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Biocomposites with polylactic acid (PLA), nanosilica parts, and water hyacinth fibres have been developed in this experimental study. By changing the weight percentage of nanosilica particulate matter (0, 2, 4, 6, and 8 percent) with PLA and water hyacinth fibres, five composite mates were produced through a double screw extruder and compression moulding machine. According to the ASTM standards, the process to machine, the composite specimens have been adopted from the water jet machining process. The tensile, compression, flexural, impact, hardness, and water absorption tests were performed on the composite specimens to assess various mechanical properties and absorbance behaviour. The test findings reveal the significant improvement in the tensile and flexural properties of the composites. Composites contain 6 percent of the fine nanosilica particles by weight. Concerning adding the growing weight percentage (4 percent) of nanosilica particles to the composites, the water absorption properties of the composites have significantly improved. The tensile strength of 6% nanosilica mixed specimens showed the highest tensile stress rate as 36.93 MPa; the value was nearly 3.5% higher than the 4% nanosilica mixed composite specimens.

The enhancements related to optical devices are highly required for high-speed compact wireless optical transmission systems. This paper focuses on development and analysis of the communication system for inter-aircraft applications. The vertical cavity surface emitting laser (VCSEL) is employed at the transmitter for generating directly modulated non-return to zero (NRZ) signal. Direct detection along with Gaussian low pass filtering is employed in the receiver. The performance of the system is examined as well as compared with and without application of filtering at the receiver. The performance of optical wireless system is analyzed in terms of BER, eye-pattern, sensitivity, SNR, and Q-factor. The data rate is enhanced by 4-fold and transmission distance is improved by 250% in comparison with earlier inter-satellite links.

Objective: To analyze and find risk factors associated with the development of DI using a multicenter case series via TSE. Materials and methods: Medical records of patients who underwent TSS for PA resection between 2010-2021 at three different neurosurgical centers by four experienced neurosurgeons were retrospectively analyzed. The patients were divided into two groups (DI Group or Control Group). Logistic regression analysis was conducted to identify risk factors associated with postoperative DI. Univariate logistic regression was performed to identify variables of interest, and covariates with a p-value < 0.15 were incorporated into multivariate logistic regression models to identify independently associated risk factors for DI. All statistical tests were conducted using RStudio. Results: 344 patients were included; 68% were women, the mean age was 46.5 years, and non-functioning adenomas were the most frequent (171, 49.7%). The mean tumor size was 20.3 mm. Covariates associated with postoperative DI were female gender, cavernous sinus invasion (left or bilateral), intraoperative CSF leak, endoscopic surgery, left preoperative visual field involvement, complete tumor resection, Knosp score of 2 and 4, and macroadenomas. Age was associated with a lower OR for postoperative DI. Multivariable model showed female gender (OR 3.34 CI 1.50-7.99, p=0.004) and intraoperative CSF leak (OR 3.25 CI 1.25-8.85, p=0.017) were found to be independently associated with higher OR of developing postoperative DI. Age was not shown to be a protective factor for DI (OR 0.97; CI: 0.94-1.00; p=0.038). Conclusions: The independent risk factors for the development of DI were female patients and intraoperative CSF leak.

Energy efficiency is a significant issue in portable wireless networks since the battery life of versatile terminals is restricted. Protection of battery power has been tended to utilizing numerous procedures. Wireless sensor networks (WSNs), framed by various little gadgets fit for detecting, processing, and wireless correspondence are arising as a progressive innovation, with applications in different territories. The novel highlights of wireless sensor networks have carried new difficulties and issues to the field of conveyed and communitarian data preparing. In the light of the importance of reducing operating consumpt and maintaining cellular network profitability, energy efficiency in cell networks has received a crucial consideration from both scholars and the business, despite the fact that these networks are “green communication.” Since the base station is the most important energy buyer in the business, efforts have been undertaken to review the use of the base station and to identify ways to energy efficiency improvements. The trade-offs between energy utilization and throughput, under nearby just as under helpful detecting, are portrayed. The Energy efficient tradeoffs have been arranged dependent on every convention layer and examined its effect in the organization energy efficiency.

The cascade annulation between alkylidene malononitriles and cyclic sulfamidate imines has been controlled by leveraging the sulfamate functionality under organocatalysis, which allows selective access to polycyclic and densely functionalized dihydropyridines and pyridines in high yields. The protocol is scalable and shows broad substrate scope. The products were also engaged in the preparation of tetracyclic pyridopyrimidines, showcasing the synthetic versatility.

This study analyzed patient, radiologic, and clinical factors associated with operative brain abscesses and patients' functional outcomes.A retrospective analysis was conducted of neurosurgical cases of brain abscesses from 2009 to 2019 at a Canadian center. Functional outcome was recorded as Modified Rankin Scale score and Extended Glasgow Outcome Scale score. Multivariate analysis was conducted to identify relevant prognostic factors.We identified 139 patients managed surgically for brain abscesses. Resection alone was performed in 64% of patients, whereas 26.6% underwent aspiration alone. Most were adults (93.2%) and male (68.3%). Immunocompromise risk factors included diabetes (24.5%), cancer (23.7%), and immunosuppressive therapy (11.5%). Likely sources were postoperative (17.3%), systemic spread (16.5%), and poor dentition (12.9%). Microorganisms cultured from abscess samples were mixed growth (28%), Streptococcus anginosus (24.5%), and Staphylococcus aureus (7.9%). Disposition was home (42.4%) or repatriation to a home hospital (50.4%). By Extended Glasgow Outcome Scale, 25.2% had an unfavorable outcome including a mortality of 11.5%. Factors on multivariate analysis associated with poor outcome included diabetes (odds ratio, 2.8; 95% confidence interval [CI], 1.2-5.0) and ventricular rupture (odds ratio, 5.0; 95% CI, 1.7-13.5; hazard ratio, 12; 95% CI, 3.9-37.0). Supratentorial superficial eloquently located abscess was also associated with poor outcome (hazard ratio, 5.5; 95% CI, 1.8-16.7). Outcomes were similar with surgical excision and aspiration.Ventricular rupture and diabetes are significant risk factors for poor outcomes in intraparenchymal brain abscesses. No clear difference in outcomes was found between surgical excision or aspiration in our retrospective cohort.

Background Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear. Objective To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS. Methods A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma. Results A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported. Conclusion Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.

Background Colloid cysts are rare developmental lesions, accounting for approximately 1% of intracranial tumors. Often, these benign lesions are asymptomatic, but they are associated with significant mortality as a result of acute hydrocephalus. This mortality in patients with vague or no symptoms dictates a need for better understanding of the etiology of colloid cysts to expedite diagnosis and management. We present a case of monozygotic twins with colloid cysts to propose a genetic etiology for colloid cyst. Case Description Previously healthy male monozygotic twins presented 4 years apart with headache secondary to hydrocephalus as a result of colloid cysts. Both patients underwent multiple surgeries and were doing well at last follow-up. Conclusions The present case adds to a body of literature of familial colloid cysts, suggesting higher concordance in monozygotic compared with dizygotic twins. This may be due to high genetic load, shared intrauterine environment, epigenetic changes, or genetic mutation. This literature review suggests that given high morbidity and mortality of colloid cysts, screening may be beneficial. Even in the absence of a single, definitive genetic etiology, we recommend consideration of genetic screening or, at a minimum, screening with neuroimaging for monozygotic twins in cases where 1 twin is diagnosed with colloid cyst.

Historically, the brain has been viewed as a specialized neurovascular inert organ with a distinctive immune privilege. Therefore, radiation-induced extracranial abscopal effects would be considered an unusual phenomenon due to the difficulty of the immunogenic signaling molecules to travel across the blood-brain barrier (BBB). However, it is now possible that localized central nervous system radiation has the ability to disrupt the structural integrity of the BBB and increase its endothelial permeability allowing the free passage of immunogenic responses between the intracranial and extracranial compartments. Thus, the nascent tumor-associated antigens produced by localized brain radiation can travel across the BBB into the rest of the body to modulate the immune system and induce extracranial abscopal effects. In clinical practice, localized brain radiation therapy-induced extracranial abscopal effects are a rarely seen phenomenon in metastatic melanoma and other advanced cancers. In this article, we provide a detailed overview of the current state of knowledge and clinical experience of central nervous system radiation-induced extracranial abscopal effects in patients with malignant melanoma. Emerging data from a small number of case reports and cohort studies of various malignancies has significantly altered our earlier understanding of this process by revealing that the brain is neither isolated nor passive in its interactions with the body's immune system. In addition, these studies provide clinical evidence that the brain is capable of interacting actively with the extracranial peripheral immune system. Thus, localized radiation treatment to 1 or more locations of brain metastases can induce extracranial abscopal responses. Collectively, these findings clearly demonstrate that localized brain radiation therapy-induced abscopal effects traverses the BBB and trigger tumor regression in the nonirradiated extracranial locations.

Background Despite maximal safe cytoreductive surgery and postoperative adjuvant therapies, glioblastoma (GBM) inevitably recurs and leads to deterioration of neurological status and eventual death. There is no consensus regarding the benefit of repeat resection for enhancing survival or quality of life in patients with recurrent GBM. We aimed to examine if reoperation for GBM recurrence incurs a survival benefit as well as examine its complication profile. Methods We performed a single-center retrospective chart review on all adult patients who underwent resection of supratentorial GBM between January 1, 2008 and December 1, 2013 at our center. Patients with repeat resection were manually matched for age, sex, tumor location, and Karnofsky Performance Status (KPS) with patients who underwent single resection to compare overall survival (OS), and postoperative morbidity. Results Of 237 patients operated with GBM, 204 underwent single resection and 33 were selected for repeat surgical resections. In a matched analysis there was no difference in the OS between groups (17.8 ± 17.6 months vs 17 ± 13.5 months, P = .221). In addition, repeat surgical resection had a higher rate of postoperative neurological complications compared to the initial surgery. Conclusions When compared with matched patients who underwent a single surgical resection, patients undergoing repeat surgical resection did not show significant increase in OS and may have incurred more neurological complications related to the repeat resection. Further studies are required to assess which patients would benefit from repeat surgical resection and optimize timing of the repeat resection in selected patients.

Background:Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumor-like lesion with unknown pathogenesis. It is likely under-reported due to diagnostic challenges including the nonspecific radiographic features, lack of diagnostic markers, and often asymptomatic nature of the lesions.Methods:We performed detailed examination of 11 CAPNON specimens diagnosed by histopathology, with the help of electron microscopy and immunohistochemistry.Results:Electron microscopy revealed the presence of fibrillary materials consistent with neurofilaments. In addition to some entrapped axons at the periphery of CAPNONs, we discovered that all specimens stained positive for neurofilament-light (NF-L) within the granular amorphous cores, but not neurofilament-phosphorylated (NF-p). CAPNONs also showed variable infiltration of CD8+ T-cells and a decreased ratio of CD4/CD8+ T-cells, suggesting an immune-mediated process in the pathogenesis of CAPNON.Conclusion:NF-L and CD4/CD8 immunostains may serve as diagnostic markers for CAPNON and shed light on its pathogenesis.

Background The endoscopic endonasal approach (EEA) has been increasing in popularity as an alternative to traditional transcranial and transorbital approaches in the treatment of orbital pathological entities. The purpose of the present study was to examine the outcomes of patients who had undergone EEA resection of orbital lesions at our center. Methods We performed a retrospective medical record review of patients who had undergone the EEA for resection of orbital lesions and orbital apex decompression from January 1, 2006 to December 1, 2019. For all the patients, the demographic data, presenting symptoms, symptom duration, imaging data, operative details, and postoperative outcomes were collected and reviewed. Results Nine patients underwent endoscopic endonasal resection of orbital lesions and orbital apex decompression at our center, including 6 male patients and 3 female patients. The mean age was 49.4 years, and the mean follow-up period was 3.8 years (range, 1–13.5 years). The orbital pathological lesions that were treated included nasopharyngeal carcinoma, hemangioma, fibrous dysplasia, IgG4 pseudotumor, inverted papilloma, angioleiomyoma, adenocarcinoma, and neuroendocrine paraganglioma metastasis. All the patients presented with exophthalmos of the affected orbit. Of the 9 patients, 5 presented with decreased visual acuity on examination. Postoperatively, 1 of these 5 patients had improved to baseline visual acuity, 3 had stable vision, and 1 had brief improvement before experiencing progressive visual decline 1 month postoperatively. Two patients presented with diplopia, and both improved postoperatively. Three patients experienced new, transient, and self-limiting postoperative diplopia. Conclusions For patients with orbital lesions causing compressive optic neuropathy, the endoscopic endonasal approach can be used as an alternative strategy in appropriately selected patients.

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is thought to be a rare tumefactive lesion with unknown pathogenesis. Its prevalence is questionable with few previously reported cases of incidental CAPNON, and likely underdiagnosis. We report a unique case of incidental multifocal CAPNON. A 64-year-old female was admitted with loss of consciousness due to a ruptured right middle cerebral artery aneurysm with subarachnoid and intraventricular hemorrhage. She has a craniotomy and clipping. At time of operation, numerous small dural-based nodules were found, and one was excised for biopsy and was diagnosed as CAPNON. Retrospective review of her CT images identified nodules that were all ipsilateral to the ruptured aneurysm. A literature review revealed that incidental and/or multifocal CAPNONs are rare but likely underreported. Our case suggests a reactive process in the pathogenesis of CAPNON.

Spontaneous CSF–venous fistulas may be present in up to one-fourth of patients with spontaneous intracranial hypotension. This is a recently discovered type of CSF leak, and much remains unknown about these fistulas. Spinal CSF–venous fistulas are usually seen in coexistence with a spinal meningeal diverticulum, suggesting the presence of an underlying structural dural weakness at the proximal portion of the fistula. The authors now report the presence of soft-tissue venous/venolymphatic malformations associated with spontaneous spinal CSF–venous fistulas in 2 patients with spontaneous intracranial hypotension, suggesting a role for distal venous pathology. In a third patient with spontaneous intracranial hypotension and a venolymphatic malformation, such a CSF–venous fistula is strongly suspected.

Background: Malignant melanoma represents the deadliest form of skin cancer with a high tendency to metastasize during the early course of the disease. Radiation therapy has long played a key role in the management of both local and metastatic melanoma. Although local radiation therapy exerts antitumor effects by damaging the cellular DNA, it also induces an important out-of-field (distant) effect known as the “abscopal effect” in nonirradiated sites. Radiation therapy-induced abscopal effects are believed to be mediated by activation and stimulation of the immune system. Objective: To provide a detailed overview of the current state of knowledge and clinical experience of radiation therapy-induced abscopal effects in patients with malignant melanoma. Methods: Using electronic databases such as MEDLINE via PubMed and Google Scholar, a systematic literature review was performed to find published clinical evidence for radiation therapy-induced abscopal effects in patients with malignant melanoma. The clinical data on radiation therapy-induced abscopal effects were reviewed and the outcomes summarized. Results: Clinical evidence of patients with malignant melanoma was gathered using databases from MEDLINE and those findings were summarized. Although the precise mechanism of the abscopal effect of radiation therapy is still not completely understood, evidence suggests that tumor cell destruction by radiation releases tumor antigens that stimulate the immune system of the host to activate the body’s immune effector cells systemically and produce distant non-target antitumor effects. This forms a basis for using the radiation therapy with immunotherapy to augment the abscopal response rates. Conclusions: Current clinical evidence suggests that there is a large potential to enhance the abscopal effect when radiation therapy is combined with immunotherapeutic agents for the treatment of malignant melanoma. Ongoing and planned clinical trials may provide us with a more in-depth understanding of how this combination therapy can be optimally utilized clinically to achieve improved survival outcomes among patients with malignant melanoma.

Background:Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumefactive lesion. CAPNONs can mimic calcified meningiomas at the skull base.Methods:Here, we report two cases of CAPNON and present a systematic review of the literature on skull base CAPNONs, to compare CAPNONs with calcified meningiomas.Results:Case 1: A 57-year-old man presented with right-sided lower cranial neuropathies and gait ataxia. He underwent a subtotal resection of a right cerebellopontine angle lesion, with significant improvement of his gait ataxia. However, his cranial neuropathies persisted. Pathological examination of the lesion was diagnostic of CAPNON, with the entrapped nerve fibers identified at the periphery of the lesion, correlating with the patient’s cranial neuropathy. Case 2: A 70-year-old man presented with progressive headache, gait difficulty, and cognitive impairment. He underwent a frontotemporal craniotomy for a near-total resection of his right basal frontal CAPNON. He remained neurologically stable 7 years after the initial resection without evidence of disease recurrence. We analyzed 24 reported CAPNONs at the skull base in our systematic review of the literature. Cranial neuropathies were present in 11 (45.8%) patients. Outcomes regarding cranial neuropathies were documented in six patients: two had sacrifice of the nerve function with surgical approaches and four had persistent cranial neuropathies.Conclusion:While CAPNON can radiologically and grossly mimic calcified meningiomas, they are two distinctly different pathologies. CAPNONs located at the skull base are commonly associated with cranial neuropathies, which may be difficult to reverse despite surgical intervention.

The endoscopic endonasal approach (EEA) has become increasingly employed in the treatment of suprasellar meningiomas. These tumors often cause visual symptoms due to compression of the anterior visual pathway. We aimed to examine long-term visual outcomes after EEA for optic nerve decompression and resection of suprasellar meningioma at our center, and to identify preoperative factors predictive of postoperative visual improvement. We performed a retrospective cohort study on 27 patients who underwent the EEA for resection of meningiomas extending into the suprasellar cistern and decompression of anterior visual pathway between January 1, 2005, and March 1, 2019. We treated 8 male and 19 female patients, with a mean follow-up of 7.6 years. The mean age of our patients at initial presentation was 60.1 years. Eighteen patients (66.7%) presented with visual acuity deficits, and 12 (44.4%) patients presented with visual field deficits. Postoperatively, 11 patients had improved visual acuity, 6 had stable visual acuity, and 1 patient had slow and progressive decline of visual acuity; 5 patients had improved visual field, 6 had stable visual field, and 1 patient had slow and progressive decline in visual field. Patients less likely to have postoperative improvement of visual acuity were those with longer than 6-month duration of visual symptoms (P = 0.024*) as well as patients with the presence of a relative afferent pupillary defect (RAPD) (P = 0.023*). The EEA can achieve good visual outcomes in patients harboring suprasellar meningiomas. Symptom duration of less than 6 months and lack of a RAPD were positive predictors of postoperative visual acuity.

The understanding of localized radiation therapy's immunostimulatory properties combined with its well-known effects on the cell cycle and insights into the immunomodulation mechanisms that occur at the molecular and cellular levels has changed our traditional view of the anticancer effects of ionizing radiation. The potential interactions between the tumor's immune system and radiation therapy have revealed that local radiation has the ability to induce systemic antitumor responses in patients with advanced cancers. The recognition of systemic antitumor effects of radiation therapy has allowed investigators to begin uncovering the integral players in these pathways. Parallel to this, there has been progress in understanding how tumor immunology leads to the development of novel immunotherapies using immune checkpoint blockade therapies in the treatment of advanced cancers. To date there has been limited success in this benefiting only a small fraction of patients. The concept of priming the body's immune system by radiation to make less responsive tumors more responsive to immunotherapy provides an opportunity to explore the use of the combination of radiation therapy and immunotherapy for the treatment of advanced non-small cell lung cancer and other cancers. This article provides an overview of the current state of knowledge of the clinical experience using radiation therapy in combination with immune therapy and discusses the rationale for integrating these 2 modalities in the treatment of advanced non-small cell lung cancer. Available data supports the use of radiation therapy in combination with immunotherapy to achieve improved local and systemic tumor control. Evidence from the early clinical trials has shown that using radiation therapy and immune checkpoint blockade therapies together produces a greater clinical effect than using either modality alone. To maximize the clinical benefit and successful integration of these two modalities as well as optimizing radiation therapy dosing and its schedule, improvement in its field design and the development of reliable predictors of clinical tumor response needs to be established.

An extracranial abscopal effect induced by central nervous system (CNS)-radiation therapy is considered an unusual event because of the belief that brain has a distinctive immune microenvironment. Regular immune responses from radiation therapy or other interventions were thought to be very limited in the CNS. In addition, CNS autoimmunity and neurodegeneration were presumed automatic consequences of immune cell encounters with CNS antigens. Moreover, the traditional assumption is that nascent tumor-associated antigens produced by radiation therapy could not pass through the blood-brain barrier back into the rest of the body to modulate the immune system and induce extracranial abscopal responses. Emerging data from a small number of case series and individual case reports of various malignancies have radically altered our earlier understanding by revealing that the CNS is neither isolated nor passive in its interactions with the body's immune system. Furthermore, current data indicate that the CNS is both immune-competent and interacts actively with the peripheral immune system. Therefore, radiation treatment to ≥1 location of CNS metastases can induce abscopal responses in tumors away from the treated CNS metastatic sites. These observations suggest the abscopal effect traverses the blood-brain barrier. In this article, we reviewed and assessed the clinical evidence of extracranial abscopal responses of CNS-radiation therapy in patients with advanced lung cancer.

Background and importance Hypertrophic interstitial neuropathy (HIN) is an uncommon, non-neoplastic lesion typically affecting peripheral nerves. Cranial nerve (CN) involvement is exceedingly rare. We present a case of isolated trigeminal nerve HIN manifesting with V3 distribution neuralgia. Clinical presentation A 50-yr-old male presented with left sided trigeminal neuralgia refractory to medical management. The patient underwent retromastoid craniectomy for possible microvascular decompression. Intra-operatively, the trigeminal nerve appeared to be focally enlarged with a sausage-like configuration. We selectively resected 1 fascicle which was predominantly involved. Histopathological examination revealed onion bulb formations composed of Schwann cells around centrally placed axons. A diagnosis of HIN was made. Postoperatively, the patient experienced complete resolution of symptoms. Conclusion This is the third case of isolated trigeminal nerve HIN in the literature. We performed a selective resection in a patient presenting with trigeminal neuralgia, resulting in complete resolution of symptoms. It is reported here with intraoperative microscope images, along with a review and analysis of this topic as it related to CN.

Background: Missile embolism is the process of slow velocity projectiles penetrating into vascular spaces followed by arterial, venous, or paradoxical embolism of the fragments. This is a rare complication in craniocerebral gunshot injuries (CGI), with only five other cases previously published demonstrating pulmonary or arterial emboli from these injuries. There is a high rate of mortality from these injuries. Case Description: A patient presented with a CGI from an occipital trajectory, causing penetrating fragments into the venous sinus system. The weapon was a Glock Model 17M 9 mm with a hollow-point bullet, fired close range. Initial chest X-ray demonstrated only atelectasis. After stabilization, 18 min from the initial chest X-ray, subsequent computed tomography (CT) imaging demonstrated extensive intracranial injuries and fragmentation of the bullet with the expected devastating intracranial injuries. Unexpectedly, chest CT revealed metallic fragments in the right cardiac ventricle which was redemonstrated on follow-up chest X-ray. Unfortunately, his extensive intracranial injuries and poor clinical status were nonsurvivable, and thus the family elected to discontinue supportive measures. Conclusion: This case demonstrates radiographic imaging of a metallic intravascular fragment from CGI through presumed transvenous mechanisms. The imaging provides a consistent timeline demonstrating migration can occur in the acute phase. This study additionally supports the presumed mechanism for pulmonary of migration through the right heart. Fragment embolization should be considered in cases of acute deterioration in this patient population.

We present a new approach for debugging two router configurations that are intended to be behaviorally equivalent. Existing router verification techniques cannot identify all differences or localize those differences to relevant configuration lines. Our approach addresses these limitations through a _modular_ analysis, which separately analyzes pairs of corresponding configuration components. It handles all router components that affect routing and forwarding, including configuration for BGP, OSPF, static routes, route maps and ACLs. Further, for many configuration components our modular approach enables simple _structural equivalence_ checks to be used without additional loss of precision versus modular semantic checks, aiding both efficiency and error localization. We implemented this approach in the tool Campion and applied it to debugging pairs of backup routers from different manufacturers and validating replacement of critical routers. Campion analyzed 30 proposed router replacements in a production cloud network and proactively detected four configuration bugs, including a route reflector bug that could have caused a severe outage. Campion also found multiple differences between backup routers from different vendors in a university network. These were undetected for three years, and depended on subtle semantic differences that the operators said they were "highly unlikely" to detect by "just eyeballing the configs."

Follicular lymphoma is one type of cancer which belongs to Non Hodgkin lymphoma [NHL], in which the lymphatic system would affect the most. The lymphatic system plays a key role in immune system as it provides protection to the body in order to fight from infections and diseases. Generally the lymphocytes are categorized into 2 types such as B-lymphocytes and T-lymphocytes. B- cells works by producing specific type of antibodies which mainly helps to fight against specific type of microorganism but in other type the infected host cells will be killed directly by the T- cells and further activates other immune cells which may produce cytokines and helps in the regulation of immune system. Follicular lymphoma belongs to B-cell lymphoma in which there is an alteration of normal B cell into cancerous B cell. In the follicular lymphoma we can notice an amplification of lymph nodes due to atypical, unconstrained growth and proliferation of malignant B cells and further spread to other body tissues and organs. Follicular lymphoma is considered to be the prototype of indolent lymphoma which can be marked by slow progression and increased response to the therapy. As most of the patients gradually developing resistance to disease over time, there is an transformation of indolent lymphoma to an aggressive subtype, in which there would be a poor outcome to the therapy as there is a reduced sensitivity to the chemotherapy.

An efficient (3 + 2) cycloaddition triggered annulation is reported to access 1,3-benzoxazepine frameworks. With amine base, sulfamate-derived cyclic imines readily react with glycine aldimino esters to furnish benzo-fused seven-membered heterocyclic products in good yields. The cascade reaction involves the formation of one C-C, one C-N, and one C-O bond along with the cleavage of two C-N bonds and one S-O bond. The synthesis of o-tyrosine analogues has also been accomplished from annulation products.

Purpose A review of the literature with respect to pituitary metastases (PM) with clinical and radiological considerations are summarized to facilitate clinical decision making in the management of PM Methods A review of literature associated with PM and tumour to tumour metastases in the English literature was reviewed and summarized Results Pituitary metastases account for 1.0–3.6% of all surgically treated pituitary lesions. Often identified in parallel with extensive disseminated disease, once diagnosed, the prognosis is generally poor, although survival is highly heterogeneous and dependent on the primary tumor histology. Within this anatomical region is also the observation of tumor-to-tumor metastases and collision tumours. Both the tumor macro- and microenvironment play central roles to the progression of disease with distinctive radiological features that may suggest a metastatic sellar lesion as opposed to a primary pituitary lesion. Surgical resection is the first line of therapy followed by adjuvant chemoradiotherapy and endocrinological evaluation for hormonal supplementation Conclusion PMs are relatively rare but important oncological entities representing disseminated disease in the majority of cases. Careful consideration of the relevant clinical history and radiological features can aid the clinician differentiate between a metastatic lesion to the pituitary region and a primary pituitary tumor. While surgical resection is first line therapy, stereotactic radiosurgery in carefully selected patients is emerging as a viable alternative.

Emerging studies show that radiation therapy produces an important out of field (distant) effect known as the ‘‘abscopal effect” in nonirradiated tumor sites. The objective of this study was to provide an overview of the current state of knowledge and clinical experience of radiation therapy producing abscopal effects in the management of different types of malignant diseases. Peer-reviewed published clinical evidence on the abscopal effect of radiation therapy was collected using electronic databases such as Medline via PubMed and Google Scholar. The reference lists were searched in the publications that we obtained in an attempt to find additional relevant publications. Non-indexed peer-reviewed journals were manually searched and relevant information was extracted. The search was restricted to English language articles. The clinical data on the abscopal effect of radiation therapy were reviewed and the outcomes have been summarized. Currently, only clinical case reports and anecdotes have slowly converted into solid clinical data and interest is building in the field of radiation therapy, specifically on how local radiation can produce the abscopal effects for the management of different types of malignant tumors. Extensive clinical evidence suggests that the radiation therapy induced abscopal antitumor effects are mediated by immune cells such as the T-lymphocytes. This forms a basis for using radiation therapy in combination with immunotherapy to augment the abscopal response rates in cancer patients. Current evidence demonstrates that radiation therapy induces abscopal responses across many tumor types. Together, the clinical outcomes from published reports suggest that localized radiation therapy is capable of inducing abscopal effects in a wide variety of malignant tumors. With the advent of novel immunotherapies, the potential for immune activation by radiation defines a novel role for radiation therapy in the treatment of systemic disease. A clinical consideration of the abscopal effects produced by radiation therapy could lead to a revolutionary change in the current management of patients including radiation treatment strategies and immunotherapies for various malignant tumors.

Qualitative study.The objective of this study was to compare the perceptions of patients and surgeons regarding the risks and benefits of lumbar decompressive surgery for sciatica following a consultation meeting.Evidence regarding pain improvement in patients following lumbar decompressive surgery for sciatica is inconsistent. Given this inconsistency, patients choosing to undergo lumbar decompressive surgery must accept the risks associated with the surgery despite uncertainty regarding benefits. This raises questions as to the nature of informed decision-making for patients choosing to undergo surgery for sciatica.We undertook a qualitative descriptive study with 12 adult lumbar decompressive surgery candidates and six of their spine surgeons and analyzed data using inductive content analysis.Our analysis revealed that most patients were satisfied with the consultation despite limited understanding of lumbar decompressive surgery. We found discrepancies between patients' preoperative expectations and understanding of information provided by surgeons and what surgeons believed they had conveyed. Surgeons and patients disagreed on how much information is needed about postsurgical activity modifications and long-term outcomes to make a decision about whether or not to undergo surgery, with patients desiring more information. As a result, for most patients, the decision-making process extended beyond the information provided by surgeons and incorporated information from family members, friends, family doctors, and the internet.Our results highlight misunderstandings between patients and surgeons, particularly in regard to prognosis and activity modifications. Since this information is important for patients choosing whether to undergo a surgical intervention, our study provides guidance to improve informed decisions about sciatica and, potentially, other elective surgeries.4.

Background Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). Objective To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. Methods Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. Results Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. Conclusion This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Background The trigeminocardiac reflex is a sudden onset of bradycardia, hypotension, apnea, or gastric hypermotility in response to stimulation of the trigeminal nerve. Case Description A 60-year-old female underwent a left orbitozygomatic craniotomy to debulk a large skull base epidermoid cyst compressing the brainstem and cranial nerves. Intraoperatively, retraction of the temporalis muscle consistently produced asystole. Cessation of retraction resulted in prompt return of sinus rhythm. Conclusions Our report describes an unusual and extreme example of the trigeminocardiac reflex and explores possible etiologies. This is the third reported surgical case in which manipulation of the temporalis muscle alone was sufficient to elicit bradycardia and asystole, and the first such case within the context of neurosurgery. We emphasize the importance of surgical teams to be cognizant of such extreme examples of this reflex.

Background Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. Methods A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. Results Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients’ CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon’s choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P Conclusion Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

The aim of this research work is to analysis in the presence of a transverse magnetic field with thermal radiation, variations in eckert numbers on the unstable convective flow in the saturated program on an infinite vertical plate. With dimensionless variables, the governing scheme of partial difference equations is transformed into dimensional equations. Number-free equations are resolved using the technique of finite elements for the frequency, temperature and concentration profile equations using graphs.

Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare tumefactive lesion that can develop anywhere within the neuraxis. The incidence is likely underreported, given its nonspecific imaging features and because CAPNON has often been overwhelmed by the presence of comorbid disease. CAPNON is typically diagnosed by the histopathological examination findings. However, the histopathological diagnosis is often challenging owing to the existence of similar calcifying pathological entities. Although the pathogenesis of CAPNON has remained elusive, emerging evidence supports a reactive proliferative and immune-mediated process involving the aggregation of neurofilament light chain protein and the infiltration of immune cells. The management of CAPNON is largely dependent on the symptoms, which are mainly related to the location and associated mass effects. Maximal surgical resection will result in excellent patient outcomes with rare recurrence, especially in patients presenting with epilepsy. The discovery of neurofilament light chain protein within CAPNON suggests that neurofilament might be implicated in the pathogenesis of CAPNON, serve as an immunohistochemical marker to improve the diagnostic accuracy of CAPNON, and hold therapeutic potential for the treatment of CAPNON.

Background Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. Methods We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. Results The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). Conclusions Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.