Survival and factors affecting the survival of older adult patients in palliative care.

PURPOSE: Investigate the survival and risk factors that affect the survival of aged patients in a palliative care center (PCC). METHODS: A total of 180 inpatients (aged ≥ 65 years) who were admitted to a PCC from January 2018 to March 2020 were included. Information regarding patients' demographic characteristics, chronic diseases, length of hospital stay, nutrition provided at the first hospital stay, pressure wound, pain, and laboratory results were evaluated. RESULTS: The patients 50% were women (n = 90). The mean age, mean comorbidity, and mean follow-up duration was 77.6 years, 3.4, and 115 days (median: 29 days), respectively. The mean NRS2002 score of patients was 4.0 ± 1.0 and the risk of malnutrition was 93%. The mortality rate of the patients was 91.7%. The life expectancy of patients without malignancy was higher than those with malignancy (p < 0.001). Enteral nutrition (EN) via percutaneous endoscopic gastrostomy (PEG) was associated with up to two-fold increase in the survival rates of patients with PCC (p = 0.049, HR: 2.029). High neutrophil/lymphocyte ratio (p = 0.002, HR: 1.017) and high ferritin (p = 0.001, HR: 1.000) and C-reactive protein (CRP) levels (p < 0.001, HR: 1.006) were adverse risk factors affecting life expectancy. Malignity reduced the survival rate of aged patients with PCC by 40% (p = 0.008). CONCLUSION: EN via PEG was found to be a positive factor affecting survival rates of older adult patients in palliative care, whereas malignity, high neutrophil/lymphocyte ratio, high CRP and ferritin levels, and prolonged hospital stays were negative risk factors.

A series of post-traumatic midline epidural hematoma and review of the literature.

BACKGROUND: Supratentorial midline epidural hematoma is rare but challenging in diagnosis and management. Indication for surgery can arise even following hospital admission. Being familiar to the presentation and watching out for direct and indirect signs on axial computed tomography (CT) such as suture diastasis or fracture traversing midline are essential to plan multi-planar CT enabling exact diagnosis including form and mass effect of hematoma. METHODS: Nine patients with midline epidural hematoma including two pediatric patients underwent surgery between 2013 and 2018. Pre-operative and post-operative patient status, radiological features, and surgical technique were analyzed. RESULTS: Four patients had deteriorating consciousness levels and two patients had paraparesis. All had fractures traversing midline and epidural hematomas with significant mass effect. They were operated through separated craniotomies around the midline and midline bone strip was used for dural tenting and as support for natural closure of bone flaps. No post-operative complications were developed. All patients were discharged with Glasgow Outcome Score of 5. CONCLUSION: Because of the rarity of the lesion and small number of patients, definitive conclusions may be misleading but we think that, in experienced hands, midline epidural hematomas can safely be operated on and, preservation of midline bone strip pro-vides easier bleeding control.

Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial / Terapia adjuvante de betaistina para o tratamento de indivíduos com vertigem posicional paroxística benigna posterior: um ensaio clínico randomizado

Abstract Introduction Benign paroxysmal positional vertigo is a common vestibular disorder that accounts for one fifth of hospital admissions due to vertigo, although it is commonly undiagnosed. Objective To evaluate the effects of betahistine add-on therapy in the treatment of subjects with posterior benign paroxysmal positional vertigo. Methods This randomized controlled study was conducted in a population of 100 subjects with posterior benign paroxysmal positional vertigo. Subjects were divided into the Epley maneuver + betahistine group (group A) and Epley maneuver only (group B) group. Subjects were evaluated before and 1-week after the maneuver using a visual analog scale and dizziness handicap inventory Results One hundred subjects completed the study protocol. The Epley maneuver had an overall success rate of 95% (96% in group A; 94% in group B, p= 0.024). Groups A and B had similar baseline visual analog scale scores (6.98 ± 2.133 and 6.27 ± 2.148, respectively, p= 0.100). After treatment, the visual analog scale score was significantly lower in both groups, and was significantly lower in group A than group B (0.74 ± 0.853 vs. 1.92 ± 1.288, respectively, p= 0.000). The change in visual analog scale score after treatment compared to baseline was also significantly greater in group A than group B (6.24 ± 2.01 vs. 4.34 ± 2.32, respectively, p= 0.000). The baseline dizziness handicap inventory values were also similar in groups A and B (55.60 ± 22.732 vs. 45.59 ± 17.049, respectively, p= 0.028). After treatment, they were significantly lower in both groups. The change in score after treatment compared to baseline was also significantly greater in group A than group B (52.44 ± 21.42 vs. 35.71 ± 13.51, respectively, p= 0.000). Conclusion The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo. Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory.

Resumo Introdução A vertigem posicional paroxística benigna é um distúrbio vestibular comum, responsável por um quinto das internações hospitalares por vertigem, embora seja comumente não diagnosticada. Objetivo Avaliar os efeitos da terapia adjuvante com betaistina no tratamento de indivíduos com vertigem posicional paroxística benigna posterior. Método Este estudo randomizado controlado foi feito em uma população de 100 indivíduos com vertigem posicional paroxística benigna posterior. Os indivíduos foram divididos nos grupos: manobra de Epley + betaistina (grupo A) e manobra de Epley apenas (grupo B). Os indivíduos foram avaliados antes e uma semana após a manobra por meio da escala visual analógica EVA e do questionário dizziness handicap inventory. Resultados Cem indivíduos completaram o protocolo do estudo. A manobra de Epley demonstrou uma taxa de sucesso global de 95% (96% no grupo A; 94% no grupo B, p = 0,024). Os grupos A e B tiveram escores basais semelhantes na EVA (6,98 ± 2,133 e 6,27 ± 2,148, respectivamente, p = 0,100). Após o tratamento, o escore na EVA foi significantemente menor em ambos os grupos e foi menor no grupo A do que no grupo B (0,74 ± 0,853 vs. 1,92 ± 1,288, respectivamente, p = 0,000). A mudança no escore da EVA após o tratamento em comparação com a linha basal também foi significativamente maior no grupo A do que no grupo B (6,24 ± 2,01 vs. 4,34 ± 2,32, respectivamente, p = 0,000). Os valores basais no dizziness handicap inventory também foram semelhantes nos grupos A e B (55,60 ± 22,732 vs. 45,59 ± 17,049, respectivamente, p = 0,028). Após o tratamento, eles foram significantemente menores em ambos os grupos. A mudança no escore após o tratamento em comparação com a linha basal também foi significantemente maior no grupo A do que no grupo B (52,44 ± 21,42 vs. 35,71 ± 13,51, respectivamente, p = 0,000). Conclusão A manobra de Epley é eficaz no tratamento da vertigem posicional paroxística benigna. O tratamento complementar com betaistina na vertigem posicional paroxística benigna posterior resultou em melhoria tanto no escore da EVA quanto no do dizziness handicap inventory.

A subset of arachnoid granulations in humans drain to the venous circulation via intradural lymphatic vascular channels.

OBJECTIVE: The discovery of dural lymphatics has spurred interest in the mechanisms of drainage of interstitial fluid from the CNS, the anatomical components involved in clearance of macromolecules from the brain, mechanisms of entry and exit of immune components, and how these pathways may be involved in neurodegenerative diseases and cancer metastasis. In this study the authors describe connections between a subset of arachnoid granulations (AGs) and the venous circulation via intradural vascular channels (IVCs), which stain positively with established lymphatic markers. The authors postulate that the AGs may serve as a component of the human brain's lymphatic system. METHODS: AGs and IVCs were examined by high-resolution dissection under stereoscope bilaterally in 8 fresh and formalin-fixed human cadaveric heads. The superior sagittal sinus (SSS) and adjacent dura mater were immunostained with antibodies against Lyve-1 (lymphatic marker), podoplanin (lymphatic marker), CD45 (panhematopoietic marker), and DAPI (nuclear marker). RESULTS: AGs can be classified as intradural or interdural, depending on their location and site of drainage. Interdural AGs are distinct from the dura, adhere to arachnoid membranes, and occasionally open directly in the inferolateral wall or floor of the SSS, although some cross the infradural folds of the dura's inner layer to meet with intradural AGs and IVCs. Intradural AGs are located within the leaflets of the dura. The total number of openings from the AGs, lateral lacunae, and cortical veins into the SSS was 45 ± 5.62 per head. On average each cadaveric head contained 6 ± 1.30 intradural AGs. Some intradural AGs do not directly open into the SSS and use IVCs to connect to the venous circulation. Using immunostaining methods, the authors demonstrate that these tubular channels stain positively with vascular and lymphatic markers (Lyve-1, podoplanin). CONCLUSIONS: AGs consist of two subtypes with differing modes of drainage into the SSS. A subset of AGs located intradurally use tubular channels, which stain positively with vascular and lymphatic markers to connect to the venous lacunae and ultimately to the SSS. The present study suggests that AGs may function as a component of brain lymphatics. This finding has important clinical implications for cancer metastasis to and from the CNS and may shed light on mechanisms of altered clearance of macromolecules in the setting of neurodegenerative diseases.

Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial.

INTRODUCTION: Benign paroxysmal positional vertigo is a common vestibular disorder that accounts for one fifth of hospital admissions due to vertigo, although it is commonly undiagnosed. OBJECTIVE: To evaluate the effects of betahistine add-on therapy in the treatment of subjects with posterior benign paroxysmal positional vertigo. METHODS: This randomized controlled study was conducted in a population of 100 subjects with posterior benign paroxysmal positional vertigo. Subjects were divided into the Epley maneuver + betahistine group (group A) and Epley maneuver only (group B) group. Subjects were evaluated before and 1-week after the maneuver using a visual analog scale and dizziness handicap inventory RESULTS: One hundred subjects completed the study protocol. The Epley maneuver had an overall success rate of 95% (96% in group A; 94% in group B, p =  0.024). Groups A and B had similar baseline visual analog scale scores (6.98 ±â€¯2.133 and 6.27 ±â€¯2.148, respectively, p = 0.100). After treatment, the visual analog scale score was significantly lower in both groups, and was significantly lower in group A than group B (0.74 ±â€¯0.853 vs. 1.92 ±â€¯1.288, respectively, p = 0.000). The change in visual analog scale score after treatment compared to baseline was also significantly greater in group A than group B (6.24 ±â€¯2.01 vs. 4.34 ±â€¯2.32, respectively, p = 0.000). The baseline dizziness handicap inventory values were also similar in groups A and B (55.60 ±â€¯22.732 vs. 45.59 ±â€¯17.049, respectively, p = 0.028). After treatment, they were significantly lower in both groups. The change in score after treatment compared to baseline was also significantly greater in group A than group B (52.44 ±â€¯21.42 vs. 35.71 ±â€¯13.51, respectively, p = 0.000). CONCLUSION: The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo. Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory.

Endoscopic Bilateral Optic Nerve Decompression for Treatment of Idiopathic Intracranial Hypertension.

OBJECTIVE: To evaluate the results of bilateral endoscopic optic nerve decompression (EOND) with the opening nerve sheath (ONS) technique in patients with idiopathic intracranial hypertension (IIH). METHODS: Between the years of 2017 and 2019, we retrospectively evaluated nine IIH patients with progressive visual impairment despite medical treatment and who were treated with the EOND and ONS techniques. We also demonstrated our surgical technique recipe on postmortem human heads in a stepwise manner. RESULTS: There were 9 patients (7 females and 2 males) between the ages of 21 and 72 included in this study, and the mean age was 40.8. All patients had an impairment in visual acuity and/or their visual field, with signs of papilledema and/or optic atrophy. The patients were followed up with for 9-48 months. Improvements in visual acuity were observed in 7 out of 9 patients (78%). Visual field defects improved in 5 out of 8 patients (62.5%). Papilledema was resolved in all patients (100%). Headaches improved in all symptomatic patients (100%). No intraoperative or postoperative complications were observed. CONCLUSIONS: EOND is a safe and effective surgical procedure in selected patients with IIH. Bilateral wide bony decompression and nerve fenestration can also be an additional benefit for headache relief. Further clinical series and long-term follow-up are needed for more precise results.

Serum C-Reactive Protein and Sex Hormone Levels in the Early Hyperacute Phase of Stroke.

BACKGROUND: To see the relationship of early admission parameters with the type of stroke and/or with the 30-days mortality from this disease. METHODS: Stroke patients at their early hyperacute phase (n = 180) were enrolled in this study (156 ischemic strokes and 24 hemorrhagic strokes). Blood levels of C-reactive protein (CRP), testosterone, and estradiol were determined at admission, before any specific intervention. Patients' clinical data, including the above-mentioned laboratory parameters, were compared between the above two stroke types (in total and between sexes). RESULTS: The mean age of the patients was 69.55 ± 12.03 years old (69.92 ± 11.94 years old in ischemic stroke and 67.12 ± 12.54 years old in hemorrhagic stroke). Serum estradiol levels of both males of ischemic stroke and females of hemorrhagic stroke patients were significantly higher than the females of the ischemic stroke. Serum CRP levels of both females and males of the hemorrhagic group were higher than their peers of the opposite group. Early admission serum CRP level ≥ 0.74 mg/dL in males helped predict hemorrhagic stroke while a serum estradiol level ≥ 14.07 ng/mL helped predict the same type of stroke in females. CONCLUSIONS: Our study results show that simple early laboratory measures (such as CRP and estradiol) may help in the early phase management of stroke. Further studies are needed to confirm our findings.

Anatomical Features of the Deep Cervical Lymphatic System and Intrajugular Lymphatic Vessels in Humans.

BACKGROUND: Studies in rodents have re-kindled interest in the study of lymphatics in the central nervous system. Animal studies have demonstrated that there is a connection between the subarachnoid space and deep cervical lymph nodes (DCLNs) through dural lymphatic vessels located in the skull base and the parasagittal area. OBJECTIVE: To describe the connection of the DCLNs and lymphatic tributaries with the intracranial space through the jugular foramen, and to address the anatomical features and variations of the DCLNs and associated lymphatic channels in the neck. METHODS: Twelve formalin-fixed human head and neck specimens were studied. Samples from the dura of the wall of the jugular foramen were obtained from two fresh human cadavers during rapid autopsy. The samples were immunostained with podoplanin and CD45 to highlight lymphatic channels and immune cells, respectively. RESULTS: The mean number of nodes for DCLNs was 6.91 ± 0.58 on both sides. The mean node length was 10.1 ± 5.13 mm, the mean width was 7.03 ± 1.9 mm, and the mean thickness was 4 ± 1.04 mm. Immunohistochemical staining from rapid autopsy samples demonstrated that lymphatic vessels pass from the intracranial compartment into the neck through the meninges at the jugular foramen, through tributaries that can be called intrajugular lymphatic vessels. CONCLUSIONS: The anatomical features of the DCLNs and their connections with intracranial lymphatic structures through the jugular foramen represent an important possible route for the spread of cancers to and from the central nervous system; therefore, it is essential to have an in-depth understanding of the anatomy of these lymphatic structures and their variations.

Retrospective Analysis of Survival in Patients with Brain Metastases from an Unknown Primary Tumor.

AIM: To evaluate the patients with brain metastases from unknown primary (BMUP) cancers, and to analyze the prognostic factors and survival rates. MATERIAL AND METHODS: We conducted a retrospective study with 110 patients (mean age: 62.8 years [range 23?90], n=85- 77.3% male and n=25-22.7% female) with BMUP cancers at the time of diagnosis, who presented to our outpatient oncology clinic between January 2015 and December 2019. We employed the following variables as significant prognostic factors for a prominent index of patients? survival: age, gender, Karnofsky performance score (KPS), number of metastatic lesions, primary site, and type of treatment were analyzed for their prognostic effects on survival outcomes. Patients? survival was evaluated from plotted Kaplan? Meier curves, and the log-rank test was used for univariate analysis. RESULTS: The mean follow-up was 13 months (range 4?60 months). The means of survival after the diagnosis of brain metastasis was 18.7 months for the study group. Lung cancer was the most common primary tumor (74, 5%). The KPS and number of lesions were found to have a prognostic effect on survival. Survival analysis showed no statistical significance with age and gender, primary site, type of treatment. CONCLUSION: This study showed that KPS, and the number of lesions affect the survival outcomes but both the other variables. Therefore, BMUP cancer is indeed related to poor prognosis.

Does ultrasound-guided facet joint injection reduce pain and improve mobility in patients with failed back surgery syndrome?

OBJECTIVES: This study aims to evaluate whether ultrasound (US)-guided facet joint injection reduces pain and improves mobility in patients with failed back surgery syndrome (FBSS). PATIENTS AND METHODS: This retrospective study included 27 patients (8 males, 19 females; mean age 43.6±11.5 years; range, 31 to 54 years) who underwent US-guided facet injections for FBSS between January 2017 and January 2019. Patients' medial records were assessed. Pain rating scores were evaluated with the Numeric Rating Scale (NRS). Functional status was assessed with Oswestry Disability Index (ODI) version 2.0. Lumbar flexion degree was noted. After injection (lidocaine-betamethasone mixture), patients were reevaluated at first and sixth months. The study data were analyzed with Wilcoxon signed-rank test. RESULTS: Successful facet joint injections were achieved without any complications in all patients. The median duration of time after surgery was 7.8±1.3 months. Mean duration of pain was 6.7±5.7 months. There was a significant decrease in NRS values between baseline and sixth month comparison (7.0 at baseline and 6.0 at sixth month, p=0.006). Baseline-first month and first-sixth months comparisons were not significant (p=0.165 and p=0.106, respectively). For ODI, no significant change was observed between baseline-first month, first-sixth months, and baseline-sixth month comparisons (p=0.109, p=0.857, and p=0.095, respectively). For lumbar flexion, all comparisons resulted in significant increase (50.0° for baseline, 60.0° at first month, and 70.0° at sixth month; p<0.001 for baseline-first month comparison, p<0.001 for baseline-sixth month comparison, and p<0.001 for first-sixth months comparison). CONCLUSION: Our results show that pain is reduced and mobility is improved with US-guided facet joint injections in patients with FBSS.

The Caudate Nucleus: Its Connections, Surgical Implications, and Related Complications.

BACKGROUND: The caudate nucleus is a C-shaped structure that is located in the center of the brain and is divided into 3 parts: the head, body, and tail. METHODS: We detail the anatomic connections, relationships with other basal ganglia structures, and clinical implications of injury to the caudate nucleus. RESULTS: Anatomically, the most inferior transcapsular gray matter is the lentiform peduncle, which is the connection between the lentiform nucleus and caudate nucleus as well as the amygdala. The border between the tail and body of the caudate nucleus is the posterior insular point. The tail of the caudate nucleus is extraependymal in some parts and intraependymal in some parts of the roof of the temporal horn of the lateral ventricle. The tail of the caudate nucleus crosses the inferior limiting sulcus (temporal stem), and section of the tail during approaches to lesions involving the temporal stem may cause motor apraxia. The mean distance from the temporal limen point, which is the junction of the limen insula and inferior limiting sulcus, to the tail of the caudate nucleus in the temporal stem is 15.87 ± 3.10 mm. CONCLUSIONS: Understanding of the functional anatomy and connections of the distinct parts of the caudate nucleus is essential for deciding the extent of resection of lesions involving the caudate nucleus and the types of deficits that may be found postoperatively.

Common Challenges and Solutions Associated with the Preparation of Silicone-Injected Human Head and Neck Vessels for Anatomical Study.

Neuroanatomy laboratory training is crucial for the education of neurosurgery residents and medical students. Since the brain is a complex and three-dimensional structure, it is challenging to understand the anatomical relationship of the cortex, internal structures, arteries, and veins without appropriate adjuncts. Several injection agents-including the inks/dyes, latex, polyester, acrylic resins, phenol, polyethylene glycol, and phenoxyethanol-have been explored. Colored silicon injection protocols for the head and neck vessels' perfusion have greatly aided the study of neuroanatomy and surgical planning. This report presents a colored silicone injection method in detail, and also highlights the technical shortcomings of the standard techniques and workarounds for common challenges during 35 human cadaveric head injections. The human cadaveric head preparation and the coloring of the head vessels are divided into decapitation, tissue fixation with 10% formalin, the placement of the Silastic tubing into the parent vessels, the cleaning of the vessels from clots, and the injection of the colored silicone into the vessels. We describe the technical details of the preparation, injection, and preservation of cadaveric heads, and outline common challenges during colored silicone injection, which include the dislocation of the Silastic tubing during the injection, the injection of the wrong or inappropriate colored silicone into the vessel, intracranial vessel perforation, the incomplete silicone casting of the vessel, and silicone leakage from small vessels in the neck. Solutions to these common challenges are provided. Ethyl alcohol fixed, colored human heads provided the long-term preservation of tissue, and improve the sample consistency and preservation for the teaching of neuroanatomy and surgical technique.

Medium-term results of undersized angioplasty and stenting for symptomatic high-grade intracranial atherosclerotic stenosis with Enterprise.

PURPOSE: The aim of this retrospective study is to evaluate medium-term results of undersized balloon angioplasty and stenting for symptomatic high-grade (70-99%) stenosis of a major intracranial artery with Enterprise stent. METHODS: This study included 68 consecutive symptomatic (recurrent transient ischemic attack (TIA) or ischemic stroke under dual antiplatelet treatment) patients with high-grade (70-99%) stenosis of a major intracranial artery who were endovascularly treated with undersized balloon angioplasty and Enterprise stent deployment between July 2012 and December 2017. Primary outcomes were any stroke or death within 30 days after procedure. Secondary outcomes were technical success rates, stroke and restenosis during the follow-up period. RESULTS: A total of 68 lesions in 68 patients (mean age: 62 ± 7 years) were treated with a technical success rate of 99%. The degree of pre-procedural stenosis was 92 ± 6% and dropped to 12 ± 10% after stent deployment. No patient developed any stroke or death during the periprocedural period. Intracranial hemorrhage was observed in 1 (1.5%) patient. In 60 (88%) patients with available imaging follow-up in-stent restenosis was observed in 2 patients. Mean follow-up period was 22 ± 17 months (range 6-72) and none of the patients experienced recurrent TIA or stroke during the follow-up period. CONCLUSION: In this retrospective single-center study undersized balloon angioplasty and deployment of a self-expandable stent with relatively low radial force was safe and effective for endovascular treatment of high-grade intracranial arterial stenosis with high technical success rate, low periprocedural complication rates and favorable medium-term follow-up results.

The Predictor Role of the Aqueduct Cerebrospinal Fluid Flow on Endoscopic Third Ventriculostomy: Explication on Assumption Physical Model.

AIM: To evaluate the cerebrospinal fluid (CSF) flow dynamics in the aqueductus sylvii of patients with obstructive hydrocephalus who underwent endoscopic third ventriculostomy (ETV) and to predict ventriculostomy patency via aqueduct flow measurements. MATERIAL AND METHODS: Twenty-four patients with obstructive hydrocephalus caused by primary aqueduct stenosis who underwent ETV were included in the study. All the patients underwent conventional and cine magnetic resonance imaging before and after treatment. The flow of CSF in the aqueduct of Sylvius and prepontine cistern was assessed, and the diameter of the third ventricle was also measured. Increase in the aqueduct flow velocity after a successful ETV was supported by the assumption physical model that highlights a possible mechanism that explains the clinical findings. RESULTS: The flow pattern and velocity in the prepontine cistern and aqueduct were normal in 17 out of 24 patients who responded to ETV clinically. However, seven patients who did not respond to ETV had an abnormal flow pattern in both the prepontine cistern and aqueduct. CONCLUSION: The flow pattern in the aqueduct was normalised and velocity was increased compared with those of preoperative values after a successful ETV. The flow of CSF in the prepontine cistern is routinely used for ventriculostomy patency assessment. In addition, aqueduct measurements may be useful in predicting ventriculostomy patency. The physical model provides valuable insights on a possible mechanism that affected the experimental data.

Visual Outcome of an Endoscopic Endonasal Transsphenoidal Approach in Pituitary Macroadenomas: Quantitative Assessment with Diffusion Tensor Imaging Early and Long-Term Results.

BACKGROUND: Postoperative visual recovery in patients with pituitary adenoma can be influenced by the duration of symptoms, age, and tumor volume. Diffusion tensor imaging (DTI) allows visualization of white matter structure along with quantitative information. The aims of our study were to predict the visual recovery process in the early and long-term periods and to define the parameters affecting the recovery course. METHODS: A total of 200 patients with pituitary macroadenomas underwent endoscopic transsphenoidal surgery between January 2009 and July 2016. DTI and visual analysis including visual acuity and visual field analyses were performed for these patients at 5 periods, which included 3 years of follow-up. The effects of age, duration of symptoms, and tumor volume on visual recovery were evaluated. RESULTS: Mean tumor volume was calculated as 8871 ± 2758 mm3 and mean symptom duration was 23.41 ± 3.72 weeks. Mean age of the patients was 43.8 ± 8.9 years in the full recovery group and 48.7 ± 15.1 years in the nonrecovery group. Visual field analysis results on a Humphrey visual chart showed a significant linear strong correlation with fractional anisotropy (FA) values and a reverse strong correlation with mean diffusivity (MD) values on DTI magnetic resonance. DTI FA and MD cutoff values for each group were respectively determined as 0.373 and 1386 (×10-6 mm2/second) for the preoperative period, 0.423 and 1383 (×10-6 mm2/second) for the initial period, 0.428 and 1265 (×10-6 mm2/second) for the early period, 0.432 and 1238 (×10-6 mm2/second) for the intermediate period, and 0.437 and 1198 (×10-6 mm2/second) for the late period. CONCLUSIONS: DTI can assess and predict visual recovery after endoscopic transsphenoidal surgery of patients with pituitary macroadenomas causing chiasmal compression. FA values lower than or MD values greater than the cutoff values of the specific period reflect poor prognosis. Tumor volume was found to be the featured parameter that affects visual recovery. The postoperative first year is the most prominent interval evaluating the prognosis of visual recovery.

Applications of Platelet-Rich Plasma in Lymphedema.

Platelet-rich plasma (PRP) is an autologous concentrated preparation of human platelets contained in a small volume of plasma that is characterized by hemostatic and tissue-repairing effects. Being enriched by various kinds of growth factors, and their tissue-repairing effects have made them the focus of attention for use in tissue regeneration. PRP has been safely used and documented in many different fields, including orthopedics, sports injuries, dental and periodontal surgery, and cosmetic, plastic, cardiovascular, general, and maxillofacial surgery. The current evidence obtained from in vitro and animal studies pointed out that PRP may potentially be used to regenerate injured lymphatic vessels to treat or prevent lymphedema. Therefore, we have reviewed existing literature on the clinical uses of PRP in lymphedema and inquired whether there is enough evidence to support the use of PRP in clinical practice as a treatment option. In contrast to in vitro and animal models, there is no clinical trial regarding the use of PRP in lymphedema treatment. Only two animal studies matched to our research yielded positive and promising results in terms of the potential role of PRP in future for lymphedema therapies. In the light of these findings, it is clear that this is an important issue that should be studied in greater depth to clarify the efficacy of PRP in the management of lymphedema.

The Beneficial Effect of Hypnosis in Elective Cardiac Surgery: A Preliminary Study.

Background Single-session hypnosis has never been evaluated as a premedication technique in patients undergoing coronary artery bypass grafting (CABG). The aim of the present study was to evaluate the beneficial effects of clinical hypnotherapy on perioperative anxiety, pain perception, sedation, and necessity for ventilator assistance in patients undergoing CABG. Methods Double-blind, randomized, clinical trial was performed. Forty-four patients undergoing CABG surgery were randomized into two groups. The patients in group A received preprocedural hypnosis by an anesthesiologist. Patients in group B (control) had only information on the surgical intervention by the same anesthesiologist. State-Trait-Anxiety Index-I (STAI-I) and Beck Depression Inventory (BDI) were performed preoperatively in both groups. Visual analog scale (VAS) and Ramsay sedation scale (RSS) were evaluated on 0th, 1st, 2nd, 4th, 6th, 8th, 10th, 12th, and 24th hours, postoperatively. Postoperative anxiety level, analgesic drug consumption, and duration of ventilator assistance and intensive care unit (ICU) stay were also documented. Results When anxiety and depression levels were compared, significantly lower STA-I and BDI values were detected in group A after hypnotherapy (p = 0.001, p = 0.001, respectively). Significantly less total doses of remifentanil (34.4 ± 11.4 vs. 50.0 ± 13.6 mg) and morphine (4.9 ± 3.3 vs. 13.6 ± 2.7 mg) were administered in group A in the postoperative period. Ventilator assistance duration (6.8 ± 2.0 vs. 8.9 ± 2.7 hours) was also shorter in group A when compared with that in group B (p = 0.007). Conclusion Hypnosis session prior to surgery was an effective complementary method in decreasing presurgical anxiety, and it resulted in better pain control as well as reduced ventilator assistance following CABG surgery.