Combined approach for the management of large vestibular schwannomas: Planned subtotal resection followed by gamma knife surgery in a series of 20 consecutive cases.

INTRODUCTION: The management of large lesions of the skull base, such as vestibular schwannomas (VS) is challenging. Microsurgery remains the main treatment option. Combined approaches (planned subtotal resection followed by gamma knife surgery (GKS) for residual tumor long-term control) are being increasingly considered to reduce the risk of neurological deficits following complete resection. The current study aims to prospectively evaluate the safety-efficacy of combined approach in patients with large VS. MATERIALS AND METHODS: We present our experience with planned subtotal resection followed by gamma knife surgery (GKS) in a consecutive a series of 20 patients with large vestibular schwannomas, treated between 2009 and 2014 in Lausanne University Hospital, Switzerland. Clinical and radiological data and audiograms were prospectively collected for all patients, before and after surgery, before and after GKS, at regular intervals, in dedicated case-report forms. Additionally, for GKS, dose-planning parameters were registered. RESULTS: Twenty patients (6 males and 14 females) with large VS had been treated by this approach. The mean age at the time of surgery was 51.6years (range 34.4-73.4). The mean presurgical diameter was 36.7 (range 26.1-45). The mean presurgical tumor volume was 15.9cm(3) (range 534.9). Three patients (15%) needed a second surgical intervention because of high volume of the tumor remnant considered too large for a safe GKS. The mean follow-up after surgery was 27.2months (range 6-61.3). The timing of GKS was decided on the basis of the residual tumor shape and size following surgery. The mean duration between surgery and GKS was 7.6months (range 413.9, median 6months). The mean tumor volume at the time of GKS was 4.1cm(3) (range 0.5-12.8). The mean prescription isodose volume was 6.3cm(3) (range 0.8-15.5). The mean number of isocenters was 20.4 (range 11-31) and the mean marginal prescription dose was 11.7Gy (range 11-12). We did not have any major complications in our series. Postoperative status showed normal facial nerve function (House-Brackmann grade I) in all patients. Six patients with useful pre-operative hearing (GR class 1) underwent surgery with the aim to preserve cochlear nerve function; of these patients, 5 (83.3%) of them remained in GR class 1 and one (16.7%) lost hearing (GR class 5). Two patients having GR class 3 at baseline remained in the same GR class, but the tonal audiometry improved in one of them during follow-up. Eleven patients (57.8%) were in GR class 5 preoperatively; one patient improved hearing after surgery, passing to GR class 3 postoperatively. Following GKS, there were no new neurological deficits, with facial and hearing function remaining identical to that after surgery. CONCLUSION: Our data suggest that planned subtotal resection followed by GKS has an excellent clinical outcome with respect to retaining facial and cochlear nerve function. This represents a paradigm shift of the treatment goals from a complete tumor excision perspective to that of a surgery designed to preserve neural functions. As long-term results emerge, this approach of a combined treatment (microsurgery and GKS) will most probably become the standard of care in the management of large vestibular schwanomma.

Wechsel von einem mechanischen Mikrokeratom auf einen Femtosekunden-Laser zur Korrektur von Astigmatismus mittels LASIK: klinische Ergebnisse einer retrospektiven, konsekutiven Vergleichsstudie Moving from a Mechanical Microkeratome to a Femtosecond Laser for LASIK to Correct Astigmatic Patients: Clinical Outcomes of a Retrospective, Consecutive, Comparative Study.

Background: To evaluate outcomes after optimized laser in situ keratomileusis (LASIK) for astigmatism correction with flap created by a mechanical microkeratome or a femtosecond laser. Patients and Methods: In this retrospective study, a total of 102 eyes of 71 consecutive patients were enrolled undergoing optimized LASIK treatments using the Allegretto laser system (WaveLight Laser Technologie AG, Erlangen, Germany). A mechanical microkeratome for flap creation was used (One Use, Moria®) in 46 eyes (31 patients, spherical equivalent [SE] -4.44 D ± 2.4) and a femtosecond laser was used (LDV, Ziemer®) in 56 eyes (40 patients, spherical equivalent [SE] -3.07 D ± 3.3). The two groups were matched for inclusion criteria and were operated under similar conditions by the same surgeon. Results: Overall, the preoperative spherical equivalent was -9.5 diopters (D) to +3.37 D; the preoperative manifest astigmatism was between -1.5 D and -3.5 D. At 6 months postoperatively, the mean postoperative uncorrected distance visual acuity (UDVA) was 0.93 ± 0.17 (range 0.4 to 1.2) in the Moria group and 1.0 ± 0.21 (range 0.6 to 1.6) in the Femto group, which was statistically significant (p = 0.003). Comparing the cylinder power there was a statistical difference between the two groups (p = 0.0015). Conclusions: This study shows that the method of flap creation has a significant impact on postoperative astigmatism with a significantly better postoperative UDVA in the Femto group. These findings suggest that the femtosecond laser provides a better platform for LASIK treatment of astigmatism than the commonly used microkeratome.

Effect of water and citrate solubility on agronomic effectiveness of acidulated phosphates in three consecutive corn crops

In the process of phosphate rock acidulation, several impure P compounds may be formed along with the desirable Ca and NH4 phosphates. Such compounds normally reduce the content of water-soluble P and thus the agronomic effectiveness of commercial fertilizers. In order to study this problem, a greenhouse experiment consisting of three consecutive corn crops was conducted in samples of a Red-Yellow Latosol (Typical Hapludox) in a completely randomized design (6 x 2 x 2), with four replicates. Six commercial fertilizers were added to 2 kg of soil at a rate of 70 mg kg-1 P, based on the content of soluble P in neutral ammonium citrate plus water (NAC + H2O) of the fertilizers. Fertilizer application occurred either in the original form or leached to remove the water-soluble fraction, either by mixing the fertilizer with the whole soil in the pots or with only 1 % of its volume. The corn plants were harvested 40 days after emergence to determine the shoot dry matter and accumulated P. For the first crop and localized application, the elimination of water-soluble P from the original fertilizers resulted in less bioavailable P for the plants. For the second and third crops, the effects of P source, leaching and application methods were not as evident as for the first, suggesting that the tested P sources may have similar efficiencies when considering successive cropping. The conclusion was drawn that the water-insoluble but NAC-soluble fractions of commercial P fertilizers are not necessarily inert because they can provide P in the long run.

15N uptake fom manure and fertilizer sources by three consecutive crops under controlled conditions

There are several regions of the world where soil N analysis and/or N budgets are not used to determine how much N to apply, resulting in higher than needed N inputs, especially when manure is used. One such region is the North Central "La Comarca Lagunera", one of the most important dairy production areas of Mexico. We conducted a unique controlled greenhouse study using 15N fertilizer and 15N isotopic-labeled manure that was labeled under local conditions to monitor N cycling and recovery under higher N inputs. The manure-N treatment was applied only once and was incorporated in the soil before planting the first forage crop at an equivalent rate of 30, 60 and 120 Mg ha-1 dry manure. The 15N treatments were equivalent to 120 and 240 kg ha-1 (NH4)2SO4-N for each crop. The total N fertilizer for each N fertilized treatment were 360, and 720 kg ha-1 N. We found very low N recoveries: about 9 % from the manure N inputs, lower than the 22 to 25 % from the fertilizer N inputs. The manure N recovered belowground in soil and roots ranged from 82 to 88 %. The low recoveries of N by the aboveground and low soil inorganic nitrate (NO3-N) and ammonium (NH4-N) content after the third harvested suggested that most of the 15N recovered belowground was in the soil organic form. The losses from manure N inputs ranged from 3 to 11 %, lower than the 34 to 39 % lost from fertilizer N sources. Our study shows that excessive applications of manure or fertilizer N that are traditionally used in this region will not increase the rate of N uptake by aboveground compartment but will increase the potential for N losses to the environment.

Video-assisted thoracoscopic resection of a small pulmonary nodule after computed tomography-guided localization with a hook-wire system. Experience in 45 consecutive patients.

BACKGROUND: This study is a single-institution validation of video-assisted thoracoscopic (VATS) resection of a small solitary pulmonary nodule (SPN) previously localized by a CT-guided hook-wire system in a consecutive series of 45 patients. METHODS: The records of all patients undergoing VATS resection for SPN preoperatively localized by CT-guided a hook-wire system from January 2002 to December 2004 were assessed with respect to failure to localize the lesion by the hook-wire system, conversion thoracotomy rate, duration of operation, postoperative complications, and histology of SPN. RESULTS: Forty-five patients underwent 49 VATS resections, with simultaneous bilateral SPN resection performed in 4. Preoperative CT-guided hook-wire localization failed in two patients (4%). Conversion thoracotomy was necessary in two patients (4%) because it was not possible to resect the lesion by a VATS approach. The average operative time was 50 min. Postoperative complications occurred in 3 patients (6%), one hemothorax and two pneumonia. The mean hospital stay was 5 days (range: 2-18 days). Histological assessment revealed inflammatory disease in 17 patients (38%), metastasis in 17 (38%), non-small-cell lung cancer (NSCLC) in 4 (9%), lymphoma in 3 (6%), interstitial fibrosis in 2 (4%), histiocytoma in one (2%), and hamartoma in one (2%). CONCLUSIONS: Histological analysis of resected SPN revealed unexpected malignant disease in more than 50% of the patients indicating that histological clarification of SPN seems warranted. Video-assisted thoracoscopic resection of SPN previously localized by a CT-guided hook-wire system is related to a low conversion thoracotomy rate, a short operation time, and few postoperative complications, and it is well suited for the clarification of SPN.

CHROMIUM IN SOIL ORGANIC MATTER AND COWPEA AFTER FOUR CONSECUTIVE ANNUAL APPLICATIONS OF COMPOSTED TANNERY SLUDGE

Tannery sludge contains high concentrations of inorganic elements, such as chromium (Cr), which may lead to environmental pollution and affect human health The behavior of Cr in organic matter fractions and in the growth of cowpea (Vigna unguiculata L.) was studied in a sandy soil after four consecutive annual applications of composted tannery sludge (CTS). Over a four-year period, CTS was applied on permanent plots (2 × 5 m) and incorporated in the soil (0-20 cm) at the rates of 0, 2.5, 5.0, 10.0, and 20.0 Mg ha-1 (dry weight basis). These treatments were replicated four times in a randomized block design. In the fourth year, cowpea was planted and grown for 50 days, at which time we analyzed the Cr concentrations in the soil, in the fulvic acid, humic acid, and humin fractions, and in the leaves, pods, and grains of cowpea. Composted tannery sludge led to an increase in Cr concentration in the soil. Among the humic substances, the highest Cr concentration was found in humin. The application rates of CTS significantly increased Cr concentration in leaves and grains.

Supraclavicular flap in head and neck reconstruction: experience in 50 consecutive patients.

The supraclavicular flap (SCF) is a fasciocutaneous flap used to cover head, oral, and neck region defects after tumor resection. Its main vascular supply is the supraclavicular artery and accompanying veins and it can be harvested as a vascularised pedicled flap. The SCF serves as an excellent outer skin cover as well as a good inner mucosal lining after oral cavity and head-neck tumor resections. The flap has a wide arc of rotation and matches the skin colour and texture of the face and neck. Between March 2006 and March 2011, the pedicled supraclavicular flap was used for reconstruction in 50 consecutive patients after head and neck tumor resections and certain benign conditions in a tertiary university hospital setting. The flaps were tunnelized under the neck skin to cover the external cervicofacial defects or passed medial to the mandible to give an inner epithelial lining after the oral cavity and oropharyngeal tumor excision. Forty-four of the 50 patients had 100% flap survival with excellent wound healing. All the flaps were harvested in less than 1 h. There were four cases of distal tip desquamation and two patients had complete flap necrosis. Distal flap desquamation was observed in SCFs used for resurfacing the external skin defects after oral cavity tumor ablation and needed only conservative treatment measures. Total flap failure was encountered in two patients who had failed in previous chemoradiotherapy for squamous cell cancer of the floor of mouth and tonsil, respectively, and the SCF was used in mucosal defect closure after tumor ablation. The benefits of a pedicled fasciocutaneous supraclavicular flap are clear; it is thin, reliable, easy, and quick to harvest. In head, face and neck reconstructions, it is a good alternative to free fasciocutaneous flaps, regional pedicled myocutaneous flaps, and the deltopectoral flap.

Moving from a Mechanical Microkeratome to a Femtosecond Laser for LASIK to Correct Astigmatic Patients: Clinical Outcomes of a Retrospective, Consecutive, Comparative Study.

Background: To evaluate outcomes after optimized laser in situ keratomileusis (LASIK) for astigmatism correction with flap created by a mechanical microkeratome or a femtosecond laser. Patients and Methods: In this retrospective study, a total of 102 eyes of 71 consecutive patients were enrolled undergoing optimized LASIK treatments using the Allegretto laser system (WaveLight Laser Technologie AG, Erlangen, Germany). A mechanical microkeratome for flap creation was used (One Use, Moria®) in 46 eyes (31 patients, spherical equivalent [SE] -4.44 D ± 2.4) and a femtosecond laser was used (LDV, Ziemer®) in 56 eyes (40 patients, spherical equivalent [SE] -3.07 D ± 3.3). The two groups were matched for inclusion criteria and were operated under similar conditions by the same surgeon. Results: Overall, the preoperative spherical equivalent was -9.5 diopters (D) to +3.37 D; the preoperative manifest astigmatism was between -1.5 D and -3.5 D. At 6 months postoperatively, the mean postoperative uncorrected distance visual acuity (UDVA) was 0.93 ± 0.17 (range 0.4 to 1.2) in the Moria group and 1.0 ± 0.21 (range 0.6 to 1.6) in the Femto group, which was statistically significant (p = 0.003). Comparing the cylinder power there was a statistical difference between the two groups (p = 0.0015). Conclusions: This study shows that the method of flap creation has a significant impact on postoperative astigmatism with a significantly better postoperative UDVA in the Femto group. These findings suggest that the femtosecond laser provides a better platform for LASIK treatment of astigmatism than the commonly used microkeratome.

Evidence for different expression profiles for c-Met, EGFR, PTEN and the mTOR pathway in low and high grade endometrial carcinomas in a cohort of consecutive women. Occurrence of PIK3CA and K-Ras mutations and microsatellite instability.

Molecular and genetic investigations in endometrial carcinogenesis may have prognostic and therapeutic implications. We studied the expression of EGFR, c-Met, PTEN and the mTOR signalling pathway (phospho-AKT/phospho-mTOR/phospho-RPS6) in 69 consecutive tumours and 16 tissue microarrays. We also analysed PIK3CA, K-Ras mutations and microsatellite instability (MSI). We distinguished two groups: group 1 (grade 1 and 2 endometrioid cancers) and group 2 (grade 3 endometrioid and type II clear and serous cell cancers). We hypothesised that these histological groups might have different features. We found that a) survival was higher in group 1 with less aggressive tumours (P⟨0.03); b) EGFR (P=0.01), PTEN and the AKT/mTOR/RPS6 signalling pathway were increased in group 1 versus group 2 (P=0.05 for phospho-mTOR); c) conversely, c-Met was higher (P⟨0.03) in group 2 than in group 1; d) In group 1, EGFR was correlated with c-Met, phospho-mTOR, phospho-RPS6 and the global activity of the phospho-AKT/phospho-mTOR/phospho-RPS6 pathway. In group 2, EGFR was correlated only with the phospho-AKT/phospho-mTOR/phospho-RPS6 pathway, whereas c-Met was correlated with PTEN; e) survival was higher for tumours with more than 50% PTEN-positive cells; f) K-RAS and PIK3CA mutations occurred in 10-12% of the available tumours and MSI in 40.4%, with a loss of MLH1 and PMS2 expression. Our results for endometrial cancers provide the first evidence for a difference in status between groups 1 and 2. The patients may benefit from different targeted treatments, anti-EGFR agents and rapamycin derivatives (anti-mTOR) for group 1 and an anti c-MET/ligand complex for group 2.

Prenatal diagnosis of urinary malformations: results in a series of 93 consecutive cases.

OBJECTIVE: To evaluate the pertinence of prenatal diagnosis in cases of congenital uropathy. STUDY DESIGN: Retrospective evaluation over a period of 6.5 years. METHOD: 93 cases were involved in the comparison of prenatal ultrasonographic diagnosis with neonatal findings, autopsy results, and follow-up data. RESULTS: 33 fetuses had renal parenchymal lesions, 44 had excretory system lesions, and 6 had bladder and/or urethral lesions. Seventy-three pregnancies lead to live births. Eighteen terminations of pregnancy were performed on the parents' request for extremely severe malformations. Two intrauterine deaths were observed, and two infants died in the postnatal period. Prenatal diagnosis was obtained at an average of 27 weeks gestation. Diagnostic concordance was excellent in 82% and partial in 12% of cases with renal parenchymal lesions; the false-positive rate was 6%. For excretory system lesions, concordance was excellent in 87% and partial in 7.4% of cases, with a false-positive rate of 5.6%. Finally, concordance was excellent in 100% of cases of bladder and/or urethral lesions. The overall rate of total concordance was 86%. Partial concordance cases consisted of malformations different from those previously diagnosed, but prenatal diagnosis nevertheless lead to further investigations in the neonatal period and to proper management. The false-positive diagnoses (5.4%) never lead to termination of pregnancy. CONCLUSION: Prenatal diagnosis of congenital uropathy is effective. A third-trimester ultrasonographic examination is necessary to ensure proper neonatal management, considering that the majority of cases are diagnosed at this gestational age.

Acute opiate overdose: characteristics of 190 consecutive cases.

AIMS: To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. DESIGN: Survey of a 12-month sample of AOO patients. MEASUREMENTS: Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. FINDINGS: One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. CONCLUSION: This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.

Characteristics of highly frequent users of a Swiss academic emergency department: a retrospective consecutive case series.

OBJECTIVES: The aim of this study was to describe the demographic, social and medical characteristics, and healthcare use of highly frequent users of a university hospital emergency department (ED) in Switzerland. METHODS: A retrospective consecutive case series was performed. We included all highly frequent users, defined as patients attending the ED 12 times or more within a calendar year (1 January 2009 to 31 December 2009). We collected their characteristics and calculated a score of accumulation of risk factors of vulnerability. RESULTS: Highly frequent users comprised 0.1% of ED patients, and they accounted for 0.8% of all ED attendances (23 patients, 425 attendances). Of all highly frequent users, 87% had a primary care practitioner, 82.6% were unemployed, 73.9% were socially isolated, and 60.9% had a mental health or substance use primary diagnosis. One-third had attempted suicide during study period, all of them being women. They were often admitted (24.0% of attendances), and only 8.7% were uninsured. On average, they cumulated 3.3 different risk factors of vulnerability (SD 1.4). CONCLUSION: Highly frequent users of a Swiss academic ED are a highly vulnerable population. They are in poor health and accumulate several risk factors of being even in poorer health. The small number of patients and their high level of insurance coverage make it particularly feasible to design a specific intervention to approach their needs, in close collaboration with their primary care practitioner. Elaboration of the intervention should focus on social reinsertion and risk-reduction strategies with regard to substance use, hospital admissions and suicide.