Quantitative Longitudinal Evaluation of Diaschisis-Related Cerebellar Perfusion and Diffusion Parameters in Patients with Supratentorial Hemispheric High-Grade Gliomas After Surgery

Decreased cerebral blood volume (CBV) in contralateral cerebellar gray matter (cGM) in conjunction with cerebellar white matter (cWM) damage, consistent with crossed cerebro-cerebellar diaschisis (cCCD) develop following supratentorial hemispheric stroke. In this study, we investigated the longitudinal evolution of diaschisis-related cerebellar perfusion and diffusion tensor-imaging (DTI) changes in patients after surgery for supratentorial brain tumors. Eight patients (M:F 5:3, age 8–22 years) who received surgery for supratentorial high-grade gliomas were evaluated. Initial MRI studies were performed 19–54 days postoperatively, with follow-ups at 2- to 3-month intervals. For each study, parametric maps of the cerebellum were generated and coregistered to T1-weighted images that had been previously segmented for cGM and cWM. Aggregate mean values of CBV, cerebral blood flow (CBF), and fractional anisotropy (FA) were obtained separately for cGM and cWM, and asymmetry indices (AIs) were calculated. Hemodynamic changes were more robust in cGM than in cWM. Seven patients showed decreased perfusion within cGM contralateral to the supratentorial lesion on the first postoperative study, and asymmetry was significant for both CBV (p?=?0.008) and CBF (p?p?p?=?0.0003), without evidence of subsequent recovery. Diaschisis-related hemodynamic alterations within cGM appear on early postoperative studies, but CBV recovers over time. Conversely, cWM DTI changes are delayed and progressive. Although the clinical correlates of cCCD are yet to be elucidated, better understanding of longitudinal structural and hemodynamic changes within brain remote from the area of primary insult could have implications in research and clinical rehabilitative strategies.     

Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol™): high primary perineal wound healing rates

Purpose

Extralevator abdominoperineal excision of the rectum (elAPER) is arguably the modern surgical approach to low rectal cancer and yet results in large defects that may necessitate plastic surgical reconstruction. This study aims to evaluate the quality of prone elAPER surgery with Permacol? repair of the perineum. The primary end point studied was the rate of primary perineal wound healing.

Methods

Data were prospectively collected for consecutive patients having prone elAPER at a single institution to assess surgical morbidity together with pathological and cancer-specific outcomes.

Results

Between 2006 and 2012, 48 patients had prone elAPER with median age of 63 (40–86). Thirty-four patients (72.3 %) received neoadjuvant treatment. Median length of stay was 9 days (6–66). With a prone approach, three patients had specimen perforation (6.4 %) and seven patients had circumferential margin involvement (14.9 %). Complete perineal wound healing was achieved in 34 patients (73.9 %) at 4 weeks. Four patients (8.3 %) were unhealed at 6 months; one patient required a perineal sinus to be laid open, and another patient required plastic surgical reconstruction. No perineal wound herniae have been identified during follow-up.

Conclusions

Acceptable oncological outcomes are achieved with the prone extralevator approach. The technique achieves high rates of primary healing, making it an attractive option in centres without access to plastic reconstructive expertise.     

Low leukotriene B4 receptor 1 leads to ALOX5 downregulation at diagnosis of chronic myeloid leukemia

ALOX5 is implicated in chronic myeloid leukemia development in mouse leukemic stem cells, but its importance in human chronic myeloid leukemia is unknown. Functional ALOX5 was assessed using an LTB4 ELISA and ALOX5, and LTB4R1 mRNA expression was determined via a TaqMan gene expression assay. LTB4R1 and 5-LOX protein levels were assessed by cell surface flow cytometry analysis. At diagnosis ALOX5 was below normal in both blood and CD34⁺ stem cells in all patients. On treatment initiation, ALOX5 levels increased in all patients except those who were destined to progress subsequently to blast crisis. LTB4 levels were increased despite low ALOX5 expression, suggesting that the arachidonic acid pathway is functioning normally up to the point of LTB4 production. However, the LTB4 receptor (BLT1) protein in newly diagnosed patients was significantly lower than after a period of treatment (P<0.0001). The low level of LTB4R1 at diagnosis explains the downregulation of ALOX5. In the absence of LTB4R1, the arachidonic acid pathway intermediates (5-HEPTE and LTA4) negatively regulate ALOX5. ALOX5 regulation is aberrant in chronic myeloid leukemia patients and may not be important for the development of the disease. Our data suggest caution when extrapolating mouse model data into human chronic myeloid leukemia.     

Gendered Members of Alcoholics Anonymous: Varieties of Spiritual Experiences in Recovery

Women and men share similar as well as different strategies in developing their spirituality as part of their overall 12-Step experience. Special attention is paid to gender differences to account for a variety of spiritual experiences in recovery. The language and use of metaphors as women and men work the 12 Steps in achieving a “spiritual awakening” is explored, recognizing the predominantly male ethos of Alcoholics Anonymous since its inception. The influence of age in expressions of spirituality, distinguishing between young adults, middle-age adults, and older adults, is referenced. Need for further understanding of gender differences, with a focus on the spiritual dimensions of recovery, is recommended.