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We present a patient who had surgically confirmed CD but without the full cushingoid phenotype despite markedly elevated cortisol. Nonpathologic causes of elevated ACTH and cortisol were eliminated as were pathogenic variants in the glucocorticoid receptor gene. Further studies of urine metabolites, cortisol half-life, and the ratios of cortisone to cortisol conversion revealed impaired 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) activity. There have only been 2 prior reports of impaired 11β-HSD1 resulting in lack of classic cushingoid features in the past 2 decades. Our patient's presentation and previous reports demonstrate the key role of 11β-HSD1 in modulating intracellular cortisol concentration, therefore shielding the peripheral tissues from the effects of excess cortisol. When patients present with markedly elevated cortisol but without classic cushingoid features, impaired 11β-HSD1 should be considered in the differential diagnosis. [ABSTRACT FROM AUTHOR]

This article discusses the predictors of biochemical remission after surgical resection of somatotroph adenomas, which are tumors that produce excessive growth hormone. The study analyzed data from 97 patients who underwent surgery for somatotroph adenomas and found that larger tumor size, cavernous sinus invasion, and higher levels of preoperative growth hormone and IGF-1 were associated with a higher likelihood of remission failure. A machine learning model identified 3D tumor volume and preoperative IGF-1 as important predictors of remission status. The study concludes that patients who achieve postoperative remission typically have preoperative 3D tumor volumes less than 1.51 cm3. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, explores the frequency and significance of hyperenhancement in pituitary neuroendocrine tumors (PitNETs) on preoperative MRI scans. The study involved a retrospective review of patients who underwent transsphenoidal surgery for PitNETs at a single pituitary center from 2012 to 2019. The results showed that 8.5% of PitNETs exhibited hyperenhancement on preoperative contrasted imaging studies. These hyperenhancing tumors were smaller and more commonly microadenomas compared to PitNETs with conventional hypoenhancement. Additionally, patients with hyperenhancing tumors were more likely to present with hypothyroidism and had a higher risk of postoperative diabetes insipidus. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, examines the predictors of postoperative hypopituitarism in patients who undergo surgical removal of nonfunctional pituitary neuroendocrine tumors (PitNETs). The study, which involved a retrospective review of 701 cases, found that 35% of patients experienced new postoperative hypopituitarism. Preoperative factors such as tumor size, serum follicle-stimulating hormone (FSH), prolactin, and cortisol levels were identified as significant predictors of postoperative hypopituitarism. The findings suggest that patients with larger tumors and lower levels of prolactin and cortisol may be at higher risk for this complication. Additionally, women with preoperative serum FSH levels greater than 27.95 mIU/mL were unlikely to experience hypopituitarism after surgery. [Extracted from the article]

Flood is one of the most frequently occurring and devastating disasters in Nepal. Several locations in Nepal are at high risk of flood, which requires proper guidance on early warning and safe evacuation of people to emergency locations through optimal routes to minimize fatalities. However, the information is limited to flood hazard mapping only. This study provides a comprehensive flood susceptibility and evacuation route mapping in the Siraha Municipality of Nepal where a lot of flood events have occurred in the past and are liable to happen in the future. The flood susceptibility map was created using a Geographic Information System (GIS)-based Analytical Hierarchy Process (AHP) over nine flood conditioning factors. It showed that 47% of the total area was highly susceptible to flood, and the remaining was in the safe zone. The assembly points where people would gather for evacuation were selected within the susceptible zone through manual digitization while the emergency shelters were selected within a safe zone such that they can host the maximum number of people. The network analysis approach is used for evacuation route mapping in which the closest facility analysis proposed the optimum evacuation route based on the walking speed of evacuees to reach the emergency shelter place considering the effect of slope and flood on the speed of the pedestrian. A total of 12 out of 22 suggested emergency shelters were within 30 min, 7 within 60 min, and 2 within 100 min walk from the assembly point. Moreover, this study suggests the possible areas for further shelter place allocations based on service area analysis. This study can support the authorities' decision-making for the flood risk assessment and early warning system planning, and helps in providing an efficient evacuation plan for risk mitigation. [ABSTRACT FROM AUTHOR]

The increasing adoption of minimally invasive techniques for spine surgery in recent years has led to significant advancements in instrumentation for lumbar interbody fusion. Percutaneous pedicle screw fixation is now a mature technology, but the role of expandable cages is still evolving. The capability to deliver a multiexpandable interbody cage with a large footprint through a narrow surgical cannula represents a significant advancement in spinal surgery technology. The purpose of this report is to describe a multiexpandable lumbar interbody fusion cage, including implant characteristics, intended use, surgical technique, preclinical testing, and early clinical experience. Results to date suggest that the multiexpandable cage allows a less invasive approach to posterior/transforaminal lumbar interbody fusion surgery by minimizing iatrogenic risks associated with static or vertically expanding interbody prostheses while providing immediate vertebral height restoration, restoration of anatomic alignment, and excellent early-term clinical results. [ABSTRACT FROM AUTHOR]

Statins can cause a wide spectrum of muscular adverse effects ranging from asymptomatic elevation of Creatine Kinase (CK), myalgia and exercise intolerance to rhabdomyolysis. Most of these effects generally resolve on stopping the medication. However, statins can be associated with a unique autoimmune myopathy wherein symptoms persist or even progress after statin discontinuation and require immunosuppressive therapy. The case presented is a 60-year-old woman who was on statin treatment for a period of 2 years. She developed muscle weakness with a limb girdle distribution. She had persistent elevation of CK even after discontinuation of statin therapy. EMG done revealed irritable myopathy and muscle biopsy showed necrosis without inflammation. She subsequently tested positive for anti-3-hydroxy-3-methylglutaryl-coenzyme A (anti-HMG CoA) antibody which is found to be present in patients with statin-associated necrotizing autoimmune myopathy. Patient was started on steroid without much improvement in her symptoms. After a month of follow up, her upper extremity strength was back but lower extremity continued to be weak which prompted us to start her on Methotrexate and Azathioprine. Like our patient, there are rare subgroup of patients with an immune-mediated necrotizing myopathy that does not improve after discontinuation of the drug and requires aggressive treatment with immunosuppressive agents. Awareness and early recognition of this disease is very important in patients who continue to have CK elevation and weakness after discontinuation of statin therapy. [ABSTRACT FROM AUTHOR]

Introduction: Cushing's disease is a neuroendocrine disorder marked by hypercortisolemia secondary to overproduction of ACTH by a corticotropic pituitary adenoma. Due to the diverse and deleterious effects of hypercortisolemia including diabetes mellitus, hypertension, and cardiovascular disease, prompt and accurate diagnosis followed by surgical resection of the responsible corticotropic adenoma is critical. Methods: In the following review, we present a focused synopsis of recently published data and management strategies for the post-operative Cushing's disease patient with a particular focus on studies examining perioperative complications, establishment of biochemical remission, factors associated with disease remission, and predictors of recurrence. Conclusions: Although no standard definition of remission exists, we suggest measurement of serum cortisol level on the morning of postoperative day 1 given the preponderance of evidence in the published literature suggesting its association with long-term remission and relatively low rates of recurrence. Nevertheless, all patients should be counseled that recurrence can occur in a delayed fashion and that annual endocrine testing should be utilized to track and confirm disease status. [ABSTRACT FROM AUTHOR]