Endoscopic Endonasal Approach in Craniopharyngiomas: Representative Cases and Technical Nuances for the Young Neurosurgeon.

Craniopharyngiomas (CPs) are Rathke's cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, making its resection a major challenge for the neurosurgeon with important postoperative morbidity. Nowadays, an endoscopic endonasal approach (EEA) provides an "easier" way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient. In this article, we include a comprehensive description of the EEA technique and nuances in CPs resection, including three illustrated clinical cases.

Pharmacological Modulation of the Wnt/ß-Catenin Pathway Inhibits Proliferation and Promotes Differentiation of Long-Lived Memory CD4+ T Cells in Antiretroviral Therapy-Suppressed Simian Immunodeficiency Virus-Infected Macaques.

The major obstacle to human immunodeficiency type 1 virus (HIV-1) eradication is a reservoir of latently infected cells that persists despite long-term antiretroviral therapy (ART) and is maintained through cellular proliferation. Long-lived memory CD4+ T cells with high self-renewal capacity, such as central memory (CM) T cells and stem cell memory (SCM) T cells, are major contributors to the viral reservoir in HIV-infected individuals on ART. The Wnt/ß-catenin signaling pathway regulates the balance between self-renewal and differentiation of SCM and CM T cells, and pharmacological manipulation of this pathway offers an opportunity to interfere with the proliferation of latently infected cells. Here, we evaluated in vivo a novel approach to inhibit self-renewal of SCM and CM CD4+ T cells in the rhesus macaque (RM) model of simian immunodeficiency (SIV) infection. We used an inhibitor of the Wnt/ß-catenin pathway, PRI-724, that blocks the interaction between the coactivator CREB-binding protein (CBP) and ß-catenin, resulting in the cell fate decision to differentiate rather than proliferate. Our study shows that PRI-724 treatment of ART-suppressed SIVmac251-infected RMs resulted in decreased proliferation of SCM and CM T cells and modified the SCM and CM CD4+ T cell transcriptome toward a profile of more differentiated memory T cells. However, short-term treatment with PRI-724 alone did not significantly reduce the size of the viral reservoir. This work demonstrates for the first time that stemness pathways of long-lived memory CD4+ T cells can be pharmacologically modulated in vivo, thus establishing a novel strategy to target HIV persistence.IMPORTANCE Long-lasting CD4+ T cell subsets, such as central memory and stem cell memory CD4+ T cells, represent critical reservoirs for human immunodeficiency virus (HIV) persistence despite suppressive antiretroviral therapy. These cells possess stem cell-like properties of enhanced self-renewal/proliferation, and proliferation of latently infected memory CD4+ T cells plays a key role in maintaining the reservoir over time. Here, we evaluated an innovative strategy targeting the proliferation of long-lived memory CD4+ T cells to reduce viral reservoir stability. Using the rhesus macaque model, we tested a pharmacological inhibitor of the Wnt/ß-catenin signaling pathway that regulates T cell proliferation. Our study shows that administration of the inhibitor PRI-724 decreased the proliferation of SCM and CM CD4+ T cells and promoted a transcriptome enriched in differentiation genes. Although the viral reservoir size was not significantly reduced by PRI-724 treatment alone, we demonstrate the potential to pharmacologically modulate the proliferation of memory CD4+ T cells as a strategy to limit HIV persistence.

Miotomía endoscópica por vía oral (POEM) para el tratamiento de acalasia: nuestras primeras experiencias / Peroral endoscopic myotomy (POEM) for treatment of achalasia: our first experiences

Resumen Introducción: la miotomía endoscópica por vía oral (POEM) se diseñó inicialmente para el manejo de la acalasia, que es un trastorno crónico y progresivo de la motilidad esofágica con hipertensión del esfínter esofágico inferior (EEI), para la cual el manejo estándar, hasta ahora, ha sido la cirugía de Heller; sin embargo, esta nueva técnica ofrece resultados muy comparables y prometedores. Materiales y métodos: se realizó una revisión retrospectiva de las historias clínicas de los pacientes con acalasia operados por POEM en una institución de Colombia por un solo cirujano endoscopista. Resultados: se encontraron 4 pacientes con acalasia, todas con Eckardt ≥10 y presión EEI ≥30 mm Hg; el tiempo quirúrgico osciló entre 81-120 minutos; en el seguimiento, la reducción en la presión del EEI fue mayor al 50% prácticamente en todos los pacientes, encontrando valores cercanos a la normalidad y con resultados de Eckardt que demuestran éxito en la terapia POEM a los 2 meses de evaluación. Las complicaciones fueron resueltas en el intraoperatorio, con mortalidad de 0%. Conclusiones: El manejo de la acalasia mediante POEM ha demostrado ser una técnica eficaz y segura. Nuestros primeros hallazgos concuerdan con los resultados descritos en la literatura. Este es el primer paso para la implementación de este novedoso abordaje en el manejo de la acalasia en la población colombiana.

Abstract Introduction: Peroral endoscopic myotomies (POEMs) were initially designed to manage achalasia, a chronic and progressive esophageal motility disorder with lower esophageal sphincter hypertension (LES). Until recently, standard treatment had been Heller's surgery, but this new technique offers very promising pressure. Materials and methods: This is a retrospective review of the clinical histories of patients with achalasia who underwent POEM performed by one endoscopic surgeon at a Colombian institution. Results: Four patients with achalasia were found. All had Eckardt scores of ten or more and lower esophageal sphincter (LES) pressure of 30mm Hg or more. Surgical times ranged between 81 and 120 minutes. Follow-up examinations found that LES pressure had decreased by more than 50% in practically all patients. Eckardt scores were close to normal. This demonstrates success of POEM therapy after two months of evaluation. Complications were resolved intraoperatively without mortality. Conclusions: Management of achalasia by POEM has proven to be a safe and effective technique. Our first findings agree with the results described in the literature. This is the first step in the implementation of this novel approach for management of achalasia in our Colombian population.

Efficient broadband 400 nm noncollinear second-harmonic generation of chirped femtosecond laser pulses in BBO and LBO.

We report on 400 nm broadband type I frequency doubling in a noncollinear geometry with pulse-front-tilted and chirped femtosecond pulses (λ =800 nm; Fourier transform limited pulse duration, 45 fs). With moderate power densities (2 to 10 GW/cm2) thus avoiding higher-order nonlinear phenomena, the energy conversion efficiency was up to 65%. Second-harmonic pulses of Fourier transform limited pulse duration shorter than the fundamental wave were generated, exhibiting good beam quality and no pulse-front tilt. High energy (20 mJ/pulse) was produced in a 40 mm diameter and 6 mm thick LBO crystal. To the best of our knowledge, this is the first demonstration of this optical configuration with sub-100-fs pulses. Good agreement between experimental results and simulations is obtained.

Comparative efficacy of irbesartan/ hydrochlorothiazide and valsartan/hydrochlorothiazide combination in lowering blood pressure: a retrospective observational study in Oman.

OBJECTIVE: To compare blood pressure (BP) control in patients receiving irbesartan/hydrochlorothiazide (HCTZ) and valsartan/HCTZ at a tertiary care university hospital in Oman. SUBJECTS AND METHODS: This was a retrospective observational study, where 232 patients' medical records were reviewed during a 3-month period, July to September 2010, at Sultan Qaboos University Hospital in Oman. BP readings of the previous 6 months were also retrieved from the electronic medical records. Analyses were conducted using univariate statistical techniques. RESULTS: The mean age of the cohort was 58 ± 11 years (range: 21-88). Sixty-nine (30%) patients were on the irbesartan/HCTZ combination (150/12.5 mg) and 163 (70%) were on the valsartan/HCTZ combination. The patients on the valsartan/HCTZ combination were divided into two subgroups: 117 (72%) received 160/12.5 mg and 46 (28%) 80/12.5 mg. Diabetic patients (43/69, 62%, vs. 61/163, 37%, p < 0.001) and those with diabetic nephropathy (8/69, 12%, vs. 7/163, 4%, p = 0.039) were prescribed more often irbesartan/HCTZ than valsartan/HCTZ. In comparison to the valsartan/HCTZ cohort, the irbesartan/HCTZ group was associated with significant reductions in both systolic BP (SBP; -9 vs. -2 mm Hg; p = 0.021) and diastolic BP (DBP; -5 vs. 0 mm Hg; p = 0.022). BP reductions were noted more in diabetics than nondiabetics with the irbesartan/HCTZ patients associated with significant reductions in both SBP (-12 vs. 5.1 mm Hg; p < 0.001) and DBP (-6.4 vs. 1.9 mm Hg; p = 0.001). CONCLUSIONS: The irbesartan/HCTZ combination was associated with significant reductions in both SBP and DBP when compared with the valsartan/HCTZ combination. Specifically, the reductions were noted more in diabetics than nondiabetics.

Low energy prepulse for 10 Hz operation of a soft-x-ray laser.

The influence on Nickel-like Molybdenum soft-x-ray laser performance and stability of a low energy laser prepulse arriving prior to the main laser pumping pulses is experimentally investigated. A promising regime for 10 Hz operation has been observed. A four times increase in soft-x-ray laser operation time with a same target surface is demonstrated. This soft-x-ray laser operation mode corresponds to an optimum delay between the prepulse and the main pulses and to a prepulse energy greater than 20 mJ. We also show that this regime is not associated with a weaker degradation of the target or any reduced ablation rate. Therefore the role of preplasma density gradient in this effect is discussed.

Concentrations of viable airborne fungal spores and trichloroanisole in wine cellars.

In wineries, unwanted microorganisms present not only hygienic problems but also have a negative influence on wine quality. An evaluation of Austrian/Styrian wine cellars with regard to the volume and the composition of the mycoflora is very important both for the process of wine production and for occupational safety. Thirty-six wine cellars of 20 vintners were investigated with regard to microorganisms in the air and on material surfaces. Moreover, the presence of trichloroanisole in the air was determined by means of solid-phase micro-extraction. Microorganisms were sampled using the six-stage Andersen-Cascade impactor. The results showed that the concentrations of xerophilic fungi in the air of cellars with large visible mold areas (> 80%) reached values up to 1.4 × 104 colony forming units per m³. In the wine cellars fourteen predominant fungal genera were found in the indoor air, the most frequent was Penicillium. Trichloroanisole was detected in the air of wine cellars with large visible moldy patches. The spore concentrations in the cellar air were two times higher in cellars with Zasmidium cellare growth than in cellars without Z. cellare. These results will serve as a database for further studies.

Fourier-limited seeded soft x-ray laser pulse.

We present what we believe to be the first measurement of the spectral properties of a soft x-ray laser seeded by a high-order harmonic beam. Using an interferometric method, the spectral profile of a seeded Ni-like krypton soft x-ray laser (32.8 nm) generated by optical field ionization has been experimentally determined, and the shortest possible pulse duration has been deduced. The source exhibits a Voigt spectral profile with an FWHM of 3.1+/-0.3 mA, leading to a Fourier-transform pulse duration of 4.7 ps. This value is comparable with the upper limit of the soft x-ray pulse duration determined by experimentally investigating the gain dynamics, from which we conclude that the source has reached the Fourier limit. The measured bandwidth is in good agreement with the predictions of a radiative transfer code, including gain line narrowing and saturation rebroadening.

Characterization of self-assembling copolymers in aqueous solutions using Electron Paramagnetic Resonance and Fluorescence spectroscopy.

Electron Paramagnetic Resonance and fluorescence spectroscopy have been used to determine the micropolarity and microviscosity of self-assembling systems based on mmePEG-p(CL-co-TMC) having different PEG chain lengths and different CL/TMC ratios and PEG/MOG/SA (45/5/50) polymers with different PEG chain lengths. Four reporter probes have been used: two spin probes, 16-doxyl stearic acid and 5-doxylstearic acid, and two fluorescent probes, pyrene and 1,3-bis(1-pyrenyl) propane (P3P). We found that the micelles based on mmePEG-p(CL-co-TMC) polymers are of a biphasic nature. The micelles are made of a hydrophilic corona with low viscosity while the core of the micelle is more hydrophobic and more viscous. The outer shell is made up of PEG chains, the hydrophobic part of the chains making the core. The partial hydration of the shell seems to lead to a looser chain network than that associated with deeper domains in the micelles. By contrast, in micelles composed of PEG/MOG/SA, there is no clear domain separation. This is consistent with a spatial configuration of random polymeric chains forming a loose network. In these micelles, the microviscosity is low and the hydrophobicity is high.

New developments and issues in home care policies.

This paper provides an overview of the major trends in the organization of services for the disabled elderly, and the implications for the elderly of the emphasis in recent years on remaining at home in the community. The paper presents an example of changing policies from the experience of Israel, which recently enacted a Community Long-term Care Insurance Law to increase levels of home care entitlements to the severely disabled.

A prospective study of the repeated use of sterilized papillotomes and retrieval baskets for ERCP: quality and cost analysis.

BACKGROUND: The impact on instrument quality and cost of the practice of reusing ERCP accessories has not been fully addressed. METHODS: Twenty-five new papillotomes and 15 new retrieval baskets were labeled and evaluated over time by staff blinded to the number of prior uses. Instruments were scored as to their function for the designated task. The cost of this practice was calculated from the purchase price of accessories and the costs of cleaning, sterilization, and disposal, and then compared with the estimated cost of a practice of one-time use of similar instruments. RESULTS: Twenty-five papillotomes were used 246 times (median 8; mean 9.8). Fifteen retrieval baskets were used 193 times (median 13; mean 12.9). The median survival of both papillotomes and baskets before being considered inadequate (score < 6 out of 10) was 9 uses. There were no complications attributable to using reused equipment. The projected yearly cost savings of using reusable versus disposable instruments was $94,095 for papillotomes and $61,809 for baskets, a 475% and 322% cost reduction, respectively. CONCLUSION: The papillotomes and baskets in this study could be reused reliably and safely multiple times, with considerable cost savings compared with the practice of using disposable instruments.

Quality management for health care in the Middle East and north Africa: professional cooperation as part of the peace process.

BACKGROUND: In 1993, as the peace process opened up new possibilities for professional cooperation, the Quality Management (QM) Program for Health Care Organizations in the Middle East and North Africa was born of a shared perception that there is a high-priority need to improve the quality of health care and to cope with increasing costs and financial pressures. To date 22 health care organizations--including hospitals, primary care centers, health maintenance organizations, and ministries of health--are members of the QM Program and are actively implementing QM projects. DEVELOPMENT OF THE PROGRAM: The QM Program began with an introductory conference, followed by an intensive training course. During the current phase of the program (1996-1999), a variety of facilitation activities--including training visits to the region by international experts, consultation support to member organizations by volunteer mentors in the United States, professional-exchange seminars, and site visits--are being conducted at the regional and national levels. Since the training course, the QM Program member organizations have implemented more than 40 model QM projects to improve both clinical and nonclinical processes. Projects consistent with national and organizational priorities were selected, with an emphasis on fast-paced improvements that reduce costs and enhance patient satisfaction. FUTURE PLANS: The regional QM Program is envisioned to grow in size and strength through a four-year building process. By the year 2000, a cadre of local leaders should be prepared to carry the program forward into the new millennium.

Work satisfaction and health in the middle-aged and elderly.

BACKGROUND: There is evidence that occupational factors that cause psychological strain can affect physical and mental health, but findings are not consistent. METHODS: Work satisfaction was used as a convenient global index of job-related psychological strain. Relationships with general, physical and emotional health, appraised by the use of questions, were examined in workers aged > or = 50 years in a longitudinal community health study in Jerusalem. RESULTS: Positive associations were found both in 1975-1976 and in 1985-1987, with age, origin, education, sex and other variables controlled. The odds ratio in favour of poor general health was 2.8 times as high in dissatisfied workers as in very satisfied ones. Multivariate analyses suggested that the associations were not spurious ones attributable to a proneness to report both dissatisfaction and ill-health. Workers who expressed dissatisfaction in both 1975-1976 and 1985-1987 were particularly unhealthy in 1985-1987. CONCLUSIONS: The findings support the impact of work satisfaction or its determinants on current health, and suggest that persistent dissatisfaction may be especially deleterious to health.

A model of the impact of immigration on health and social service expenditures for the elderly.

"Immigration, primarily from the former Soviet Union, has swelled the population of Israel by 10% between 1990 and 1993 and total population growth by the end of the decade is expected to be over 30%. The research presented here represents part of a larger effort to project needs and costs for the entire population in order to assist health and social welfare services in planning and resource allocation. The paper presents an overview of the current demographic situation in Israel, a theoretical model for estimating the growth in needs, and estimates of needs and costs for services for the elderly population based upon this model."

Understanding the pattern of support for the elderly: a comparison between Israel and Sweden.

Cross-cultural comparison can offer critical input to analyses of the interplay between formal and informal services for the elderly. Israel and Sweden have very different population structures and represent different points on the spectrum of welfare state development: Sweden has a much higher percentage of elderly, a less traditional family structure, and a much more developed system of public support. In addition, there are thought to be different attitudes toward family ties, with a less family-oriented value structure in Sweden. The natural question is to what extent these differences translate into differences in the extent and nature of family support for the elderly. In this article, family structure, living arrangements, disability rates, and formal and informal sources of help in Sweden and Israel are compared at various points in time. While there is a greater rate of formal service provision in Sweden and some substitution for family support seems to have occurred, informal care has nevertheless remained important. In both countries, residential patterns are critical: it is when the elderly live alone that the formal system has tended to replace the family. The rate of institutionalization is particularly important in determining the rate of disabled elderly requiring care, both formal and informal, in the community.