Severe dysphagia due to an esophageal duplication cyst in sixth decade, unusual presentation of a rare pathology.

BACKGROUND: Esophageal duplication cysts are rare congenital tumors usually diagnosed and treated during childhood. Most of them are located in the mediastinum and appear as a mass besides the esophagus. Unfortunately, symptoms are non-specific and depend on the size and location of the mass; therefore, they can easily be missed. If symptoms appear, surgical resection is necessary to prevent troublesome complications. CASE PRESENTATION: We present the case of a 60-year-old woman who presented with severe progressive dysphagia and epigastric pain. After further evaluation, a paraesophageal cystic mass was found, and surgery was required. Non-communicating esophageal duplication cyst was the final diagnosis. CONCLUSION: Esophageal duplication cysts are a rare pathology in adults; their symptoms will vary depending on their size and location. Preoperative diagnosis is difficult as symptoms are non-specific and can be missed. If severe dysphagia, pain, or any other complication appears, surgery should not be delayed.

Retrosigmoid Craniotomy and Intradural Variations: Role of Patient-Specific Preoperative Imaging to Identify Landmarks and Relevant Structures.

OBJECTIVE: There are several landmarks to safely identify the limits of the retrosigmoid approach and its intradural variations; however, there has been little discussion about how those landmarks may vary among patients. METHODS: Patient positions; surface landmarks for the retrosigmoid craniotomy; and structures to recognize for transmeatal, suprameatal, suprajugular, and transtentorial extensions were reviewed. RESULTS: The position of the dural sinuses in relation to the zygomatic-inion line and digastric notch line is readily identified on magnetic resonance imaging. For transmeatal drilling, the position of the semicircular canals, vestibular aqueduct, and jugular bulb is best evaluated on computed tomography. For suprameatal drilling, the labyrinth and the position and integrity of the carotid canal are relevant for planning the anterior extension of the approach. For transtentorial extension, it is desirable to identify incisural structures. For suprajugular drilling, the position of the jugular bulb, invasion of venous structures, and integrity of the roof of the jugular foramen must be checked preoperatively. CONCLUSIONS: The retrosigmoid approach is the workhorse of posterior skull base surgery. By recognizing patient-specific variations in known landmarks, the approach may be tailored prevent complications.

Leukocyte-Rich and Platelet-Rich Fibrin for Skull Base Reconstruction After Endoscopic Endonasal Skull Base Surgery.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) leak is one of the most common complications after endoscopic endonasal approach to the skull base. OBJECTIVE: To analyze the effect of leukocyte-rich and platelet-rich fibrin (L-PRF) as part of a standardized endonasal skull base repair protocol on postoperative infection and CSF leak rate. METHODS: One hundred three patients who underwent an endoscopic endonasal approach and were reconstructed using a standard technique (Group A) were compared with 139 patients using the same protocol with the addition of L-PRF (Group B). Postoperative intracranial infection and CSF leak at 6 months were analyzed. RESULTS: In patients with intraoperative CSF leak, postoperative leak occurred in 10.8% in Group A and 2.6% in Group B ( P .024), and in patients with intraoperative high-flow leaks, the incidences were 11.7% and 3.1%, respectively ( P .048). L-PRF reduced postoperative CSF leak by 76% in cases with intraoperative CSF leak (relative risk 0.24, 95% CI 0.06-0.87) and by 73% of patients with high-flow leak (relative risk 0.27, 95% CI 0.07-0.99). In patients undergoing surgery for diagnoses other than adenomas, there were no cases of postoperative leak in Group B, whereas in Group A occurred in 13.4% of those with intraoperative leaks ( P .047) and 15.8% with high-flow intraoperative leaks ( P .033). No significant differences were found in patients with pituitary adenoma. Meningitis occurred in 0.97% in Group A vs 2.16% in Group B ( P .639), without differences between subgroups. CONCLUSION: L-PRF reduced the rate of postoperative CSF leaks in patients with intraoperative leaks, without differences on postoperative meningitis.

Optimization of G-Quadruplex Ligands through a SAR Study Combining Parallel Synthesis and Screening of Cationic Bis(acylhydrazones).

G-quadruplexes (G4s), secondary structures adopted by guanine-rich DNA and RNA sequences, are implicated in numerous biological processes and have been suggested as potential drug targets. Accordingly, there is an increasing interest in developing high-throughput methods that allow the generation of congeneric series of G4-targeting molecules ("ligands") and investigating their interactions with the targets. We have developed an operationally simple method of parallel synthesis to generate "ready-to-screen" libraries of cationic acylhydrazones, a motif that we have previously identified as a promising scaffold for potent, biologically active G4 ligands. Combined with well-established screening techniques, such as fluorescence melting, this method enables the rapid synthesis and screening of combinatorial libraries of potential G4 ligands. Following this protocol, we synthesized a combinatorial library of 90 bis(acylhydrazones) and screened it against five different nucleic acid structures. This way, we were able to analyze the structure-activity relationships within this series of G4 ligands, and identified three novel promising ligands whose interactions with G4-DNAs of different topologies were studied in detail by a combination of several biophysical techniques, including native mass spectrometry, and molecular modeling.

How I do it: endoscopic endonasal chiasmopexy for optic chiasm prolapse.

BACKGROUND: Prolapse of the optic system into an empty sella is an unusual complication of the management of pituitary tumors. METHOD: We described the technical nuances for an endoscopic endonasal chiasmopexy, the indications for the procedure, and the caveats on the diagnosis of optic chiasm prolapse. CONCLUSION: The endoscopic endonasal chiasmopexy provides a direct route to lift the optic system. In most cases, the procedure may be achieved extradurally, protecting the chiasm from manipulation and postoperative fibrosis.

Retrosigmoid Infralabyrinthine (Suprajugular) Approach to the Jugular Foramen: Indications, Limitations, and Surgical Nuances.

BACKGROUND: Among the several approaches described to the jugular foramen (JF), the retrosigmoid infralabyrinthine (suprajugular) approach was one of the most recently described. OBJECTIVE: To describe the indications, limitations, and operative nuances of the suprajugular approach. METHODS: We provided a pertinent review of the anatomy, indications, preoperative evaluation, surgical steps and nuances, and postoperative management. RESULTS: The suprajugular approach is suitable for tumors occupying the intracranial compartment with limited extension into the JF. Volume, width, and configuration of the foramen dictate the feasibility of the approach. Tumors invading the venous system are not suitable for this approach. Preoperative 3-dimensional MRI and computed tomography are used to evaluate intrajugular extension, relationship between the tumor and the jugular bulb (JB), venous system invasion, and shape of the JF. During surgery, exposition of the entire posterior border of the sigmoid sinus is needed and removing the bone over the JB. After identification of the JF, the jugular notch and intrajugular process of the roof of the foramen are removed and intrajugular resection is completed. In cases of high-riding JB, it may be gently pushed down to allow visualization of the anterior foramen. In cases of JB laceration, it may be repaired using a muscle patch and usually does preclude further resection. CONCLUSION: The suprajugular approach is variation of the retrosigmoid approach that, when properly indicated, provides excellent exposure of the medial JF, with most anatomical variations and intraoperative complications predicted by a comprehensive preoperative evaluation.

Harnessing an emissive guanine surrogate to design small-molecule fluorescent chemosensors of O6-methylguanine-DNA-methyltransferase (MGMT).

The fluorescence properties of an emissive guanine surrogate, thienoguanine (thGN, 2-aminothieno[3,4-d]pyrimidin-4(3H)-one), were exploited to design two real-time chemosensors of O6-methylguanine-DNA-methyltransferase (MGMT), a key DNA repair enzyme involved in the resistance to DNA-alkylating anti-cancer drugs though direct reversal of O6-alkylated guanine adducts.

Acridine-O6-benzylguanine hybrids: Synthesis, DNA binding, MGMT inhibition and antiproliferative activity.

O6-Methylguanine-DNA-methyltransferase (MGMT) is a key DNA repair enzyme involved in chemoresistance to DNA-alkylating anti-cancer drugs such as Temozolomide (TMZ) through direct repair of drug-induced O6-methylguanine residues in DNA. MGMT substrate analogues, such as O6-benzylguanine (BG), efficiently inactivate MGMT in vitro and in cells; however, these drugs failed to reach the clinic due to adverse side effects. Here, we designed hybrid drugs combining a BG residue covalently linked to a DNA-interacting moiety (6-chloro-2-methoxy-9-aminoacridine). Specifically, two series of hybrids, encompassing three compounds each, were obtained by varying the position of the attachment point of BG (N9 of guanine vs. the benzyl group) and the length and nature of the linker. UV/vis absorption and fluorescence data indicate that all six hybrids adopt an intramolecularly stacked conformation in aqueous solutions in a wide range of temperatures. All hybrids interact with double-stranded DNA, as clearly evidenced by spectrophotometric titrations, without intercalation of the acridine ring and do not induce thermal stabilization of the duplex. All hybrids, as well as the reference DNA intercalator (6-chloro-2-methoxy-9-aminoacridine 8), irreversibly inhibit MGMT in vitro with variable efficiency, comparable to that of BG. In a multidrug-resistant glioblastoma cell line T98G, benzyl-linked hybrids 7a-c and the N9-linked hybrid 19b are moderately cytotoxic (GI50 ≥ 15 µM after 96 h), while N9-linked hybrids 19a and 19c are strongly cytotoxic (GI50 = 1-2 µM), similarly to acridine 8 (GI50 = 0.6 µM). Among all compounds, hybrids 19a and 19c, similarly to BG, display synergic cytotoxic effect upon co-treatment with subtoxic doses of TMZ, with combination index (CI) values as low as 0.2-0.3. In agreement with in vitro results, compound 19a inactivates cellular MGMT but, unlike BG, does not induce significant levels of DNA damage, either alone or in combination with TMZ, as indicated by the results of γH2AX immunostaining experiments. Instead, and unlike BG, compound 19a alone induces significant apoptosis of T98G cells, which is not further increased in a combination with TMZ. These results indicate that molecular mechanisms underlying the cytotoxicity of 19a and its combination with TMZ are distinct from that of BG. The strongly synergic properties of this combination represent an interesting therapeutic opportunity in treating TMZ-resistant cancers.

How I do it: endoscopic endonasal approach to the orbital apex.

BACKGROUND: The endoscopic endonasal approach provides an option to approach the medial and inferior orbital apex, with less manipulation of intraorbital structures. METHOD: We described the advantages, complications, caveats, and indications of the endoscopic endonasal approach to the orbital apex. An intraorbital extraconal cavernous malformation is shown as example. CONCLUSION: The endoscopic endonasal approach is a good corridor to the medial and inferior orbital apex, providing good exposure and little manipulation of the intraorbital contents.

Contágios / Contagions / Contagios

A história da humanidade narra sucessivas pestes que assolaram diferentes espaços geográficos, semeando sempre a morte entre as populações, dizimando milhares de pessoas. Sabemo-lo graças aos escritos de figuras históricas que relataram estes longos períodos de infecção, contágio e morte pelo menos desde o século V a.C., em que terá eclodido a primeira peste no continente europeu, conhecida como Peste de Atenas. Ao longo dos séculos que se seguiram, há relatos de reaparecimentos da peste, que proliferaram nas grandes cidades de então. Mais recentemente, o século XX, embora caracterizado pelo desenvolvimento de uma panóplia de medicamentos cada vez mais eficazes, não deixa de ser palco do surgimento de novas epidemias. O presente século XXI, é já indelevelmente marcado pela pandemia da COVID-19. Não obstante os destacados progressos das biotecnologias, as constantes mutações do vírus SARS-CoV-2 e inevitáveis incertezas advenientes colocam-nos numa posição análoga à dos nossos antepassados ignorantes relativamente às pestes que os assolavam.

The history of humanity narrates successive plagues that have struck different geographical areas, always sowing death among the populations, decimating thousands of people. We know this thanks to the writings of historical figures who have reported these long periods of infection, contagion and death since at least the 5th century b.C., when the first plague on the European continent, known as the Athens Plague, broke out.Over the centuries that followed, there are reports of plague reappearances, striking the great cities of that time. More recently, the 20th century, although characterized by the development of a panoply of increasingly effective drugs, is still the stage for the emergence of new epidemics. The present 21st century is already indelibly marked by the COVID-19 pandemic. Despite the remarkable advances in biotechnology, the constant mutations of the SARS-CoV-2 virus and inevitable uncertainties arising from it puts us in a position analogous to that of our ignorant ancestors regarding plagues that plagued them.

La historia de la humanidad narra sucesivas plagas que han azotado diferentes áreas geográficas, siempre sembrando la muerte entre las poblaciones, diezmando a miles de personas. Lo sabemos gracias a los escritos de personajes históricos que han informado de estos largos períodos de infección, contagio y muerte desde al menos el siglo V a.C., cuando estalló la primera plaga en el continente europeo, conocida como la Peste de Atenas.A lo largo de los siglos que siguieron, hubo informes de reapariciones de la plaga, golpeando las grandes ciudades de esa época. Más recientemente, el siglo XX, aunque se caracterizó por el desarrollo de una panoplia de medicamentos cada vez más eficaces, sigue siendo el escenario para la aparición de nuevas epidemias. El presente siglo XXI ya está marcado de forma indeleble por la pandemia de COVID-19. A pesar de los notables avances en biotecnología, las constantes mutaciones del virus SARS-CoV-2 y las inevitables incertidumbres que derivan de él, nos colocan en una situación análoga a la de nuestros antepasados ignorantes respecto a las plagas que los asolaron.

Pseudo-Cerebrospinal Fluid Leaks of the Anterior Skull Base: Algorithm for Diagnosis and Management.

Objective Pseudo-cerebrospinal fluid (CSF) leaks are a rare cause of unilateral, watery rhinorrhea. We proposed a step-wise approach to evaluate these cases. Design It involves a single-center retrospective cohort study. Setting The setting is that of a tertiary academic medical center. Participants Ten patients with diagnosis of pseudo-CSF leak over a 21-year period were evaluated using our proposed algorithm that includes computed tomography, magnetic resonance imaging, nasal endoscopy, ß-2 transferrin, intrathecal fluorescein, and surgical exploration of the anterior cranial base. Main Outcome Measures The occurrence of intracranial infection and resolution of the symptoms were evaluated at a mean follow-up of 94.4 months. Results Eight patients had history of skull base fracture or surgery. In all patients computed tomography, magnetic resonance imaging, and nasal endoscopy did not show signs of CSF leak. Beta-2 transferrin testing was performed in five patients, being negative in all of them. Intrathecal fluorescein was performed in seven patients, being negative in five and inconclusive in two. Surgical exploration was performed in five patients, definitively ruling out CSF leak. Six patients were treated with intranasal ipratropium, resolving the symptoms in all cases. Conclusion The presented algorithm provides a step-wise approach for patients with unilateral watery rhinorrhea, allowing to safely ruling out CSF leak.

Visual Outcomes after Endoscopic Pituitary Surgery in Patients Presenting with Preoperative Visual Deficits.

Introduction Pituitary adenomas represent 15% of primary brain tumors. Visual disturbance is a common clinical manifestation of these neoplasms due, among other factors, to local mass effect on the optic system. Objective To evaluate changes of the visual fields in patients undergoing endoscopic endonasal approach (EEA) for pituitary adenomas and to find predictive factors for successful visual field outcome. Material and Methods This is a cross-sectional study. A review was conducted of medical records of consecutive patients with tumors of the sellar region undergoing EEA between January 2008 and December 2012 at the Skull Base Unit of Guillermo Grant Benavente Hospital, University of Concepción, Concepción, Chile, and who had undergone pre- and postoperative visual field evaluation. Results A total of 35 patients, with a mean age of 50.2 years, fulfilled the inclusion criteria. All patients had objective visual field disturbances before the surgery. Following surgery, 25 patients (71.4%) had favorable outcomes, whereas 8 (22.8%) had no change and 2 (5.8%) had an unfavorable outcome. Complete tumor removal was associated with a better visual outcome than those obtained after a subtotal removal. Discussion The EEA for pituitary tumors is particularly effective for visual field disturbances, with reported improvement rates ranging from 50 to 90%. Our series show similar results, with a 71.4% improvement of visual field disturbances. Conclusion This study adds further evidence to the current belief that EEA for pituitary adenomas is a safe and effective technique to improve visual field alterations. Complete removal of the tumor during surgery seems to be a predictive factor for a good visual outcome.

Role of Leukocyte-Platelet-Rich Fibrin in Endoscopic Endonasal Skull Base Surgery Defect Reconstruction.

Objective Advancements in endoscopic endonasal approaches have increased the extent and complexity of skull base resections, in turn demanding the development of novel techniques for skull base defect reconstruction. The objective of this pilot study was to investigate the effect of leukocyte-platelet-rich fibrin (L-PRF) on the postoperative healing after endoscopic skull base surgery. Methods Between January and May of 2015, 47 patients underwent endoscopic endonasal resection of sellar, parasellar, and suprasellar lesions with the application of L-PRF membranes during the skull base reconstruction at two surgical centers. Early postoperative records were retrospectively reviewed. Results We found that 21 days following the surgery, 17/41 patients (42%) demonstrated improvement in the crusting score as compared with their 7 day postoperative examination. Ten of these patients (23%) showed no crusting. Fourteen (34%) patients had no change in the crusting score. Six patient records were incomplete. A total of 4/47 cases (8.5%) had postoperative cerebrospinal fluid leak requiring surgical repair. Conclusion This study demonstrates the potential utility of L-PRF membranes for skull base defect reconstruction. Future studies will be conducted to better assess the role of L-PRF in endoscopic skull base surgery.

Potential Effect of Leukocyte-Platelet-Rich Fibrin in Bone Healing of Skull Base: A Pilot Study.

BACKGROUND: Reconstruction of surgical defects following cranial base surgery is challenging. Others have demonstrated that leukocyte-platelet-rich fibrin (L-PRF) stimulates tissue healing and bone regeneration. However, these studies have addressed mostly maxillofacial surgical wounds. OBJECTIVE: The objective of this study was to assess the possible adjuvant role of L-PRF in inducing neoossification of the surgical bone defect in anterior skull base surgery. METHODS: We identified patients who had undergone an endoscopic endonasal surgery of the anterior skull base in which L-PRF membranes were used for the reconstruction of the bone defect and who were followed up with postoperative CT scans. CT findings were then correlated with baseline scans and with the CT scans of a patient who had undergone imaging and histologic analysis after maxillofacial surgery in which L-PRF was used and in which we demonstrated bone formation. RESULTS: Five patients fulfilled the inclusion criteria. In four patients, the CT scan demonstrated closure of the bony defect by neoosteogenesis; however, the bone appeared less dense than the surrounding normal bone. A comparison with the control patient yielded similar radiological features. CONCLUSION: This case series suggests that L-PRF may induce bone healing and regeneration at the surgical site defect. Multi-institutional studies with a larger series of patients are required to confirm this possibility.

Origen anómalo de la arteria coronaria izquierda: reporte de un caso / Anomalous origin of left coronary artery: case report

Se presenta el caso de una paciente de 8 años que acude a control médico por soplo cardiaco. El ecocardiogama evidencia valvulopatía mitral; recibe tratamiento con digoxina y enalapril que producen una leve mejoría, pero posteriomlente se manifiesta disnea que conduce a una nueva evaluación. Se realiza nuevo esquema diagnóstico por medio de tomografia helicoidal y cateterismo que permiten diagnosticar anomalía coronaria izquierda que nace en la arteria pulmonar. La paciente ingresó a esta institución de salud para proceder a la cOITección quirúrgica del origen anómalo de la arteria coronaria y plastia valvular. Fue dada de alta sin complicaciones y con tratamiento ambulatorio profiláctico para endocarditis bacteriana por patología valvular.

Malformación quística adenomatoide pulmonar congénita tipo 4 / Pulmonary congenital cystic adenomatoid malformation type 4

La malfonnación quística adenomatoide pulmonar congénita (MAQC) es una lesión poco frecuente; su etiología y patogenia son desconocidas. Se trata de una anomalía de la diferenciación embrionaria pulmonar que da como resultado la formación de estructuras quísticas; puede ser diagnosticado, durante el período prenatal, mediante ecografia. Su expresión clínica es variable y una vez diagnosticado, su tratamiento es quirúrgico

Acceso endoscopico a la silla turca / Endoscopic access to the turkish chair

El uso endoscopico en el manejo de lesiones selares se ha dinfundido en la ultima década, luego de la experiencia ganada en el tratamiento de lesiones de senos paranasales, el acceso a la logia selar parece ser una progresión lógica. Las ventajas de la técnica endoscopica en relación al microscopio quirúrgico han sido discutidas en la literatura. La familiaridad de esta técnica para los neurocirujanos debe obtenerse potenciando el trabajo en equipo con otorrinolaringólogos y realizando una curva de aprendizaje que incluye el trabajo en cadáver. Se presenta la experiencia inicial con 5 casos de tumores selares tratados con acceso transesfenoidal endoscopico, se revisa la literatura pertinente y se discuten las ventajas y desventajas de la técnica

Análisis Económico de la Construción de Terrazas de Banco y Cultivo de Cebolla en la Comunidad de Rodeo Provincia Tapacarí

CIDASC: La construcciòn de pràcticas de conservaciòn de suelos (Terrazas de banco, zanjas de infiltraciòn y otros) representa un gasto econòmico para el campesino. Por otra parte el desconocimiento de los beneficios que ocasionan las pràcticas conservacionistas contribuyen al aumento cada vez mayor de àreas si vegetaciòn. Con el objeto de analizar los costos de construcciòn de terrazas de banco, a partir de la economìa de reciprocidad y economìa de mercado. Asimismo comprobar el efecto de las pràcticas y analizar la rentabilidad y factibilidad econòmica a corto plazo. Los beneficios obtenidos con las terrazas de banco son de 163

màs en relaciòn a la parcela testigo por o que econòmicamente esfactible y rentable la ejecuciòn de la obra conservacionista. Con referencia a la evaluaciòn social el nùmero de integrantes adecuado para la construcciòn de terrazas a travès del ayni es de 5 a 8; asimismo el corte y relleno de tierra son considerados como las actividades màs laboriosas en la construcciòn de terrazas; la època seca es la màs propicia para la ejecuciòn de pràcticas conservacionistas. Por otro lado los campesinos evidenciaron un control efectivo de la erosiòn hìdrica, lavado de materia orgànica y el mejoramiento de la producciòn en las parcelas con conservaciòn.

Exito de la inducción oxitócica con malas condiciones obstétricas / The success of oxytocic induction in severe obstetric conditions

Se presenta un estudio prospectivo del éxito de la inducción oxitócica en diversas situaciones obstétricas con membranas íntegras, según condiciones obstétricas agrupadas en 60 casos con malas condiciones y 60 con buenas condiciones obstétricas, con protocolo de inducción iterativa hasta por tres días. Se registró un 76,7% de parto vaginal con malas condiciones obstétricas, y 100% con buenas condiciones obstétricas, no demostrándose diferencias en cuanto a complicaciones de la inducción, y morbilidad perinatal y materna asociada. Se recomienda, frente a la necesidad de interrupción del embarazo, no inmediata, con membranas íntegras, con malas condiciones obstétricas, la alternativa de la inducción oxitócica, por su alta posibilidad de éxito sin riesgos mayores maternos o fetales, con las ventajas inherentes a la reducción del índice de cesáreas en este grupo