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Immuno- globulin/light chain deposition disease is difficult to recognize by light microscopy generic clomid 50 mg on-line. The major histologic abnormality is mesangial expansion due to paraprotein deposition buy clomid 100 mg online. Like amyloidosis purchase clomid online pills, this disease often strongly resembles nodular diabetic glomerulopathy clomid 50mg without prescription. This case of kappa light chain deposition disease demonstrates modest mesangial matrix increase with early nodule formation, identical to changes that could be seen in diabetic glomerulopathy. They form in the mesangium and may result in prominent nodular mesangial expansion, as in this case. The deposits also locate along the inner aspect of the capillary loop basement membrane (arrow ) 244 6 Glomerular Diseases 6. Fibrillary glomerulopathy is a disease of older adults and primarily affects whites. Patients present with hematuria and proteinuria, which may be in the nephrotic range. The histologic finding most often is a mesangial proliferative or membranoproliferative pattern. However, they are distinguished from amyloid fibrils because they are approximately twice the diameter of amyloid fibrils; demonstrate a positive reaction for IgG, C3, and both light chains; and are Congo red negative. Because the tubular basement membranes invariably are involved in this process, they are very useful in confirming the diagnosis in equivocal cases. The granular paraprotein deposits are located along the outer aspect of the tubular basement membrane (arrow) and extend into the adjacent inter- stitium, as shown here Fig. This case of fibrillary glomeru- lopathy shows global hypercellularity, a common presentation, although lesser degrees of cellularity do occur. The fibrillary deposits, both those within the mesangium and those involving the capillary loops, often are extensive. They are weakly argyrophilic, resulting in lucent mesangial expansion, as shown here. The deposits in fibrillary glom- brane duplication also may be present, as in the case, producing a mem- erulopathy invariably are mesangial and frequently also involve the branoproliferative pattern of injury. The deposits in this case stain much darker than the fibrillary deposits in most cases. The deposits in fibrillary glom- erulopathy stain for IgG, C3, kappa, and lambda, as in other IgG- mediated immune complex diseases. The deposits often appear more lumpy or smudgy compared with the more granular appearance of other immune complex diseases. This permits many cases to be suspected before electron microscopic demonstration of the distinctive fibrillary structure of the deposits Fig. They are in random arrays; however, they have a much larger diameter (in the 20–30-nm range). Conversely, there are proteinuria and hematuria, clinical course, and the immune several very rare renal diseases resulting from enzyme muta- complex nature of the deposits. However, in contrast to tions that perturb intracellular metabolic pathways or affect fibrillary glomerulopathy, patients tend to be older and there the function of transport proteins, leading to a number of is an association with monoclonal gammopathy and hemato- storage diseases. The ultrastructural appearance of the depos- • Diabetic glomerulopathy its is unique; they consist of long hollow tubules in parallel • Idiopathic nodular glomerulosclerosis arrays, which their name attempts to capture. The histology and immunofluorescence findings in immunotactoid glomerulopathy are Diabetic nephropathy is the most common cause of similar to those in fibrillary glomerulopathy. The morphologic distinc- proteinuria and nephrotic syndrome, and is the leading cause tion is predicated on the microtubular structure on electron microscopy. Shown are large electron-dense accumulations containing curvilinear of end-stage renal disease. When it does develop, it usually requires 8–10 years of diabetes before clinically overt nephropathy is evident. Once microalbuminuria develops, nephropathy is inevitable, although its rate of evolution varies among patients. There is a morphologically identical nodular glomerulopathy, known as idiopathic nodular glomerulosclerosis, that develops in nondiabetics. These patients usually are smokers who have hypertension or the metabolic syndrome. These conditions, like diabetes, result in elevation of advanced glycation end products in the blood, which affects glomerular matrix pro- duction and turnover. It is not illustrated here because it is indistinguishable from nodular diabetic glomerulopathy; it is a diagnosis of exclusion. This case of immunotac- toid glomerulopathy contains deposits composed entirely of uniform compact masses of microtubules. In established diabetic glomeru- lopathy, there is diffuse mesangial matrix expansion and acellular mesangial nodule formation known as Kimmelstiel-Wilson nodules. The severity of mesangial expan- sion and nodule formation is remarkably variable both between glom- eruli and within a glomerulus. This image shows a large nodule and smaller nodules with several mesangial regions showing no nodule for- mation, only mild mesangial sclerosis. In this example of mild diabetic glomerulopathy, note that in addition to mesangial matrix expansion there is mild seg- mental mesangial hypercellularity, a common feature Fig. A finding highly correlated with but not specific for diabetes is the combination of afferent and efferent arteriolar hyalinosis. Despite the severity of the arteriolar lesions, the glom- erulus does not show severe mesangial sclerosis 248 6 Glomerular Diseases 6. The mutations result in marked elevation of the plasma concentrations of unesterified cholesterol, triglycerides, and phosphatidylcholine, with resultant lipid deposition in multiple organs. Patients present as a neonate or in child- hood with proteinuria; renal insufficiency develops several decades later. The first ultrastructural abnor- mality that develops in diabetic glomerulopathy is capillary loop base- ment membrane thickening. The pallor is caused by the accumulation of foamy lipid within the mesangium and capillary loops. The subtle vacuolization is strates the abundant lipid deposits that have expanded the mesangium more apparent at higher magnification, especially within the mesan- and involve the capillary loops. There is capillary loop thickening, but its cause may be uncertain ing processing, leaving the mesangium and capillary loops riddled with because the presence of abundant lipid deposition is difficult to lucent defects (arrows). The subendothelial appreciate lipid deposits in this case have induced capillary loop basement mem- brane duplication. The vacuolated nature of the lus, lipid deposits have occluded the capillary loop and permeate expanded mesangium is readily demonstrated on silver stain. Although much of the lipid material lary loop basement membranes also may have a vacuolated appearance has been extracted during processing, there are black lamellar and cur- or show a double contour. However, the most striking finding is in the glomerular capillaries, which are distended by pale, wispy-appearing lipoprotein “thrombi” Fig. The lipid is extracted during tissue processing for paraffin section, although its protein component remains. However, an oil red O stain on frozen tissue typically is impressive, demonstrating abundant lipid in the capillary loop lipopro- tein thrombi Fig. Males are severely affected; they present with proteinuria, and progressive renal failure develops over several decades unless treated. Females have variable enzyme levels and therefore exhibit a wide range of severity. This image shows numerous lipid vacuoles (arrow) with a proteinaceous matrix filling a distended capil- lary loop. The glomeruli in Fabry’s disease show cytoplasmic vacuolization, most prominent in podocytes, as shown here. Admixed with the lipid is granular electron-dense proteinaceous material of unknown composi- tion. In this glomerulus from a female carrier of glomerulus show striking enlargement and vacuolization. The mesan- Fabry’s disease, who presented with proteinuria and normal serum cre- gium shows no abnormality. Masson trichrome stain atinine, silver stain reveals two vacuolated podocytes, one of which is markedly enlarged. This glomerulus is from a female carrier of embedded tissue for electron microscopy allows appreciation of the Fabry’s disease presenting with proteinuria and normal serum creati- true extent of lipid deposition.

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When mivacurium is administered for tracheal intubation buy clomid us, four factors increase the probability of achieving excellent conditions: increasing mivacurium dose; opioid coadministration; delaying time to intubation (from 1 minute to 2 minutes); and patient age (>70 years) purchase clomid 50 mg amex. Because of its rapid metabolism buy clomid 100 mg with amex, the41 differential onset between the central (laryngeal) and peripheral (adductor pollicis) muscles is exaggerated clomid 50mg discount. Thus, if the timing of tracheal intubation is guided by neuromuscular responses of peripheral muscles (e. Reversal of mivacurium-induced neuromuscular block is either spontaneous or pharmacologic, using anticholinesterases. Neostigmine also inhibits plasma cholinesterases (that should slow mivacurium metabolism), but these effects are less than the inhibition of acetylcholinesterases, resulting in a “net” reversal of nondepolarizing block. Administration of whole blood or fresh frozen plasma (each of which42 contains pseudocholinesterase) is not recommended unless there is another primary indication for the transfusion. Although mivacurium had been withdrawn from the United States market, it recently (2017) has been re- introduced into clinical use. Usually, combining two chemically similar drugs with similar duration of action (e. Combining different drugs43 25 95 with different duration of action is a special case of interaction: when a short- duration drug (mivacurium) is added at the end of a vecuronium-based block, recovery will follow the intermediate (vecuronium) block. In contrast, when vecuronium is added during recovery from mivacurium, the vecuronium recovery will be shorter, similar to that of mivacurium. This apparent paradox is due to the fact that recovery will always follow that of the drug that blocked the majority (70% to 90%) of the receptors (the loading dose drug); the additional, maintenance drug dose is in comparison very small, and only blocks a small proportion (10% to 15%) of the free receptors. Thus, the predominant characteristics of recovery will be those of the loading drug. Inhalational anesthetic agents potentiate neuromuscular block (desflurane > sevoflurane > isoflurane > halothane > nitrous oxide), likely by direct effects at the postjunctional receptors. The intravenous agent propofol has minimal effect on neuromuscular transmission, although the potency of rocuronium is enhanced after a 30-minute propofol infusion. It is likely that these apparently47 contradictory effects of local anesthetics on neuromuscular transmission depend more on their plasma concentration rather than the type of local anesthetic. Hypercarbia, acidosis, or48 hypothermia, however, may further potentiate the depressant effects of antibiotics in the critically ill patient. In patients receiving acute administration of anticonvulsants (phenytoin, carbamazepine), neuromuscular block is potentiated, whereas chronic administration significantly decreases the duration of action of aminosteroids while having little effect on benzylisoquinolinium compounds. Multiple reports have documented their benefits in facilitating tracheal intubation and maintenance of mechanical ventilation, particularly in patients requiring prone positioning for acute respiratory distress. In addition, continuous neuromuscular block for prolonged periods (days) should be avoided, particularly in patients who receive steroid therapy concurrently. In general, neuromuscular diseases can be classified into disorders of55 neuromuscular transmission, disorders of muscle and muscle membrane, disorders of lipid or glycogen storage, peripheral neuropathies, and disorders of the central nervous system with neuromuscular manifestations (Table 21- 4). Hypokalemia potentiates nondepolarizing block and decreases the effectiveness of anticholinesterases (neostigmine) in antagonizing nondepolarizing block. Acidosis interferes with the effects of anticholinesterases in reversing a nondepolarizing block. All drugs with significant hepatic and renal metabolism (aminosteroids) will be affected and their duration of action prolonged by liver and kidney dysfunction. Given that there are over 230 million major surgeries performed every year worldwide, the number of patients exposed to potential complications is56 huge, and appropriate monitoring is a major patient safety issue. Aside from the cost of the monitors and related disposables (electrodes), there are no significant potential complications from monitoring neuromuscular function, so the risk–benefit ratio is heavily in favor of monitoring. Several57 anesthesiology organizations around the world have recently published best- practice guidelines that recommend neuromuscular monitoring when neuromuscular blocking drugs are administered. Nerve stimulators (and the stimulation units of the neuromuscular monitors) deliver a range of currents between 0 and 70 milliamperes (mA). The impulse generated by the nerve stimulator should have a square-wave pattern (i. The intensity of60 neurostimulation (charge, in Coulombs, Q) is a product of current (in amperes, A) and the duration of stimulation (pulse width, in seconds). For61 instance, a charge of 4 μC can be achieved by either using a current stimulus of 20 mA with a pulse width of 200 μsec or a current stimulus of 10 mA with a pulse width of 400 μsec. The current should be constant over the duration of the impulse (which is at least 100 μsec to ensure depolarization of all nerve endings, but less than 300 to 400 μsec to avoid exceeding the nerve refractory period). The current is delivered via surface (skin) stimulating electrodes that have a silver–silver chloride interface with the skin, reducing its resistance. Surface electrodes are preferred to the invasive, transcutaneous needle electrodes. The optimal conducting surface area is circular, with a diameter of 7 to 8 mm; this area provides sufficient current density to depolarize peripheral nerves. Skin can have very high resistance (up to 100,000 Ohms), and “curing” the skin (i. Monitoring Modalities The first nerve stimulators delivered single repetitive stimuli at frequencies between 0. The amplitude of the evoked muscle response is plotted over time, and has a sigmoidal shape. Once the amplitude of the muscle response no longer increases as current intensity increases, the response is maximal, and the current required is called “maximal current. The characteristics of the various patterns of neurostimulation currently in use clinically are summarized in Table 21-5. B: Acceleromyographic neuromuscular monitor—StimPod (Xavant Technologies, Pretoria, South Africa). Electrodes are placed along the ulnar nerve, with the negative (black) electrode distal to the positive (red) electrode. The accelerometer is taped to the thumb, with the sensor perpendicular to the direction of thumb adduction. T = first stimulus in the sequence; T =1 2 second stimulus in the sequence; T = third stimulus in the sequence; T = fourth3 4 stimulus in the sequence. Unblocked state, no fade between tension at the beginning of the 5-second stimulation (S ) and the end of the stimulation (S ). The ratio of tension at the end of the1 5 5-second stimulation to that at the beginning is the tetanic ratio (S /S ratio). The ratio of tension at the end of the 5-second stimulation1 5 to that at the beginning is the tetanic ratio (S /S ratio). The number of rapidly fading twitches is counted; the resulting number of twitches is the posttetanic count. Because the stimuli are mini-tetanic, each of the two bursts result in a single (fused) muscle contraction. Because the stimuli are mini- tetanic, each of the two bursts result in a single (fused) muscle contraction. Because the stimuli are mini-tetanic, each of the two bursts results in a single (fused) muscle contraction. Because D consists of2 only two mini-tetanic stimuli, the evoked (fused) muscle response is slightly less than that induced by D. Because the stimuli are mini-tetanic, each of the two bursts results in a single (fused) muscle contraction. During a partial nondepolarizing block, the ratio decreases (fades) as the degree of block increases (Fig. Below this threshold, repetitive nerve stimuli result in individual, rapid contractions. At frequencies above 30 Hz, the muscle responses become fused into a sustained contraction without fade (tetanic ratio = 1. During partial nondepolarizing block, the tetanic contraction gets weaker (fades; Fig. Tetanus has been studied extensively for durations of 5 seconds, so clinicians should always use 5-second durations to evaluate neuromuscular function—decisions based on tetanic durations shorter than 5 seconds will undoubtedly be inaccurate. Depending on the tetanic frequency, this period of potentiated responses may last 1 to 2 minutes after a 5-second, 50-Hz tetanus, or up to 3 minutes after 100-Hz tetanus. The72 number of posttetanic twitches is inversely proportional to the depth of block: the fewer posttetanic twitches there are, the deeper the block.

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Hyperbaric dye solution distribution characteristics after pencil-point needle injection in a spinal cord model purchase discount clomid line. Air versus saline in the loss of resistance technique for identification of the epidural space buy 50 mg clomid with visa. A retrospective effectiveness study of loss of resistance to air or saline for identification of the epidural space 100 mg clomid with amex. The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space discount 25mg clomid overnight delivery. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Techniques in morbidly obese parturients undergoing cesarean delivery: time for initiation of anesthesia. The frequency and magnitude of cerebrospinal fluid pulsations influence intrathecal drug distribution: Key factors for interpatient variability. 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Correlation between the distribution of contrast medium and the extent of blockade during epidural anesthesia. Analgesic effect and adverse events of 2337 dexmedetomidine as additive for pediatric caudal anesthesia: a meta-analysis. What epidural opioid results in the best analgesia outcomes and fewest side effects after surgery? The serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. A prospective randomized trial of lidocaine 30 mg versus 45 mg for epidural test dose for intrathecal injection in the obstetric population. High spinal anesthesia after epidural test dose administration in five obstetric patients. Does epinephrine improve the diagnostic accuracy of aspiration during labor epidural analgesia? Unintentional subdural placement of epidural catheters during attempted epidural anesthesia. 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Results of Int J Radiat Oncol Biol Phys 2003;55:1177–1181 stereotactic radiosurgery in patients with hormone-producing pitu- 50 proven clomid 25 mg. J erance of functioning pituitary tissue in gamma knife surgery for Neurosurg 2002;97:525–530 pituitary adenomas cheap clomid 50 mg on line. Factors associated with endo- Radiat Oncol Biol Phys 2002;54:839–841 crine defcits after stereotactic radiosurgery of pituitary adenomas cheap clomid on line. Gamma knife radiosurgery for medically and surgically refrac- Atypical Adenoma best purchase clomid, Pituitary Carcinoma, 26 and the Role of Chemotherapy in the Management of Refractory Pituitary Adenoma Tannaz Moin, William H. This chapter provides a general overview of I Pituitary Tumor Classifcation the presenting features of each tumor type and discusses treat- Pituitary adenomas are the most common intracranial tu- ment options and outcomes for pituitary carcinomas based on mors, and although they may cause signifcant morbidity this albeit scant and occasionally anecdotal literature. Pituitary carcinomas are very rare and are diag- I Pituitary Carcinomas nosed when cerebrospinal or systemic metastasis is dem- onstrated. Atypical adenomas are tumors that display a more aggressive phenotype characterized by early recur- Pituitary carcinoma is defned by the presence of a pituitary tu- rence, local invasion of surrounding structures, or pro- mor that is either noncontiguous with the primary sellar tumor gression despite surgical resection, medical therapy, and or has spread to sites distant from the primary. Atypical adenomas are believed to represent a bio- noma in the literature describing a total of 154 patients. Invasive pituitary adenomas, which infltrate and lung, kidney, and colon can metastasize to the sella or pituitary destroy the dura, bone, blood vessels, and nerve sheaths, are gland and are difcult to distinguish from primary disease. It is im- concern was voiced that changes induced following radia- portant to note that neuroimaging cannot distinguish a tion therapy or manipulation during surgical procedures carcinoma from an adenoma, unless cerebrospinal metas- played a role in the progression of these tumors. Increased methyla- and invasion, so the role of Ki-67 in diferentiating typical tion of CpG islands on the p27 promoter results in lower p27 from atypical pituitary tumors or likelihood of recurrence 40 expression and has been reported in pituitary carcinomas remains unclear. Additionally, point mutations in oncogenic H-ras authors routinely analyze this marker in pituitary adeno- have been identifed in pituitary tumor metastasis, although mas and believe it complements the other more standard 45 few studies exist. For example, signifcantly higher values have been gical options have been exhausted or to treat residual tumor noted in metastatic tumors with median of 72% (range 8– after subtotal tumor resection. Molecular Pathogenesis: Oncogenes and Tumor Over the past few years, limited data have emerged on Suppressor Genes the role of chemotherapy in pituitary carcinomas from small studies and case reports. Given the rarity of cases, no randomized studies have been conducted, and protocols and p53 Protein inclusion or exclusion criteria have varied widely. Although The p53 protein (also known as protein 53 or tumor pro- pituitary carcinomas have a high proliferation index, they tein 53) is a widely studied tumor suppressor gene that is seem to retain certain aspects of well-diferentiated tumors, commonly mutated in many human cancers and encodes a or in some way are importantly diferent from other cancers nuclear phosphoprotein essential for cell proliferation. However, Although many single-agent and combination chemother- several studies have documented abundant immunohisto- apy regimens have been tried over many years, the most 276 Endoscopic Pituitary Surgery commonly reported cytotoxic drugs utilized in pituitary vincristine, mitotane, and methotrexate. The reported re- carcinomas include chloroethylcyclohexylnitrosourea and sponse rates to chemotherapy have been conficting. Pituitary carcinoma containing gonadotropins: treatment by radical excision and chemotherapy: case report. In patients with recurrent pituitary tumors or even therapeutic options for these rare but rapidly fatal cancers. Pituitary 2008 Although this risk is small, it may become relevant in pi- [Epub ahead of print] tuitary tumor patients who will potentially be treated for 2. Neurosurgery 1996;38:99–106, discus- sion 106–107 sulted in tumor recurrence after 18 months, which implies 4. It is unclear at sive pituitary tumors with special reference to functional classifca- this juncture whether intermittent dosing or low-dose con- tion. J Neurosurg 1986;65:733–744 tinuous therapy would ofer stabilization of disease in some 5. Silent subtype 3 car- of pituitary carcinoma is clear, and large-scale randomized cinoma of the pituitary: a case report. Primary pituitary carcinoma: a clin- pamycin and its orally bioavailable analogue everolimus. Neurosurgery 1985;16:90–95 Rapamycin is produced by the bacterium Streptomyces hy- 11. Tumors metastatic to groscopicus and was initially developed as an antifungal the pituitary gland: case report and literature review. J Clin Endocri- agent but was later found to have immunosuppressive and nol Metab 2004;89:574–580 antineoplastic properties. Pituitary tumors: molecular targets and new mus were frst shown to decrease the number of viable cells medical therapies. Nature Rev Can 2004;4:285–294 and inhibit proliferation of rat pituitary cells and human 13. Ultrastruct Pathol 2001;25:227–242 more recent in vitro study containing 40 nonfunctioning 14. A comparison of cabergoline Because randomized control studies are technically chal- and bromocriptine in the treatment of hyperprolactinemic amenor- lenging unless global clinical trials are conducted, treatment rhea. N Engl J Med 1994;331:904–909 options at present must be based on available case reports. Cushing’s syndrome produced by a poultry basophil carcinoma with hepatic metastases. Am J Med Most studies have shown that chemotherapy, although not 1954;17:134–142 capable in most situations of ofering full or partial disease 18. Invest 1994;17:135–139 Other options that have ofered enhanced efcacy in other 19. Silent corticotroph cancers, including the use of combination conventional che- carcinoma of the adenohypophysis: a report of fve cases. Am J Surg motherapy with kinase-based agents, are as yet unexplored Pathol 2003;27:477–486 26 Atypical Adenoma, Pituitary Carcinoma 281 20. Pathobiology of pituitary noma in an acromegalic patient: response to bromocriptine and adenomas and carcinomas. Neurosurgery 2006;59:341–353, discus- pituitary testing: a review of the literature on 36 cases of pituitary sion 341–353 carcinoma. Pituitary carcinoma containing gonadotropins: treatment 18:217–222 by radical excision and cytotoxic chemotherapy: case report. J Clin Endocrinol Metab 1993;76:529–533 2005;56:1066–1074, discussion 1066–1074 28. Temozolo- noma with a single metastasis causing cervical spinal cord compres- mide treatment of a pituitary carcinoma and two pituitary mac- sion. Fine-needle aspiration biopsy 2009;161:631–637 of pituitary carcinoma with cervical lymph node metastases: a 53. Diagn Cytopathol with an aggressive prolactin-secreting pituitary neoplasm: Morpho- 1994;11:68–73 logical fndings. Acta Pathol Microbiol Scand 1959;45:243–249 pression predicts responsiveness of pituitary tumors to temozolo- 36. Acta Neuropathol 2008;115:261–262 nation from a growth hormone-secreting pituitary tumor. J Neurosurg 1986;64:140–144 for aggressive pituitary tumors: correlation of clinical outcome with 37. Temozolomide in the treatment of biologic study of pituitary tumors: report of 62 cases with a review an invasive prolactinoma resistant to dopamine agonists. Endocrinol 2007;156:203–216 Endocr Relat Cancer 2009;16:1017–1027 282 Endoscopic Pituitary Surgery 58. A pituitary parasellar factors in prolactin pituitary tumors: clinical, histological, and mo- tumor with extracranial metastases and high, partially suppressible lecular data from a series of 94 patients with a long postoperative levels of adrenocorticotropin and related peptides. Malignant growth itary Cushing’s disease arising from a previously non-functional hormone-secreting pituitary adenoma with hematogenous du- corticotrophic chromophobe adenoma. Marked improve- mone- and adrenocorticotropin-producing pituitary carcinoma with ment in a patient with an invasive pituitary tumour. Acta Endocrinol metastases to the liver and lung in a patient with Cushing’s disease. Prolac- with an aggressive prolactin-secreting pituitary neoplasm: Morpho- tin secreting pituitary carcinoma. Prolactin- mide in a man with a large, invasive prolactin-producing pituitary secreting pituitary carcinoma with implants in the cheek pouch and neoplasm. Acta Neuropathol 2008;115:261–262 static prolactinoma: efect of octreotide, cabergoline, carboplatin 73. Use of and etoposide; immunocytochemical analysis of proto-oncogene temozolomide in aggressive pituitary tumors: case report. J Clin Endocrinol Metab 1997;82:2962–2965 surgery 2009;64:E773–E774, discussion E774 65. I Operating Room Setup In addition to other advanced technologies that have been introduced into the operating room in recent years Today several diferent industrial companies ofer low-feld for transsphenoidal surgery such as neuronavigation1–5 (0.