USHING disease, which is induced by a functional ACTH-producing adenoma of the anterior pituitary gland, is the most common cause of ACTH-dependent Cushing syndrome. The treatment of Cushing disease remains challenging for neurosurgeons and endocrinologists. Transsphenoidal surgery is currently the treatment of choice in patients who harbor ACTH-secreting pituitary tumors associated with Cushing disease. This surgery provides the best option for rapid biochemical remission with excellent long-term results. Remission rates after transsphenoidal resection performed by experienced surgeons have ranged from approximately 70 to 90%. 3,9,15,17,26,37,38,42, 47,54 Long-term follow-up with biochemical testing is necessary to detect tumor recurrence because remission rates decline with longer follow-up periods. 14,16 Although many patients achieve complete remission, these tumors are difficult to cure surgically, and some patients may exhibit persistent or recurrent hypersecretion of ACTH and hypercortisolism resulting in increased morbidity and death related to their malignant endocrinopathy. Unfortunately, the results of endocrinological analyses after transsphenoidal surgery vary in the literature because different definitions of a biochemical cure are given in the various studies. If biochemical evidence of Cushing disease persists or recurs after an initial transsphenoidal surgery, the surgeon should be familiar with the treatment options available to offer the patient, including repeat transsphenoidal surgery, radiation therapy, medical therapy, and bilateral adrenalectomy. A multimodal approach using a combination of these treatments may be an appropriate strategy in some patients to achieve the best outcome. For optimal results, a multidisciplinary team approach should be coordinated at a specialized center. In this paper, we provide an overview of the management options available after unsuccessful transsphenoidal surgery and review the current outcome data for each option based on results reported in the literature. Repeat Transsphenoidal Surgery As indicated earlier, transsphenoidal surgical removal of ACTH-producing pituitary adenomas is currently recommended as the first-line treatment for Cushing disease. The reported rates of remission are variable because of the wide

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Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors’ early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.

Turkey is one of the countries that have debates on the necessary arrangements and preparations before the adoption of "International Financial Reporting Standard for Small and Mid-sized Entities" which was issued in July 2009 by International Accounting Standards Board. In the adoption process, the views of different parties should be sought and the steps should be taken very carefully. This study aims to bring to light the views of small and medium-sized entities (SMEs) which are the most important party in these debates and which will be affected from the adoption most. The objectives of this study are to determine the current structure of SME accounting and financial reporting, the views of SMEs on the adoption and application of the standard and the possible variables that might be affecting SMEs' thoughts. 216 SMEs participated to the research by filling up a questionnaire, and the results show that SMEs support the adoption of the new standard, they want it to be elective, rather than compulsory, and even if it is elective, most of the respondents are eager to apply it.

Objectives Previous animal studies have shown that mixtures of Cynanchum wilfordii and Phlomis umbrosa extract (IPLUS-CWPU) increases femur length and insulin like growth factor-1 (IGF-1) secretion. IPLUS-CWPU may thus be a promising ingredient in functional foods aimed at growing child's height. The purpose of the study is to investigate the effect of IPLUS-CWPU on height growth in children with short stature. Methods For this purpose, we recruited 90 children aged 4 to 12 years who had heights ranging from the 5th to 25th percentiles of Korean children's growth curve and randomized to either the IPLUS-CWPU or the placebo group. Results The IPLUS-CWPU group showed a significant increase in the change of the height growth compared to the placebo group after 20 weeks of administration (p=0.02). The height growth velosity also showed a statistically significant difference in the test group compared to the placebo group at 10 weeks (p=0.04). The IGF-1 levels showed a tendency to increase in the IPLUS-CWPU group (p=0.08). Moreover, the IPLUS-CWPU significantly increased IGF-1/IGFBP-3 ratio (p=0.02). However, there were no significant differences in blood biochemical parameters including growth hormone, bone age, thyroid stimulating hormone, and osteocalcin levels. Conclusions In conclusion, the data of this trial indicate that IPLUS-CWPU is effective and safe, generally well-tolerated without severe adverse events, in the treatment of children with short stature over a 20 weeks period.