Non-functional recurrent pituitary adenoma with intracranial metastasis-Pituitary carcinoma: A case report and review of the literature.

INTRODUCTION: Pituitary carcinomas are rare, with only a few case reports to date. We present a null cell type non-functioning pituitary carcinoma (NFPC) with intracranial metastases and a review of the literature. CASE REPORT: A 56-year-old male with a history of an aggressive pituitary adenoma was admitted. Initial MRI highlighted a large intracranial mass with leptomeningeal involvement, simulating meningioma. Based on his previous pathology report of the sellar mass, a diagnosis of null cell type non-functioning pituitary carcinoma has been made. CONCLUSIONS: An aggressive recurrent pituitary tumor with suprasellar and/or cavernous sinus invasion is the main characteristics of the NFPC. Single or multiple enhancing dural-based mass(es) mimicking meningioma is the most common MRI finding. The proof of malignancy is the same histopathological features of the recurrent aggressive pituitary tumor in the metastases. The histology alone is not distinctive in terms of malignancy. Most patients require a combined surgery, radiotherapy and chemotherapy.

Resuscitation quality of rotating chest compression providers at one-minute vs. two-minute intervals: A mannequin study.

OBJECTIVE: The aim of this randomized cross-over study was to compare one-minute and two-minute continuous chest compressions in terms of chest compression only CPR quality metrics on a mannequin model in the ED. MATERIALS AND METHODS: Thirty-six emergency medicine residents participated in this study. In the 1-minute group, there was no statistically significant difference in the mean compression rate (p=0.83), mean compression depth (p=0.61), good compressions (p=0.31), the percentage of complete release (p=0.07), adequate compression depth (p=0.11) or the percentage of good rate (p=51) over the four-minute time period. Only flow time was statistically significant among the 1-minute intervals (p<0.001). In the 2-minute group, the mean compression depth (p=0.19), good compression (p=0.92), the percentage of complete release (p=0.28), adequate compression depth (p=0.96), and the percentage of good rate (p=0.09) were not statistically significant over time. In this group, the number of compressions (248±31 vs 253±33, p=0.01) and mean compression rates (123±15 vs 126±17, p=0.01) and flow time (p=0.001) were statistically significant along the two-minute intervals. There was no statistically significant difference in the mean number of chest compressions per minute, mean chest compression depth, the percentage of good compressions, complete release, adequate chest compression depth and percentage of good compression between the 1-minute and 2-minute groups. CONCLUSION: There was no statistically significant difference in the quality metrics of chest compressions between 1- and 2-minute chest compression only groups.

Assessment of Palliative Care in Lung Cancer in Turkey.

OBJECTIVE: To investigate the symptoms of lung cancer in Turkey and to evaluate approaches to alleviate these symptoms. SUBJECTS AND METHODS: This study included 1,245 lung cancer patients from 26 centers in Turkey. Demographic characteristics as well as information regarding the disease and treatments were obtained from medical records and patient interviews. Symptoms were evaluated using the Edmonton Symptom Assessment Scale (ESAS) and were graded on a scale between 0 and 10 points. Data were compared using the χ2, Student t, and Mann-Whitney U tests. Potential predictors of symptoms were analyzed using logistic regression analysis. RESULTS: The most common symptom was tiredness (n = 1,002; 82.1%), followed by dyspnea (n = 845; 69.3%), appetite loss (n = 801; 65.7%), pain (n = 798; 65.4%), drowsiness (n = 742; 60.8%), anxiety (n = 704; 57.7%), depression (n = 623; 51.1%), and nausea (n = 557; 45.5%). Of the 1,245 patients, 590 (48.4%) had difficulty in initiating or maintaining sleep. The symptoms were more severe in stages III and IV. Logistic regression analysis indicated a clear association between demographic characteristics and symptom distress, as well as between symptom distress (except nausea) and well-being. Overall, 804 (65.4%) patients used analgesics, 630 (51.5%) received treatment for dyspnea, 242 (19.8%) used enteral/parenteral nutrition, 132 (10.8%) used appetite stimulants, and 129 (10.6%) used anxiolytics/antidepressants. Of the 799 patients who received analgesics, 173 (21.7%) reported that their symptoms were under control, and also those on other various treatment modalities (dyspnea: 78/627 [12.4%], appetite stimulant: 25/132 [18.9%], and anxiolytics/antidepressants: 25/129 [19.4%]) reported that their symptoms were controlled. CONCLUSION: In this study, the symptoms progressed and became more severe in the advanced stages of lung cancer, and palliative treatment was insufficient in most of the patients in Turkey.

Evaluation of auditory functions in patients with asthma.

OBJECTIVE: The objective of this study is to evaluate the auditory functions in chronic asthma patients with the use of pure tone high frequency audiometry. PATIENTS AND METHODS: Twenty-two healthy controls and 42 adult patients were included as a prospective, randomized, and controlled study. Pulmonary function tests and blood gas studies were completed on all subjects. Asthma patients have divided into two groups [Group A: Arterial oxygen tension (PaO2) > 75 mmHg, Group B: PaO2 ≤ 75 mmHg, Group C: Control group). Acoustic assessments of patients were performed in 250-20,000 Hz by using pure-tone audiometry (PTA) and tympanometry. RESULTS: The mean value of air and bone conduction hearing threshold levels were in normal range for all groups. All patients had normal peripheral hearing all threshold levels across 250 Hz to 3000 Hz in the both ears. Significant differences were observed between the chronic asthma patients and control group for the extended high frequencies (10,000-20,000 Hz). Group B had statistically more significant increased hearing threshold levels than Group A in frequencies higher than 10,000 Hz. There were no statistical differences between the hearing threshold levels and FEV1, FVC, FEV1/FVC and tympanogram results in the groups. CONCLUSIONS: This is the first study of evaluating the auditory functions in asthma patients. Sensorineural hearing loss in high frequencies (10,000 Hz-20,000 Hz) is common in chronic asthma and is probably present more often than were formerly thought.

Effect of verapamil and lidocaine on TRPM and NaV1.9 gene expressions in renal ischemia-reperfusion.

BACKGROUND: To determine effects on calcium and sodium channels of Ca(2+) and Na(+) channel blockers in the present study, expression levels of TRPM1, TRPM2, TRPM3, TRPM4, TRPM5, TRPM6, TRPM7, TRPM8, and NaV1.9 genes were evaluated in kidney tissues after induced ischemia-reperfusion. MATERIAL AND METHODS: Forty albino Wistar male rats were equally divided into 4 groups as follows: group I: control group (n = 10), group II: ischemia group (60 minutes of ischemia + 48 hours of reperfusion; n = 10), group III: ischemia (60 minutes of ischemia + 48 hours of reperfusion) + calcium channel blocker (n = 8), group IV: ischemia (60 minutes of ischemia + 48 hours of reperfusion) + sodium channel blocker (n = 8). RESULTS: When compared to ischemia group expression levels of TRPM2, TRPM4, TRPM6, and NaV1.9 in Ca(2+) and Na(+) channel blocker groups were increased, whereas that of TRPM7 was decreased. However, expression levels of TRPM1, TRPM3, TRPM5, and TRPM8 were not determined in kidney tissue. Histologically, the Ca(2+) channel blocker verapamil and the Na(+) channel blocker lidocaine inhibited the cell death in kidney tissue compared to control. CONCLUSION: Our study suggested that verapamil and lidocaine significantly reduce the degree of ischemia-reperfusion injury due to effects to TRPM and Nav1.9 genes.

Long-term follow-up of chronic obstructive pulmonary disease patients on long-term oxygen treatment.

AIMS: Few studies exist on influence of long-term oxygen treatment (LTOT) on survival of chronic obstructive pulmonary disease (COPD) patients. This study was designed to determine whether LTOT improves survival or not in severely hypoxaemic COPD patients. MATERIALS: COPD patients prescribed oxygen concentrator were consecutively included. Patients' baseline characteristics were noted. During follow-up, patients were divided into three groups according to LTOT utilisation: (i) non-utilisers, (ii) intermittent utilisers (< 15 h/day) and (iii) true utilisers (≥ 15 h/day). Patients' status (live or death) and, if died, the date of death were checked throughout the study. The factors which might influence mortality during 5-year period were analysed. RESULTS: Two-hundred and twenty-eight patients completed the study. Of these patients, 55 were in Group 1, 112 were in Group 2 and 61 were in Group 3. Regarding the initial characteristics, there was not any significant difference between groups. Mean follow-up for whole group was 27.8 ± 18.5 months. Median survivals were similar between groups (19.5 ± 5.6, 32.5 ± 4.1 and 30.0 ± 5.7 months respectively) (p > 0.05). Compared with Group 1, survival was improved in Group 2 (p < 0.05) and there was a positive trend for Group 3 during first 2-year period. However, this improvement disappeared during further follow-up. Analysis of multiple factors which might influence mortality during 5-year period did not yield statistically significant parameter. DISCUSSION AND CONCLUSION: We found that, regarding survival, any kind of LTOT proved to be beneficial over no LTOT only in the first 2 years of follow-up, and that there was not any difference between intermittent and true LTOT utilisation.

Gamma knife radiosurgery in non small cell lung cancer patients with brain metastases: treatment results and prognostic factors.

PURPOSE: To evaluate the efficacy of gamma knife radiosurgery (GKRS) for the treatment of brain metastases from non small cell lung cancer (NSCLC) and find out the prognostic factors for overall survival. METHODS: Between February 1997 and August 2003 100 patients underwent treatment for 184 brain metastases from NSCLC, either for recurrence (n=49) or with a new diagnosis (n=51). Median age was 55 years and 77 patients were male. Seventy-eight of the patients received whole brain radiotherapy (WBRT) prior to or after GKRS and 26 patients had surgical removal of the metastasis. Imaging and clinical status were monitored every 3 months following treatment. Kaplan-Meier survival curves, Cox proportional hazards regression for risk factor analysis were used. RESULTS: The median follow up after the procedure was 8 months and after the diagnosis 11 months. The median overall survival for all patients was 9 months from the date of GKRS and 14 months from the diagnosis of brain metastasis. Local tumor control was achieved in 95% of the lesions. In multivariate analysis, adenocarcinoma histology, Karnofsky performance status (KPS) score > 80, 1-3 metastases and tumor diameter <2 cm were related to longer survival. Addition of WBRT did not have any effect on overall survival. CONCLUSION: Gamma knife surgery appears to be effective in treating patients with brain metastases from NSCLC, either alone or with WBRT in selected groups of patients.

Anterior clinoidal meningiomas: analysis of 43 consecutive surgically treated cases.

BACKGROUND: Anterior clinoidal meningiomas are considered different from meningiomas of the medial sphenoid wing, but there is still some confusion about identification. The current classification scheme only considers tumour origin and invasion pattern around the clinoid process as indicators of resectability. However, the size of the tumour has important effects on surgical outcome. The purpose of this study was to analyze our clinical experience with anterior clinoidal meningiomas and refine the current classification scheme. METHOD: Forty-three consecutive cases of anterior clinoidal meningioma were retrospectively analyzed. All were surgically treated at the Marmara University Department of Neurosurgery, the Marmara University Institute for Neurological Sciences, and the Department of Neurosurgery at Acibadem Hospital between 1987 and 2006. A pterional approach was used in all cases. FINDINGS: The mean tumour volume was 34.2 +/- 46.6 cc. Sixteen (37.2%) of the tumours were giant (largest diameter >4 cm). Total surgical removal was achieved in 39 cases (90.7%) and subtotal removal in 4 cases (9.3%). Eight patients (18.6%) developed early postoperative complications. The median and range of follow-up time was 39, R = 99 (3, 102) months. Four (9.3%) of the 43 tumours recurred during follow-up and were treated with radiosurgery. CONCLUSION: Anterior clinoidal meningioma is a separate disease entity from other meningiomas of the medial third of the sphenoid wing. Relatively good outcomes can be stated in this specific subgroup if growth criteria competable with true diagnosis are fulfilled. Size should be incorporated into any classification scheme for determining clinical and surgical risk. The standard pterional approach is sufficient for removing anterior clinoidal meningiomas.

Gamma-knife radiosurgery in the treatment of trigeminal schwannomas.

BACKGROUND: Trigeminal nerve schwannomas account for 0.07%-0.28% of all intracranial tumours. Advances in skull base surgery have led to more aggressive resection of these tumours, but surgery may associated with development of new neurological deficits. METHODS: In this report, we analyse the long-term results 15 patients with newly diagnosed or residual/recurrent trigeminal schwannoma who underwent gamma-knife treatment. FINDINGS: During a mean 61 months of follow-up, MRI revealed reduction of tumour size in 13 and no size change in 2 patients. The tumour growth control rate was 100% and only 1 patient had transient facial numbness and diplopia. CONCLUSIONS: For patients with small to moderate size trigeminal schwannomas, gamma-knife radiosurgery is associated with good tumour control and a minimal risk of adverse radiation effects.

Efficacy of gamma-knife surgery for treating meningiomas that involve the superior sagittal sinus.

BACKGROUND: Meningiomas involving the superior sagittal sinus (SSS) are among the most challenging tumors to treat. Authors of some recent series have advocated total removal with SSS reconstruction. However gamma-knife surgery is a reasonable choice for these tumors. PATIENTS: This study focused on 43 cases of meningioma invading the SSS that were treated with gamma-knife therapy. Twenty-eight patients had undergone previous resection. The follow-up period after radiosurgery ranged from 24 to 86 months (median, 46 months). The median marginal dose was 15 Gy. RESULTS: During follow-up, 22 (51%) tumors decreased in size, 16 (37%) remained unchanged, and 5 (12%) expanded. The overall rate of tumor control with radiosurgery was 89%. CONCLUSION: When a small meningioma involves the SSS and the sinus is patent, the first-line treatment should be radiosurgery. If the tumor is large and the sinus is patent, we recommend gross total resection with no removal of SSS. If postoperative or follow-up MR imaging demonstrates residual tumor or recurrence, gamma-knife surgery should be performed. If a large meningioma has completely obliterated the SSS, our policy is to remove the tumor and all sinus tissue without reconstructing the SSS.

Biventricular involvement in a Turkish boy with palmoplantar hyperkeratosis and curly hair, an unusual presentation of Naxos-Carvajal syndrome.

Naxos disease is an autosomal recessively inherited familial syndrome characterized by woolly hair, palmoplantar keratoderma and a cell adhesion cardiomyopathy, especially arrhythmogenic right ventricular dysplasia (ARVD). Carvajal syndrome is a variant of Naxos disease in which curly or woolly hair, biventricular--predominantly left ventricular involvement were seen. Mutations in genes encoding the cell adhesion proteins like plakoglobin and desmoplakin were related with these syndromes. We report a 17-year-old boy and his family findings with curly hair, palmoplantar hyperkeratosis, ARVD and left ventricular involvement. The family was of Arabic origin, and a third-degree consanguinity was reported between the parents. They are from east part of Turkey and there were no relatives from Cyclades Island (Greece). Patient's younger brother had ARVD without cutaneous manifestations of the syndrome and his grand father had mild ARVD, curly hair and palmoplantar hyperkeratosis.

Relation between proinflammatory to anti-inflammatory cytokine ratios and long-term prognosis in patients with non-ST elevation acute coronary syndrome.

OBJECTIVE: To investigate the relation between serum high sensitivity (hs) C reactive protein (CRP), proinflammatory cytokine concentrations, proinflammatory to anti-inflammatory cytokine ratios and long-term prognosis in patients with non-ST elevation acute coronary syndrome (NSTEACS). DESIGN: Prospective follow-up study for the first six months and then for the first year after admission to hospital. SETTING: Tertiary referral centre. PATIENTS: 80 patients (60 men, 20 women, mean age 60 (SD 10) years) with NSTEACS and moderate to high TIMI (Thrombolysis In Myocardial Infarction) risk scores. INTERVENTIONS: Blood samples from patients with NSTEACS were obtained at the time of admission. Serum concentrations of hs-CRP, (hs) pro-inflammatory (interleukin (IL) -1beta, IL-6, tumour necrosis factor alpha) and (hs) anti-inflammatory (IL-10) cytokines were analysed and proinflammatory to anti-inflammatory cytokine ratios were calculated by dividing proinflammatory cytokine concentrations by anti-inflammatory cytokine IL-10. MAIN OUTCOME MEASURE: The primary end point of the study was new coronary events (NCE) defined as the combination of cardiac death, non-fatal myocardial infarction and recurrent rest angina that required hospitalisation within 12 months of follow up. RESULTS: During the one-year follow-up period, 23 patients (29%) met the NCE criteria. Concentrations of hs-CRP, IL-1beta and IL-6 and ratios of IL-1beta:IL-10 and IL-6:IL-10 were significantly higher in patients with NCE than in patients without NCE. In the logistic regression analysis, IL-6:IL-10 ratio was the most important predictor for NCE (p = 0.006) with an odds ratio of 2.24 (95% CI 1.26 to 3.97). CONCLUSIONS: Cytokine concentrations and proinflammatory to anti-inflammatory cytokine ratios may be useful markers for predicting vascular risk in patients with NSTEACS.

Outcome determinants of pterional surgery for tuberculum sellae meningiomas.

BACKGROUND: Current literature on tuberculum sellae meningiomas is very heterogenous due to wide variation in nomenclature, diagnostic and operative techniques. The aim of this study is specifically to analyze the results of pterional craniotomy for tuberculum sellae meningiomas. A homogenous cohort of 42 consecutively operated tuberculum sellae meningioma cases are reviewed with special emphasis on the effects of pterional microsurgery on visual outcome. METHODS: This is a retrospective clinical analysis. 42 consecutive patients operated upon during the period of 15 years in a single institution using standard imaging protocols and pterional microsurgery are presented and effect of various variables on visual outcome analysed. FINDINGS: 81% of the patients presented with visual symptoms. The mean duration of symptoms was 12 months. Tumour volumes ranged from 7.5 to 210 mm(3). A right sided pterional microsurgery was used in all patients. Complete resection rate was 81%. Vision improved in 58%, worsened in 14%. Non-visual morbidity was 7.1% and mortality was 2.4%. The follow up period of patients ranged from 3 to 192 months (median: 30 months). The mean was 37.5 months (SD = +/-36.7 months) and a recurrence rate of 2.4% was observed. CONCLUSIONS: A standard pterional craniotomy using microsurgical technique provides the necessary exposure enabling total removal while keeping the complications to a minimum. Upon analysis of our findings we found that patient age of more than 60, duration of visual symptoms longer than 1 year, severe visual symptomatology, predominantly vertical growth, presence of significant peri-tumoural oedema, absence of an intact arachnoid plane and subtotal removal were correlated with a dismal visual outcome.

Microsurgical anatomy of the lateral walls of the pituitary fossa.

BACKGROUND: The aim was to evaluate the microanatomy of the lateral wall of the pituitary fossa in cadavers. METHODS: Histological sections of sellar-parasellar specimens from 13 cadaver heads were examined. The thickness of the pituitary capsule and inferior and lateral walls of the pituitary fossa were measured, and the collagenous structure of these layers was evaluated. FINDINGS: The pituitary gland is enveloped by a tough, thin, fibrous capsule. The inferior wall of the pituitary fossa is composed of relatively thick dura (mean thickness in the 13 specimens, 171 microm). Each lateral wall of the fossa has a thin layer of dura (mean thickness in the specimens, 85 microm). The pituitary capsule and the dural layers in the lateral and inferior walls of the fossa were immunopositive for collagen types I and II. Collagen types III, IV and V were detected only in the pituitary capsule. CONCLUSIONS: Weakness of the lateral walls of the pituitary fossa and the degree to which collagen fibres in the pituitary capsule have been biochemically damaged are important factors in infiltration of the cavernous sinus by a pituitary adenoma.

Relief of hemifacial spasm after radiosurgery for intracanalicular vestibular schwannoma.

Secondary hemifacial spasm due to vestibular schwannoma is very rare. This is the first reported case of hemifacial spasm responsive to gamma knife radiosurgery in a patient with an intracanalicular vestibular schwannoma. Both the resolution of the spasm as well as tumor growth control were achieved with a single session of gamma knife radiosurgery. We report a 49-year-old male patient with a 6-month history of right-sided hearing loss and hemifacial spasm. MR examination revealed an intracanalicular vestibular schwannoma. The patient was treated with radiosurgery and received 13 Gy to the 50 % isodose line. Tumor growth control was achieved and no change in the tumor volume was present at the last follow-up at 22 months. The hemifacial spasm completely resolved after one year. Surgical removal of the presumably causative mass lesion has been reported to be the sole treatment in secondary hemifacial spasm. This case report indicates that it may be responsive to gamma knife radiosurgery. Whether or not this might be a treatment option in selected refractory cases of hemifacial spasm remains to be defined.