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BACKGROUND: High intakes of fructose are associated with metabolic diseases, including hypertriglyceridemia and intestinal tumor growth. Although small intestinal epithelia consist of many different cell types, express lipogenic genes, and convert dietary fructose to fatty acids, there is no information on the identity of the cell type(s) mediating this conversion and on the effects of fructose on lipogenic gene expression. OBJECTIVES: We hypothesized that fructose regulates the intestinal expression of genes involved in lipid and apolipoprotein synthesis, that regulation depends on the fructose transporter solute carrier family 2 member a5 [Slc2a5 (glucose transporter 5)] and on ketohexokinase (Khk), and that regulation occurs only in enterocytes. METHODS: We compared lipogenic gene expression among different organs from wild-type adult male C57BL mice consuming a standard vivarium nonpurified diet. We then gavaged twice daily for 2.5 d fructose or glucose solutions (15%, 0.3 mL per mouse) into wild-type, Slc2a5-knockout (KO), and Khk-KO mice with free access to the nonpurified diet and determined expression of representative lipogenic genes. Finally, from mice fed the nonpurified diet, we made organoids highly enriched in enterocyte, goblet, Paneth, or stem cells and then incubated them overnight in 10 mM fructose or glucose. RESULTS: Most lipogenic genes were significantly expressed in the intestine relative to the kidney, liver, lung, and skeletal muscle. In vivo expression of Srebf1, Acaca, Fasn, Scd1, Dgat1, Gk, Apoa4, and Apob mRNA and of Scd1 protein increased (P < 0.05) by 3- to 20-fold in wild-type, but not in Slc2a5-KO and Khk-KO, mice gavaged with fructose. In vitro, Slc2a5- and Khk-dependent, fructose-induced increases, which ranged from 1.5- to 4-fold (P < 0.05), in mRNA concentrations of all these genes were observed only in organoids enriched in enterocytes. CONCLUSIONS: Fructose specifically stimulates expression of mouse small intestinal genes for lipid and apolipoprotein synthesis. Secretory and stem cells seem incapable of transport- and metabolism-dependent lipogenesis, occurring only in absorptive enterocytes.
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Fructoquinasas/metabolismo , Fructosa/farmacología , Regulación de la Expresión Génica/efectos de los fármacos , Intestino Delgado/efectos de los fármacos , Animales , Fructoquinasas/genética , Regulación de la Expresión Génica/fisiología , Intestino Delgado/enzimología , RatonesRESUMEN
Increased understanding of fructose metabolism, which begins with uptake via the intestine, is important because fructose now constitutes a physiologically significant portion of human diets and is associated with increased incidence of certain cancers and metabolic diseases. New insights in our knowledge of intestinal fructose absorption mediated by the facilitative glucose transporter GLUT5 in the apical membrane and by GLUT2 in the basolateral membrane are reviewed. We begin with studies related to structure as well as ligand binding, then revisit the controversial proposition that apical GLUT2 is the main mediator of intestinal fructose absorption. The review then describes how dietary fructose may be sensed by intestinal cells to affect the expression and activity of transporters and fructolytic enzymes, to interact with the transport of certain minerals and electrolytes, and to regulate portal and peripheral fructosemia and glycemia. Finally, it discusses the potential contributions of dietary fructose to gastrointestinal diseases and to the gut microbiome.
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Fructosa/metabolismo , Intestinos/fisiología , Animales , Transporte Biológico , Dieta , Regulación de la Expresión Génica , HumanosRESUMEN
OBJECTIVES: Patient education is critical in obtaining informed consent and reducing preoperative anxiety. Written patient education material (PEM) can supplement verbal communication to improve understanding and satisfaction. Published guidelines recommend that health information be presented at or below a sixth-grade reading level to facilitate comprehension. We investigate the grade level of online PEMs regarding parathyroid surgery. METHODS: A popular internet search engine was used to identify PEM discussing parathyroid surgery. Four formulas were used to calculate readability scores: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG). RESULTS: Thirty web-based articles discussing parathyroid surgery were identified. The average FRE score was 42.8 (±1 standard deviation [SD] 16.3; 95% confidence interval [CI], 36.6-48.8; range, 6.1-71.3). The average FKGL score was 11.7 (±1 SD 3.3; 95% CI, 10.5-12.9; range, 6.1-19.0). The SMOG scores averaged 14.2 (±1 SD 2.6; 95% CI, 13.2-15.2; range, 10.7-21.9), and the GFOG scores averaged 15.0 (±1 SD 3.5; 95% CI, 13.7-16.3; range, 10.6-24.8). CONCLUSION: Online PEM on parathyroid surgery is written above the recommended sixth-grade reading level. Improving readability of PEM may promote better health education and compliance.
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Comprensión , Evaluación Educacional/métodos , Internet , Enfermedades de las Paratiroides/cirugía , Paratiroidectomía , Educación del Paciente como Asunto/métodos , Materiales de Enseñanza/normas , Humanos , Lectura , Estudios Retrospectivos , Estados UnidosRESUMEN
Recent technological advances and developments in surgical technique have made the craniocervical junction (CCJ) accessible through the transnasal surgical corridor. Endoscopic endonasal transclival and transodontoid approaches have been previously described in the literature. Traditionally, these approaches entail a posterior bony and mucosal septectomy. This posterior bony and mucosal septectomy can compromise the integrity of the posterior septum and damage the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option. With the possibility of an intraoperative cerebrospinal fluid (CSF) leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. Here, we present a new variation which preserves the mucosal integrity of the posterior nasal septum and PNSF. This mucosal-sparing variation of the traditional endoscopic endonasal transclival and transodontoid approaches allows for the preservation of posterior mucosal nasoseptal integrity, and salvages a reconstructive option for future usage. This is accomplished at no expense to visualization, surgical access, or maneuverability.
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Articulación Atlantoaxoidea/cirugía , Artropatías/cirugía , Tabique Nasal/cirugía , Cirugía Endoscópica por Orificios Naturales/métodos , Compresión de la Médula Espinal/cirugía , Fusión Vertebral/métodos , Vértebras Cervicales , Femenino , Humanos , Artropatías/complicaciones , Artropatías/patología , Persona de Mediana Edad , Mucosa Nasal/cirugía , Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/patologíaRESUMEN
OBJECTIVES: Nodular regenerative hyperplasia (NRH) is a rare vascular disorder of the liver. Clinically, patients present with portal hypertension with or without a cholestatic pattern of injury. Histologically, the liver parenchyma is composed of small nodules of hypertrophic hepatocytes surrounded by atrophic hepatocytes without significant fibrosis. Nodular regenerative hyperplasia is a difficult diagnosis on biopsy specimens, but biopsy remains the gold standard for diagnosis. In this retrospective review, cytokeratin 7 (CK7) immunohistochemistry (IHC) was used to aid in the diagnosis and further characterization of NRH and NRH-like changes. METHODS: The H&E-stained slides, reticulin, and CK IHC were reviewed for 22 cases. The percentage of hepatocytes staining for CK7 (0%-100%), the location of staining (centrilobular hepatic progenitor cells vs periportal/bile ductular reaction), and the pattern of staining distribution (patchy or diffuse) were recorded for comparison. RESULTS: Of the 22 cases, 9 were CK7 positive. Cases of NRH, however, expressed various degrees of CK7 positivity in centrilobular hepatic progenitor cells, unlike NRH-like changes, which were either CK7 negative or CK7 positive in periportal hepatocytes or in areas of bile ductular reaction. CONCLUSIONS: In cases with the appropriate clinical history and histology, CK7 immunohistochemistry can be performed to distinguish nodular regenerative hyperplasia (primary) and NRH-like changes (secondary). In difficult cases, CK7 positivity in centrilobular hepatic progenitor cells can help confirm the diagnosis of NRH. These data support NRH as a true entity with a distinct pathophysiology from NRH-like changes.
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Introduction It has been long established that open surgeries were the only options available for the management of intra-abdominal abscesses or collections. These were associated with increased morbidity and mortality. Traditionally, the idea of percutaneous needling could not gain popularity due to poor localization of collections. However, with the advent of ultrasound, percutaneous pigtail-catheter drainage has proven to be minimally invasive and allows precise localization of the drainage site. Objectives To study the effectiveness of ultrasound-guided pigtail catheter drainage as an alternative to exploratory laparotomy for the management of intra-abdominal abscesses or collections. Materials and methods A total of 48 patient cases, which included liver abscesses, perinephric collections, malignant ascites, splenic collections, pseudocysts, and psoas abscesses, were studied prospectively in a medical college in India from October 2020 to October 2021. The efficacy of the drainage was assessed by serial ultrasound. Results Out of 48 patients, 34 were male and 14 were female, ranging in age from 19 to 64 years, who were diagnosed with intra-abdominal abscesses or collections and underwent ultrasound-guided pigtail catheter drainage. The average hospital stay for patients was 2.5 days. They were followed up periodically for three months post-procedure, and none had significant complications or recurrence. Conclusion The pigtail catheter is the treatment of choice for liquefied intra-abdominal collections or abscesses, which helps to reduce post-procedure hospital stays and complications. Contribution This article reiterates the use of minimally invasive techniques in place of open surgeries with less morbidity.
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CALFAN syndrome is an extremely rare disease consisting of recurrent pediatric acute liver failure (PALF), neurodegenerative diseases, and skeletal abnormalities associated with SCYL1 gene mutation. To date, three of 18 patients reported underwent liver transplantation in infancy and early childhood (7-23 months). Here, we report a case of CALFAN syndrome with infantile onset, recurrent jaundice/PALF requiring liver transplantation in early adulthood. At the most recent follow-up, 3 years after transplantation, the patient is doing well.
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BACKGROUND: Delirium, an acute confusional state highlighted by inattention, has been reported to occur in 10% to 50% of patients with COVID-19. People hospitalized with COVID-19 have been noted to present with or develop delirium and neurocognitive disorders. Caring for patients with delirium is associated with more burden for nurses, clinicians, and caregivers. Using information in electronic health record data to recognize delirium and possibly COVID-19 could lead to earlier treatment of the underlying viral infection and improve outcomes in clinical and health care systems cost per patient. Clinical data repositories can further support rapid discovery through cohort identification tools, such as the Informatics for Integrating Biology and the Bedside tool. OBJECTIVE: The specific aim of this research was to investigate delirium in hospitalized older adults as a possible presenting symptom in COVID-19 using a data repository to identify neurocognitive disorders with a novel group of International Classification of Diseases, Tenth Revision (ICD-10) codes. METHODS: We analyzed data from 2 catchment areas with different demographics. The first catchment area (7 counties in the North-Central Florida) is predominantly rural while the second (1 county in North Florida) is predominantly urban. The Integrating Biology and the Bedside data repository was queried for patients with COVID-19 admitted to inpatient units via the emergency department (ED) within the health center from April 1, 2020, and April 1, 2022. Patients with COVID-19 were identified by having a positive COVID-19 laboratory test or a diagnosis code of U07.1. We identified neurocognitive disorders as delirium or encephalopathy, using ICD-10 codes. RESULTS: Less than one-third (1437/4828, 29.8%) of patients with COVID-19 were diagnosed with a co-occurring neurocognitive disorder. A neurocognitive disorder was present on admission for 15.8% (762/4828) of all patients with COVID-19 admitted through the ED. Among patients with both COVID-19 and a neurocognitive disorder, 56.9% (817/1437) were aged ≥65 years, a significantly higher proportion than those with no neurocognitive disorder (P<.001). The proportion of patients aged <65 years was significantly higher among patients diagnosed with encephalopathy only than patients diagnosed with delirium only and both delirium and encephalopathy (P<.001). Most (1272/4828, 26.3%) patients with COVID-19 admitted through the ED during our study period were admitted during the Delta variant peak. CONCLUSIONS: The data collected demonstrated that an increased number of older patients with neurocognitive disorder present on admission were infected with COVID-19. Knowing that delirium increases the staffing, nursing care needs, hospital resources used, and the length of stay as previously noted, identifying delirium early may benefit hospital administration when planning for newly anticipated COVID-19 surges. A robust and accessible data repository, such as the one used in this study, can provide invaluable support to clinicians and clinical administrators in such resource reallocation and clinical decision-making.
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It is now known that COVID-19 not only involves the lungs, but other organs as well including the gastrointestinal tract. Although clinic-pathological features are well-described in lungs, the histopathologic features of gastrointestinal involvement in resection specimens are not well characterized. Herein, we describe in detail the clinicopathologic features of intestinal resection specimens in four patients with COVID-19 infection. COVID-19 viral particles by in situ hybridization and immunofluorescence studies are also demonstrated. All four patients were males, aged 28-46 years, with comorbidities. They initially presented with a severe form of pulmonary COVID-19 and showed gastrointestinal symptoms, requiring surgical intervention. Histopathologic examination of resected GI specimens, mostly right colectomies, revealed a spectrum of disease, from superficial mucosal ischemic colitis to frank transmural ischemic colitis and associated changes consistent with pneumatosis cystoides intestinalis. Three patients were African American (75%), and one was Caucasian (25%); three patients died due to complications of their COVID-19 infection (75%), while one ultimately recovered from their GI complications (25%), but experienced prolonged sequela of COVID-19 infection including erectile dysfunction. In conclusion, COVID-19 infection, directly or indirectly, can cause ischemic gastrointestinal complications, with predilection for the right colon.
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Solid organ transplant recipients are at risk for a wide range of opportunistic infections, the most common being cytomegalovirus. These infections may occur as reactivation of latent disease, donor-derived, or de novo. In this article, we present a case of acute liver failure secondary to toxoplasmosis following orthotopic liver transplantation. Our patient presented 5 weeks after orthotopic liver transplantation with altered mental status and fatigue. She was found to have disseminated cytomegalovirus infection, which resolved with intravenous ganciclovir; however, she subsequently developed acute liver failure due to toxoplasmosis, which is hypothesized to be donor-derived. Infection with Toxoplasma may be asymptomatic in the immunocompetent host; however, in immunocompromised hosts, such as solid organ transplant recipients, this infection can be life threatening. Though prophylaxis with trimethoprim-sulfamethoxazole may prevent infections with Toxoplasma, it is often held for renal dysfunction, hyperkalemia, or other side effects, placing patients at risk. With 13 cases now reported, routine screening of donor and recipient for toxoplasma exposure may be warranted.
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Fallo Hepático Agudo , Trasplante de Hígado , Toxoplasma , Toxoplasmosis , Femenino , Humanos , Fallo Hepático Agudo/etiología , Trasplante de Hígado/efectos adversos , Donantes de Tejidos , Toxoplasmosis/diagnóstico , Toxoplasmosis/etiologíaRESUMEN
OBJECTIVES/HYPOTHESIS: The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. STUDY DESIGN: Retrospective Cohort study. METHODS: Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. RESULTS: Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P < .05). There was no difference found between free mucosal grafts and miniflaps. CONCLUSIONS: Utilization of mucosa to partially line a circumferentially de-epithelialized drainage pathway after EEA for PACG reduce recurrence rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2513-E2517, 2021.
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Granuloma/cirugía , Membrana Mucosa/trasplante , Hueso Petroso/cirugía , Colgajos Quirúrgicos , Adulto , Anciano , Colesterol , Drenaje/métodos , Endoscopía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Recurrencia , Estudios RetrospectivosRESUMEN
The Combat Wound Initiative (CWI) program is a collaborative, multidisciplinary, and interservice public-private partnership that provides personalized, state-of-the-art, and complex wound care via targeted clinical and translational research. The CWI uses a bench-to-bedside approach to translational research, including the rapid development of a human extracorporeal shock wave therapy (ESWT) study in complex wounds after establishing the potential efficacy, biologic mechanisms, and safety of this treatment modality in a murine model. Additional clinical trials include the prospective use of clinical data, serum and wound biomarkers, and wound gene expression profiles to predict wound healing/failure and additional clinical patient outcomes following combat-related trauma. These clinical research data are analyzed using machine-based learning algorithms to develop predictive treatment models to guide clinical decision-making. Future CWI directions include additional clinical trials and study centers and the refinement and deployment of our genetically driven, personalized medicine initiative to provide patient-specific care across multiple medical disciplines, with an emphasis on combat casualty care.
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Ondas de Choque de Alta Energía/uso terapéutico , Personal Militar , Investigación Biomédica Traslacional , Heridas y Lesiones/terapia , Biomarcadores , Quemaduras/terapia , Ensayos Clínicos como Asunto , Humanos , Neovascularización Fisiológica , Asociación entre el Sector Público-Privado , Estados Unidos , Guerra , Cicatrización de HeridasRESUMEN
BACKGROUND: The femoral component is generally aligned perpendicularly to the distal femoral intramedullary axis with conventional instruments. Various aids like computer navigation, patient-specific instrumentation and robotic surgery use the mechanical axis as the reference for the femoral component alignment. We studied the flexion of the distal femoral intramedullary axis compared to the mechanical axis using an interactive 3D tool in 407 Indian osteoarthritic knees undergoing total knee replacement to better understand optimal flexion alignment. MATERIALS AND METHODS: 407 knees (301-Female, 106-Male) in Indian patients undergoing total knee replacement underwent CT scans. A 3D interactive knee system was used for 3D reconstruction and planning. Distal femoral flexion angle (DFFA) was calculated between the anatomic distal femoral (intramedullary) axis and the mechanical axis. Statistical analysis was performed using ANOVA test and Chi-square test using a data analysis tool pack (Analysis ToolPak by Excel Easy) additionally installed in Microsoft Excel 2010. RESULTS: The mean DFFA was found to be 2.54 with a standard deviation of 1.38. The maximum and minimum values noted were 7.5 and 0.5 respectively. There was no correlation found between sex, age, height or weight (p > 0.05). CONCLUSIONS: While taking the distal femur cut with systems other than an intramedullary rod, in Indian osteoarthritic knees, it would be safer to take the distal femoral cut between 2 and 3 degrees of flexion to mechanical axis, as it would ensure that the cut is within 3 degrees from the anatomic axis for 98% patients. Most surgeons routinely using navigation or similar aids take the cut at 0 degrees of flexion to the mechanical axis. This will lead to more than 3 degrees of extension with reference to the intramedullary axis in more than 39% patients. This would result in either an increase in femoral component sizing or an increased risk of notching.
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Cirrhotomimetic hepatocellular carcinoma is a recognized pattern exhibiting cirrhosis-like growth and a reputation for evading pretransplant detection. Five cases encountered from our institution were retrospectively reviewed. Clinicopathologic and literature reviews were performed. All five patients were male, aged 50-66. Diffuse, innumerable nodules were seen grossly, exhibiting predominantly well-to-moderate differentiation with pseudoglandular and trabecular patterns microscopically. By immunohistochemistry, the tumor was diffusely positive for Glypican-3, showed sinusoidal capillarization by CD34 and slightly increased MIB-1 proliferation index. At up to 3.25 years of follow-up, our cohort of cirrhotomimetic hepatocellular carcinoma had no recurrence in 60% (3/5), solitary recurrence in 20% (1/5) and one patient had died of disease in 20% (1/5). Literature review suggests that these tumors recurred at a frequency of 50% (19 of 38 patients).
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Meckel's cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches-such as the retrosigmoid approach-challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.
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Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a rare primary and highly aggressive intestinal T-cell lymphoma derived from intraepithelial lymphocytes. MEITL is previously designated as type II enteropathy-associated T cell lymphoma (EATL). Unlike to classic form of EATL, MEITL is not associated with celiac disease. The diagnosis of MEITL is very challenging and the clinical outcome of patients with MEITL is very poor. Herein we describe a series of four patients diagnosed with MEITL identified upon a 10-year institutional retrospective review. Histopathologic examination of these cases revealed monotonous population of medium sized cells infiltrating intestinal mucosa, positive for CD3, CD8 and CD56 in all four cases. Two patients had the combination chemotherapy; however, the average survival time was only 7.5 months for these two patients after diagnosis. The aim of the present case series is to highlight the pathology, diagnosis and clinical course of the patients with MEITL based on the current literature.
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Linfoma de Células T Asociado a Enteropatía/diagnóstico , Linfoma de Células T Asociado a Enteropatía/patología , Linfoma de Células T/patología , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor , Linfoma de Células T Asociado a Enteropatía/complicaciones , Epitelio/patología , Femenino , Humanos , Mucosa Intestinal/patología , Linfoma de Células T/complicaciones , Linfoma de Células T/diagnóstico , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Heavy alcohol drinking dysregulates lipid metabolism, promoting hepatic steatosis - the first stage of alcohol-related liver disease (ALD). The molecular circadian clock plays a major role in synchronizing daily rhythms in behavior and metabolism and clock disruption can cause pathology, including liver disease. Previous studies indicate that alcohol consumption alters liver clock function, but the impact alcohol or clock disruption, or both have on the temporal control of hepatic lipid metabolism and injury remains unclear. Here, we undertook studies to determine whether genetic disruption of the liver clock exacerbates alterations in lipid metabolism and worsens steatosis in alcohol-fed mice. To address this question, male liver-specific Bmal1 knockout (LKO) and flox/flox (Fl/Fl) control mice were fed a control or alcohol-containing diet for 5 weeks. Alcohol significantly dampened diurnal rhythms of mRNA levels in clock genes Bmal1 and Dbp, phase advanced Nr1d1/REV-ERBα, and induced arrhythmicity in Clock, Noct, and Nfil3/E4BP4, with further disruption in livers of LKO mice. Alcohol-fed LKO mice exhibited higher plasma triglyceride (TG) and different time-of-day patterns of hepatic TG and macrosteatosis, with elevated levels of small droplet macrosteatosis compared to alcohol-fed Fl/Fl mice. Diurnal rhythms in mRNA levels of lipid metabolism transcription factors (Srebf1, Nr1h2, and Ppara) were significantly altered by alcohol and clock disruption. Alcohol and/or clock disruption significantly altered diurnal rhythms in mRNA levels of fatty acid (FA) synthesis and oxidation (Acaca/b, Mlycd, Cpt1a, Fasn, Elovl5/6, and Fads1/2), TG turnover (Gpat1, Agpat1/2, Lpin1/2, Dgat2, and Pnpla2/3), and lipid droplet (Plin2/5, Lipe, Mgll, and Abdh5) genes, along with protein abundances of p-ACC, MCD, and FASN. Lipidomics analyses showed that alcohol, clock disruption, or both significantly altered FA saturation and remodeled the FA composition of the hepatic TG pool, with higher percentages of several long and very long chain FA in livers of alcohol-fed LKO mice. In conclusion, these results show that the liver clock is important for maintaining temporal control of hepatic lipid metabolism and that disrupting the liver clock exacerbates alcohol-related hepatic steatosis.
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Objective Most pituitary adenomas are of soft consistency and can be resected during surgery with routine suction instruments. However, fibrous adenomas may require more aggressive techniques. The ability to predict consistency on magnetic resonance imaging (MRI) would improve preoperative preparation and may have implications on the extent of resection. Design A retrospective review of MRI and tumor histology of 50 consecutive patients who underwent endoscopic endonasal resection for nonfunctional adenomas was performed. Methods An intensity ratio was calculated based on quantitative MRI signal intensity of the adenoma and pons. Intraoperatively, a sequentially graded technique required for resection ranged from suction (R1) for softer tumors, curettes (R2) for tumors with intermediate consistency, and aspirators and/or other microinstruments (R3) for firmer tumors. Fibrotic content was determined from histologic collagen percentage, and rates of gross total resection (GTR) were calculated from postoperative imaging. Statistical analyses were performed to determine if resection classification could be predicted by intensity ratio or collagen percentage, calculate ratio of cut-off points for clinical use, and assess for correlation between intensity ratios and collagen percentage. Results Tumors with ratios < 1.6 on the T2-weighted coronal image and collagen content > 5.3% were likely to have required a more aggressive resection technique. Statistically significant lower rates of GTR and higher rates of perioperative complications were seen with such tumors. Conclusion Preoperative MRI analyses can be helpful but not definitive in predicting adenoma consistency. Fibrous adenomas, associated with higher collagen content, are more difficult to resect and have higher rates of subtotal resection.
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BACKGROUND: Perioperative steroid management for pituitary adenoma resections is multifaceted due to possible hypothalamic-pituitary-adrenal (HPA) axis disruption. Although many different strategies have been proposed, there is no standard protocol for prophylaxis of potential hypocortisolemia. METHODS: We performed a retrospective analysis of consecutive endoscopic endonasal pituitary adenoma resections. Before March 2016, patients received ≥100 mg of hydrocortisone intraoperatively followed by 2 mg of dexamethasone immediately postoperatively in most of the patients. Subsequently, patients received only 50 mg of hydrocortisone intraoperatively. A morning cortisol level was checked on postoperative day (POD) 2, and if it was <10 mcg/dL, patients remained on maintenance hydrocortisone. At 6 weeks, serum cortisol was redrawn and low-dose therapy was weaned when indicated. RESULTS: Of those who received ≥100 mg of hydrocortisone, 8 of 24 (33.3%) were discharged on hydrocortisone compared to 1 of 14 (7.1%) who received 50 mg. 18 of 24 (75%) of ≥100 mg group received dexamethasone on POD 1, and of those, 8 (44.4%) were discharged on hydrocortisone. Of those who received ≥100 mg and were on outpatient steroid therapy initially, 3 of 8 (37.5%) required continuation after 6 weeks compared to none who received 50 mg. There was an association between patient's intraoperative/immediate postoperative steroid use and steroid continuation at discharge. CONCLUSION: Through our experience, we hypothesize that ≥100 mg of hydrocortisone intraoperatively followed by postoperative dexamethasone may be overly suppressive in patients with otherwise normally functioning HPA. A 50 mg intraoperative dose alone may be considered to lower rates of unnecessary steroid regimens postoperatively.
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BACKGROUND: Pituitary metastasis of cervical adenocarcinoma is an exceedingly rare phenomenon. CASE DESCRIPTION: The authors present a case of a 66-year-old female with cervical adenocarcinoma who was discovered to have a rapidly growing intrasellar mass in the work-up of adrenal insufficiency and hypothyroidism. The patient underwent subsequent endoscopic endonasal subtotal resection of the mass. Histopathological analysis of the resected lesion demonstrated features consistent with metastatic mucinous adenocarcinoma of the cervix. While initially neurologically asymptomatic following surgery, the patient developed an oculomotor nerve palsy several weeks following surgical debulking, at which time neuroimaging revealed marked regrowth and suprasellar extension of the metastatic lesion. CONCLUSIONS: While metastatic cervical adenocarcinoma to the sella is rare, it should be considered in the differential based on the history of the patient.