efficacy of the COT approach to morbid obesity. Furthermore, they underscore the use of ILI programmes in the hospital setting to effectively treat morbidly obese patients and might help to reduce the number of candidate patients for bariatric surgery.

[TRAMOMTANA (Multidisciplinary treatment of morbid obesity: medication, behavioral therapy, nutritional support, and physical activity). From question to reality in an investigator-initiated clinical trial (II)]. / TRAMOMTANA (Tratamiento Multidisciplinar de la Obesidad Mórbida: Medicamentos, Terapia de comportamiento, Apoyo Nutricional y Actividad física). De la pregunta a la realidad de un ensayo clínico investigador iniciado (II).

Implementation of an intensive, multidisciplinary weight loss program in patients with morbid obesity is reported. This program is based on behavioral changes, lifestyle intervention, medication, and group therapy sessions. Our objective is to show that the results achieved with this two-year weight loss program will be at least similar to those achieved with bariatric surgery in patients with morbid obesity. We also intend to show that this multidisciplinary treatment induces an improvement in the comorbidity rate associated to smaller costs for our national health system.

Evaluation of tolerability and efficacy of imatinib mesylate in elderly patients with chronic phase CML: ELDERGLI study.

Imatinib mesylate (IM) is the treatment of choice in patients with newly diagnosed chronic myeloid leukemia (CML), irrespectively of their age. Nevertheless, information regarding tolerability and responses in advanced-age patients, a subgroup in which co-morbidities and other factors may influence outcome, is scarce, since they were excluded from most clinical trials. In this observational study (ELDERGLI), information regarding demographics, concomitant medication, physical examination, performance status, hemogram, biochemistry, hematologic, cytogenetic and molecular responses, time to progression, adverse events (AE) and severe adverse events (SAE) were prospectively recorded in a series of 36 elderly patients with CML, with a median age of 76.6 years. Most patients had cardiovascular co-morbidities, especially hypertension. Regarding IM toxicity, around one third of patients required treatment interruptions because of adverse events, especially hematologic toxicity (66% of cases that needed dose interruptions). When analyzing non hematologic adverse events, the most frequent ones were superficial edemas and GI symptoms. Of note, 9 of patients experienced an infection episode during the follow-up, and 4 were diagnosed during the study period of another type of cancer. Finally, cardiovascular events were reported in 7 patients, most of them with prior cardiovascular risk factors. Regarding responses, after 12 months of imatinib therapy, the rate of complete hematologic response (CHR), complete cytogenetic response (CCyR) and major molecular response (MMolR) were 89%, 72% and 55% respectively. In summary, IM display, in advanced-age patients with chronic phase CML, an efficacy and safety profile comparable to younger patients.

Incidence and prognostic impact of secondary cytogenetic aberrations in a series of 145 patients with mantle cell lymphoma.

Mantle cell lymphoma (MCL) is a mature B-cell neoplasm with an aggressive behavior, characterized by the t(11;14)(q13;q32). Several secondary genetic abnormalities with a potential role in the oncogenic process have been described. Studies of large MCL series using conventional cytogenetics, and correlating with proliferation and survival, are scarce. We selected 145 MCL cases at diagnosis, displaying an aberrant karyotype, from centers belonging to the Spanish Cooperative Group for Hematological Cytogenetics. Histological subtype, proliferative index and survival data were ascertained. Combined cytogenetic and molecular analyses detected CCND1 translocations in all cases, mostly t(11;14)(q13;q32). Secondary aberrations were present in 58% of patients, the most frequent being deletions of 1p, 13q and 17p, 10p alterations and 3q gains. The most recurrent breakpoints were identified at 1p31-32, 1p21-22, 17p13, and 1p36. Aggressive blastoid/pleomorphic variants displayed a higher karyotypic complexity, a higher frequency of 1p and 17p deletions and 10p alterations, a higher proliferation index and poor survival. Gains of 3q and 13q and 17p13 losses were associated with reduced survival times. Interestingly, gains of 3q and 17p losses added prognostic significance to the morphology in a multivariate analysis. Our findings confirm previous observations indicating that proliferation index, morphology and several secondary genetic alterations (3q gains and 13q and 17p losses) have prognostic value in patients with MCL. Additionally, we observed that 3q gains and 17p losses detected by conventional cytogenetics are proliferation-independent prognostic markers indicating poor outcome.

Changes in lipid profile and insulin resistance in obese patients after Scopinaro biliopancreatic diversion.

BACKGROUND: Obesity is associated with many cardiovascular risk factors. The aim of this study is to evaluate the effect of bariatric surgery (BS) in lipid profile and insulin resistance in obese patients. MATERIAL AND METHODS: We studied changes in lipid parameters glucose, insulin, and insulin resistance (IR) before biliopancreatic diversion and 3, 6, 12, 18, and 24 months after surgery, in 115 obese patients divided in two groups: diabetics (DM) and nondiabetics (non-DM). RESULTS: In both groups, all parameters significantly decreased at 3 months; however, high-density lipoprotein cholesterol levels (HDL-c) and total cholesterol (TC) to HDL-c ratio decreased up to 6 months. At baseline, in DM, we found a negative correlation between body mass index (BMI) and TC to HDL-c ratio and glucose with HDL-c and homeostasis model assessment (HOMA) with BMI and a direct correlation between glucose with TC to HDL-c ratio and glucose with triglycerides. In non-DM, no correlations were found. Comparing both groups for each parameter, we found significant differences at basal levels for glucose, HOMA, triglycerides (TG), and TG to HDL-c ratio. Changes between basal levels and 1 year after surgery were significantly different in glucose and HOMA. CONCLUSION: BS offers excellent results in weight reduction and significantly improves IR, diabetes, and the lipid profile, decreasing global cardiovascular risk.

Depot- and gender-related differences in the lipolytic pathway of adipose tissue from severely obese patients.

The present study was performed to analyze in detail gender- and site-related alterations in the adrenergic signal transduction pathway of lipolysis in fat cells isolated from subcutaneous abdominal and visceral fat depots from severely obese patients. The study group consisted of 30 morbidly obese subjects (9 men and 21 women) aged 41.1+/-1.9 years, with a body mass index (BMI) of 54.7+/-1.7 kg/m2, who had undergone abdominal surgery. Protein levels of hormone-sensitive lipase (HSL) and adrenergic receptors (AR), as well as HSL activity and the lipolytic response to adrenergic agents were analyzed. Both fat depots had similar basal lipolysis, but the capacity of catecholamines to activate lipolysis was greater in visceral fat, both at AR and postreceptor levels. Basal lipolysis and lipolytic activity induced by dibutyryl cyclic AMP were higher in men than in women. However, the visceral depot of women showed a higher maximal stimulation by noradrenaline than that of men, in accordance with higher beta1- and beta3-AR protein levels. In conclusion, the main gender-related differences were located in the visceral depot, with women exhibiting a higher sensitivity to catecholamines associated with an increased provision of beta-AR, while men showed an enhanced lipolytic capacity at the postreceptor level.

Tissue leptin and plasma insulin are associated with lipoprotein lipase activity in severely obese patients.

The development of metabolic complications of obesity has been associated with the existence of depot-specific differences in the biochemical properties of adipocytes. The aim of this study was to investigate, in severely obese men and women, both gender- and depot-related differences in lipoprotein lipase (LPL) expression and activity, as well as the involvement of endocrine and biometric factors and their dependence on gender and/or fat depot. Morbidly obese, nondiabetic, subjects (9 men and 22 women) aged 41.1+/-1.9 years, with a body mass index (BMI) of 54.7+/-1.7 kg/m(2) who had undergone abdominal surgery were studied. Both expression and activity of LPL and leptin expression were determined in adipose samples from subcutaneous and visceral fat depots. In both men and women, visceral fat showed higher LPL mRNA levels as well as lower ob mRNA levels and tissue leptin content than the subcutaneous one. In both subcutaneous and visceral adipose depots, women exhibited higher protein content, decreased fat cell size and lower LPL activity than men. The gender-related differences found in abdominal fat LPL activity could contribute to the increased risk for developing obesity-associated diseases shown by men, even in morbid obesity, in which the massive fat accumulation could mask these differences. Furthermore, the leptin content of fat depots as well as plasma insulin concentrations appear in our population as the main determinants of adipose tissue LPL activity, adjusted by gender, depot and BMI.

[Giant epidermoid splenic cyst]. / Quiste epidermoide esplénico gigante.

Giant epidermoid splenic cysts are rare benign tumors. Their treatment is becoming increasingly less aggressive and more conservative. We report the case of a young woman with a giant epidermoid cyst, which required open total splenectomy, and review the literature on benign congenital tumors of the spleen.

Estudio comparativo del consumo crónico de vino tinto sobre la expresión y la actividad del citocromo P450 en Hígado y riñon de rata / Comparative study of chronic red wine consumption on the expression and activity of the cytochrome p-450 in trat and kidney

El metabolismo del etanol involucra la participación de isoenzimas del citocromo P450 (CYP), principalmente con la contribución de la isoenzima 2E1 (CYP 2E1), cuya actividad es inducida por la exposición crónica al alcohol. El metabolismo etílico está relacionado con la producción de especies reactivas de oxígeno (ROS), responsables de la generación de estrés oxidativo. Por otra parte, se ha sugerido que los antioxidantes contenidos en el vino ejercerían un efecto protector contra la injuria oxidativa. El objetivo de este estudio fue comparar el efecto del consumo moderado de vino tinto sobre la expresión y la actividad del CYP 2E1 en hígado y riñón de rata. Ratas macho adultas fueron tratadas con agua (control), etanol (12,5 por ciento), vino tinto (12,5 por ciento de etanol) o vino tinto desalcoholizado por 10 semanas. El contenido de CYP total y CYP 2E1 fue evaluado en la fracción microsomal de riñón e hígado. La oxidación del etanol y p-nitrofenol fue tomada como índice de actividad de CYP 2E1, analizándose la contribución relativa de etanol y componentes no alcohólicos del vino. El etanol aumentó los contenidos de CYP total y CYP 2E1, así como la hidroxilación del p-nitrofenol y la oxidación del etanol tanto en hígado como en riñón. Esos efectos fueron atenuados por la administración de vino tinto. Con esta información es posible sugerir que los componentes no alcohólicos del vino tinto son capaces de modular el aumento en la expresión y la actividad del CYP 2E1 de hígado y riñón de la rata inducida por etanol

Efecto antagónico del consumo crónico de vino tinto y etanol sobre la actividad de la (Na+K)ATPasa renal / Antagonic effect of chronic consumption of red wine and ethanol on renal (Na+K)ATPase activity

El consumo crónico de etanol aumenta la actividad de (Na+K)ATPasa en diferentes tipos celulares, a través de un mecanismo mediado por especies reactivas de oxigeno (EROs). El consumo moderado de vino tinto puede aumentar las defensas antioxidantes ya que sus componentes no alcohólicos actúan como atrapadores de EROs, quelantes de metales y moduladores enzimáticos. La hipótesis del presente trabajo es que el efecto del consumo crónico de etanol sobre (Na+K)ATPasa es abolido por el vino tinto, siendo el objetivo diseñar un modelo experimental que analice separadamente los efectos del etanol y de los componentes no alcohólicos del vino tinto sobre la enzima. Ratas Wistar se dividieron en tres grupos y recibieron por diez semanas: agua (grupo control); etanol al 12.5 por ciento v/v (grupo etanol) o vino tinto conteniendo 12.5 por ciento de etanol (grupo vino), como única bebida. Los riñones fueron utilizados para determinar lipoperoxidación y actividad de (Na+K)ATPasa, en corteza y en papila renal. El etanol no modificó la lipoperoxidación ; sin embargo, la actividad de la bomba aumentó en corteza y en papila un 25 por ciento y 68 por ciento, respectivamente. El vino tinto disminuyó la lipoperoxidación a un tercio en corteza y a la mitad en papila, no observándose variaciones en la actividad de (Na+k)ATPasa. Estos resultados sugieren que el efecto estimulante que tiene el consumo crónico de etanol sobre la actividad (Na+K)ATPasa renal es suprimido por el consumo de vino tinto. Los componentes no alcohólicos podrían contribuir a este efecto a través de sus propiedades antioxidantes