Morphometry of the anterior third ventricle region as a guide for the transcallosal-interforniceal approach

The transcallosal-interforniceal approach is the most appropriate approach to localize and totally remove space-occupying lesions around the anterior third ventricle region such as craniopharyngiomas and gliomas. This study examined the microsurgical anatomy of the normal anterior third ventricle region in 81 adult cadaver hemispheres. The central sulcus was identified and surface landmarks determined as the points 5 cm (P5) and 7 cm anterior to the central sulcus (P7). The distances between P5 and P7 and the upper margin of the interventricular foramen, which delineate the surgical corridor chosen to avoid disturbance of important neural structures, were 46.26-60.96 (54.09 +/- 3.35) mm and 48.00-62.00 (54.94 +/- 3.09) mm, respectively. The distances between the upper margin of the hemisphere and the cingulate sulcus, especially important for avoiding damage to the cingulate gyrus and other mesiolimbic structures, were 13.54-30.00 (21.28 +/- 3.89) mm and 12.22-29.52 (21.12 +/- 3.90) mm at the level of P5 and P7. The distances between the upper margin of the hemisphere and the callosal cistern containing the pericallosal artery were 28.34-40.50 (33.94 +/- 2.84) mm and 28.16-40.26 (33.50 +/- 2.61) mm, respectively. Normative morphometric data of the structures involved in the surgical procedure are necessary for planning and performance of the transcallosal-interforniceal approaches. This study of a large series of specimens shows that these measurements have large individual variations.     

Structure-activity study of LVV-hemorphin-7: angiotensin AT4 receptor ligand and inhibitor of insulin-regulated aminopeptidase

The decapeptide LVV-hemorphin-7 binds with high affinity to the angiotensin IV (Ang IV) receptor (AT(4) receptor), eliciting a number of physiological effects, including cellular proliferation and memory enhancement. We have recently shown that the AT(4) receptor is identical to insulin-regulated aminopeptidase (IRAP) and that both LVV-hemorphin-7 and Ang IV inhibit the catalytic activity of IRAP. In the current study, a series of alanine-substituted and N- or C-terminally modified analogs of LVV-hemorphin-7 were evaluated for their abilities to compete for (125)I-Ang IV binding in sheep adrenal and cerebellar membranes. Selected analogs were also analyzed for binding to recombinant human IRAP and inhibition of IRAP aminopeptidase activity. C-Terminal deletions of LVV-hemorphin-7 resulted in modest changes in affinity for IRAP, whereas deletion of the first three N-terminal residues abolished binding. Monosubstitutions of Tyr(4) and Trp(6) with alanine resulted in a 10-fold reduction in affinity. Competition binding studies using recombinant human IRAP demonstrated the same rank order of affinity as obtained for the ovine tissues. All LVV-hemorphin-7 analogs tested, except for Leu-Val-Val-Tyr, inhibit the cleavage of the synthetic substrate, leucine beta-naphthylamide, by IRAP, with K(i) values between 56 and 620 nM. We find that the Val(3) residue is crucial for LVV-hemorphin-7 binding to IRAP, whereas the C-terminal domain seems to play a minor role. The current study highlights the minimal residues necessary for binding and inhibition of IRAP and provides a basis to design peptidomimetic analogs for experimental and potentially clinical use.     

Effects of extended-wear soft contact lenses on the ocular surface and central corneal thickness

PURPOSE: New contact lens materials with high oxygen permeability are said to be convenient for the extended-wear (EW) schedule. We evaluated the short-term effect of EW soft contact lens usage on ocular surface and central corneal thickness. PATIENTS AND METHODS: Fifty-two eyes of 26 patients were included in the study. Sixteen of the patients used the high oxygen-permeable lenses for a 30-day extended-wear schedule (group I). Ten patients used the lenses on a daily wear basis (DW, group II). All patients were evaluated for visual acuity and central corneal thickness by corneal and conjunctival biomicroscopy, Schirmer and tear break-up time (BUT) tests. Impression cytology was performed in the superior/temporal, inferior/nasal quadrants of the conjunctiva, 1 mm from the limbus, with cellulose acetate filter paper. The specimens were graded under light microscopy according to Nelson's classification. RESULTS: Three patients in the EW group were excluded from the study as they discontinued lens usage due to slight discomfort and hyperemia. Biomicroscopic findings and tear function tests indicated no increased pathological results. Central corneal thickness decreased from 554 +/- 9.55 to 546 +/- 9.30 microm (mean +/- SEM) in the EW group (p = 0.002), whereas no significant change occurred in the DW group. Cytological evaluation of the EW group showed an 88% increase in metaplasia (p = 0.007), especially close to the limbal areas and in the superior quadrants; this ratio was 30% in the DW group. Snake-like chromatin changes were found to be increased, from 4 to 6 patients, in the EW group while it remained the same in the DW group (p > 0.05). Individual comparisons of the initial and final pathological conditions of the ocular surfaces in the two groups showed that there was an increase in pathology in the EW group while there was no significant difference in the DW group. CONCLUSIONS: On a 30-day extended-wear basis with high oxygen-permeable lenses, the possible development and increase of conjunctival cytologic changes secondary to mechanical trauma is one of the main remaining problems. Conjunctival and related immunologic pathologies should not be overlooked when prescribing an extended-wear lens schedule.     

Maternal serum screening for Down's syndrome, open neural tube defects and trisomy 18.

Maternal serum screening identifies women at an increased risk of a pregnancy with Down's syndrome or trisomy 18 or an open neural tube defect. The triple test, consisting of maternal serum alpha-fetoprotein, unconjugated estriol and human chorionic gonadotropin was carried out by a chemiluminescence immunoassay method in our laboratory. The study consisted of 373 pregnant women. The gestational range for the study group was 14-22 weeks. The mean maternal age for the study group was 28.53 +/- 5.46 years (range 17.4 to 43.5 years); 9.1% of the women were considered at high risk for Down's syndrome based on the test results. In our study the detection rate for Down's syndrome by prenatal karyotyping was 66.6%. Maternal serum screening allows reduction of the number of women requiring amniocentesis without a significant decrease in the detection rate.     

Effects of amlodipine and fosinopril on heart rate variability and left ventricular mass in mild-to-moderate essential hypertension

The differences between long-acting dihydropyridines and angiotensin-converting enzyme inhibitors with regard to their long-term effects on 24-h heart rate variability (HRV) and left ventricular (LV) mass are less clear in mild-to-moderate essential hypertension. We studied the long-term effects of amlodipine and fosinopril on 24-h HRV and LV mass in mild-to-moderate essential hypertension. In this study, 27 patients with never treated mild-to-moderate essential hypertension were randomised to receive either amlodipine or fosinopril once daily as monotherapy. At baseline and at the end of the third and sixth months, each of the patients underwent 24-h HRV and ambulatory systolic (SBP) and diastolic (DBP) blood pressure analysis. LV mass index was calculated from echocardiographic examination at baseline and at the end of the sixth month. In amlodipine group (n = 14), 24-h SBP/DBP (mmHg) decreased from 144 +/- 8/94 +/- 4 to 128 +/- 6/83 +/- 3 at the end of the third month and to 125 +/- 5/81 +/- 2 at the end of the sixth month (p < 0.0001). In fosinopril group (n = 13), the respective changes were 143 +/- 9/97 +/- 7, 132 +/- 6/87 +/- 5 and 127 +/- 6/82 +/- 3 (p < 0.0001). At the end of the sixth month, LV mass index (g/m(2)) decreased from 122 +/- 26 to 105 +/- 21 in amlodipine group (p < 0.0001) and from 118 +/- 23 to 101 +/- 14 in fosinopril group (p < 0.0001). There were no significant changes in HRV parameters in both the groups. It was concluded that both drugs caused significant decrease in SBP and DBP, and LV mass in patients with mild-to-moderate essential hypertension did not have significant long-term effects of either amlodipine or fosinopril on 24-h HRV parameters reflecting sympathetic or parasympathetic activity in these patients.     

Concomitant Laparoscopic Adjustable Gastric Banding and Laparoscopic Cholecystectomy in a Super-Obese Patient with Situs Inversus Totalis Who Previously Underwent Intragastric Balloon Placement

Laparoscopic adjustable gastric banding has been increasingly performed since its introduction in 1990. Situs inversus totalis is a rare anomaly in which transposition of organs to the opposite side of the body occurs. Laparoscopic gastric banding in such few patients has been reported in the literature. We discuss a super-obese patient with situs inversus totalis and asymptomatic cholelithiasis who previously underwent endoscopic intragastric balloon placement in preparation for bariatric surgery. Afterwards, laparoscopic cholecystectomy and laparoscopic adjustable gastric banding were performed in the same session. Special attention is paid to the literature review and the mirror-image modification of the laparoscopic cholecystectomy and laparoscopic gastric banding procedures. With preoperative assessment, modifications in the surgical team, and equipment, the operation can be performed safely.     

Radio-guided occult lesion localisation for breast lesions under computer-aided MRI guidance: the first experience and initial results

Objective

The purpose of this study was to present an alternative technique for the pre-operative localisation of solely MRI-detected suspicious breast lesions using a computer-assisted MRI-guided radio-guided occult lesion localisation (ROLL) technique.

Methods

Between January 2009 and June 2010, 25 females with a total of 25 suspicious breast lesions that could be detected only by MRI, and for whom breast surgery was planned, underwent the computer-assisted MRI-guided ROLL technique. A seven-channel biopsy breast array coil and computerised diagnostic workstation were used for the localisation procedure. Three-phase dynamic contrast-enhanced axial images were taken. After investigating the localisation co-ordinates with the help of intervention software on a workstation, an 18 G coaxial cannula was placed in the exact position determined. Following verification of the cannula position by additional axial scans, ^99mTc-labelled macroalbumin aggregate and MRI contrast material were injected. Post-procedure MRI scans were used to confirm the correct localisation.

Results

All the procedures were technically successful. The mean lesion size was 10.8 mm (range: 4–25 mm). The mean total magnet and the mean localisation times were 28.6 min (range: 18–46 min) and 13.1 min (range: 8–20 min), respectively. Grid and pillar methods were used for localisation in 24 procedures and 1 procedure, respectively. On histopathological examination, 6 malignant, 10 high-risk and 9 benign lesions were identified. All patients tolerated the procedure well. There were no major complications.

Conclusion

This is the first report documenting the application of MRI-guided ROLL. Based on our preliminary results, this technique is very efficient and seems to be a good alternative to wire localisation.MRI of the breast has now become an integral and necessary component of breast imaging practice [1]. It is a valuable tool with high sensitivity for the identification of breast cancer in high-risk patients, follow-up of patients with known breast cancer and in patients at a pre-operative stage in order to rule out any ipsilateral or contralateral disease [2-5]. It can detect suspicious breast lesions that are occult to clinical examination, mammography and ultrasonography [4,6,7]. It was reported that, although the addition of MRI to current evaluation (clinical, radiological and pathological) has no benefit on a reduction of operation rates, cost-effectiveness and quality of life, it has the potential to aid tumour localisation [8].An MRI-guided intervention is necessary to make a definitive histological diagnosis of such “solely” MRI-detected suspicious breast lesions. Histopathological assessment can be performed by MRI-guided wire localisation followed by surgical excision [6,9,10], or by alternative techniques to surgery such as MRI-guided percutaneous biopsy using fine needles [11], core needles [12,13] or vacuum-assisted biopsy devices [7,14]. For such a breast intervention to be clinically useful, factors such as safety, accuracy, availability, cost, patient preference for surgical biopsy and surgeon''s request should be considered. With fine or core needle, lesions measuring <1 cm may not always be accurately sampled, and vacuum biopsy would bring an extra cost burden if surgical biopsy is already planned.MRI-guided wire localisation is a well-known (and currently the most commonly utilised) technique. Several authors have reported success with this technique for surgical biopsy [6-10]. According to them, it can be performed quickly and safely with relatively simple methods and commercially available equipment. However, this technique harbours several limitations and poses potential challenges during and/or after its application, such as the necessity to perform surgery on the same day owing to the risk of wire migration and/or accordion effect [6], breast pain, and poor cosmetic outcome after surgery [15].Radio-guided occult lesion localisation (ROLL) has been documented as a more reliable and effective method than wire for the identification of non-palpable breast lesions [16,17]. Routine ROLL involves the injection of ^99mTc-labelled human serum albumin into the suspicious lesion under ultrasonography or mammography control within 24 h prior to surgery. Subsequently, surgical excision is performed with the help of a hand-held gamma probe [18].To the best of our knowledge, ROLL has never been reported as an adjunct for the pre-operative localisation of solely MRI-detected suspicious breast lesions. Thus, the purpose of this study was to introduce a new technique—computer-aided and MRI-guided ROLL—to present its technical aspects and document our initial results.