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.

Glutamate exocytosis from astrocytes controls synaptic strength.

The release of transmitters from glia influences synaptic functions. The modalities and physiological functions of glial release are poorly understood. Here we show that glutamate exocytosis from astrocytes of the rat hippocampal dentate molecular layer enhances synaptic strength at excitatory synapses between perforant path afferents and granule cells. The effect is mediated by ifenprodil-sensitive NMDA ionotropic glutamate receptors and involves an increase of transmitter release at the synapse. Correspondingly, we identify NMDA receptor 2B subunits on the extrasynaptic portion of excitatory nerve terminals. The receptor distribution is spatially related to glutamate-containing synaptic-like microvesicles in the apposed astrocytic processes. This glial regulatory pathway is endogenously activated by neuronal activity-dependent stimulation of purinergic P2Y1 receptors on the astrocytes. Thus, we provide the first combined functional and ultrastructural evidence for a physiological control of synaptic activity via exocytosis of glutamate from astrocytes.

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Neutrophil-derived APRIL concentrated in tumor lesions by proteoglycans correlates with human B-cell lymphoma aggressiveness.

A PRoliferation-Inducing TNF Ligand (APRIL) costimulates B-cell activation. When overexpressed in mice, APRIL induces B-cell neoplasia, reminiscent of human B-cell chronic lymphoid leukemia (B-CLL). We analyzed APRIL expression in situ in human non-Hodgkin lymphomas. APRIL up-regulation was only observed in high-grade B-cell lymphomas, diffuse large B-cell lymphoma (DLBCL), and Burkitt lymphoma (BL). Up-regulation was seen in 46% and 20% of DLBCL and BL, respectively. In DLBCL, neutrophils, constitutively producing APRIL and infiltrating the tumor tissue, were the main cellular source of APRIL. Rare DLBCL cases showed a predominance of histiocytes or mesenchymal cells as APRIL source. APRIL secreted by neutrophils accumulated on tumor cells via proteoglycan binding. In addition to proteoglycans, DLBCL tumor cells expressed the APRIL signaling receptor, TACI and/or BCMA, indicating that these tumor cells are fully equipped to respond to APRIL. A retrospective clinical analysis revealed a significant correlation between high expression of APRIL in tumor lesions and decreased overall patient survival rate. Hence, APRIL produced by inflammatory cells infiltrating lymphoma lesions may increase tumor aggressiveness and affect disease outcome.

Wealth, financial intermediation and growth

This paper presents empirical support for the existence of wealth effects in the contribution of financial intermediation to economic growth, and offers a theoretical explanation for these effects. Using GMM dynamic panel data techniques applied to study the growth-promoting effects of financial intermediation, we show that the exogenous contribution of financial development on economic growth has different effects for different levels of income per capita. We find that this contribution is generally increasing with thelevel of income per capita of the economy, up to a relatively high level of income. This contribution is consistently lower for poor countries; and for some low levels of income per capita it can be negative. We provide a model to account for these wealth effects. The model is a overlapping generations growth model where financial intermediaries implement liquidity risk sharing among depositors. We show that at early stages of economic development, a bank can increase welfare of its depositors only at the cost of lowering investment and growth. However, once the economy has crossed certain wealth threshold, the liquidity role of banks becomes unambiguously growth enhancing. As wealth increases, banks offer improving liquidity insurance, and higher growth; however, for high levels of wealth, growth generated byfinancial intermediation declines as the economy attains the optimal level of consumption risk sharing.

Uso de bibliotecas digitais versus tradicionais em contexto de info-exclusão

O acesso a recursos bibliográficos nos países mais pobres é um grande desafio e as bibliotecas digitais afiguram-se como sendo uma alternativa, com o falhanço dos mecanismos tradicionais de distribuição, não obstante os constrangimentos eventualmente existentes no acesso a recursos das TIC. Este artigo apresenta um estudo comparativo entre a utilização de uma biblioteca digital e uma tradicional, num país de difícil acesso a materiais bibliográficos e recursos das TIC. Além de procurar compreender como são utilizadas as bibliotecas digital e tradicional nesse contexto, analisa igualmente em que medida a biblioteca digital poderá contribuir para aumentar o acesso a recursos bibliográficos que existem na biblioteca tradicional, por parte de um público-alvo local que tem acesso às duas bibliotecas.

BOAVISTA: AS CONJUNTURAS INTERNACIONAIS, ECONÓMICO E A CRISE DE UMA SOCIEDADE1 O CRESCIMENTO

Boavista é hoje uma ilha turística por excelência, graças aos produtos ligados ao mar, às praias, ao sol e às paisagens, para além dos histórico-patrimoniais, que oferece. Assim também no passado ofereceu produtos de alto valor comercial, como os do gado, o sal, a urzela, entre outros. Esses produtos do passado conferiram à ilha uma opulência económica, social e cultural invejável no contexto de Cabo Verde de então, o que lhe mereceu o epíteto de “empório das ilhas de Barlavento”. A opulência, entretanto, duraria pouco, devido principalmente à perde do valor comercial externo dos produtos económicos, por causa, por seu turno, das conjunturas políticas e económicas internacionais da época. Este nosso artigo tenta, através de uma abordagem histórica, sugerir uma reflexão sobre as políticas do turismo pensadas e a serem (re)pensadas para a Boavista, nomeadamente no que concerne, ao mesmo tempo, à preservação dos produtos naturais e criados que a ilha da Boavista oferece ao turismo e a iniciativas que deverão ser tomadas, desde agora, por parte dos investidores, governantes e populações, no sentido da sustentabilidade económica e social numa longínqua mas possível era pós-turismo.

Extra burden of psychosomatic complaints among adolescents suffering from chronic conditions.

OBJECTIVE:: To determine whether there are differences in health perception and health care use among adolescents with psychosomatic symptoms (PS), with chronic conditions (CCs), and with both conditions compared with healthy controls. METHODS:: By using the SMASH02 database, 4 groups were created: youths with PS but no CCs (N = 1010); youths with CCs but no PS (N = 497); youths with both psychosomatic symptoms and chronic conditions (PSCC, N = 213); and youths with neither PS nor CC (control, N = 5709). We used χ tests and analysis of variance to compare each variable between the 4 groups. In a second step, all health and health care use variables were included in a multinomial regression analysis controlling for significant (p < .05) background variables and using the control group as the reference. RESULTS:: Overall, PS and PSCC youths were significantly more likely to rate their health as poor, to be depressed, and to have consulted several times their primary health care provider or a mental health professional than their healthy peers. With the exception of being depressed, PSCC adolescents reported worse health perception and higher health care use than CC and PS. CONCLUSIONS:: Although PS youths do not define PS as a CC, it should be considered as one. Moreover, having PS represents an additional burden to chronically ill adolescents. Health professionals dealing with adolescents must be aware of the deleterious health effects that PS can have on adolescents and have this diagnosis in mind to better target the treatment and improve their management.

L'Academie des princes , où les roys apprennent l'art de regner de la bouche des roys. Ouvrage tiré de l'histoire tant ancienne que nouvelle; et traduit par Pierre Menard

Comprend : Présent royal de Jaques I, roy d'Angleterre... au prince Henry, son fils