text:
|Year : 2020 | Volume
| Issue : 1 | Page : 3-16
Imaging of sella: Pituitary adenoma and beyond
Shilpa Sankhe1, Lohith Ambadipudi1, Rutwik Ketkar1, SK Susheel Kumar2
1 Department of Radiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India
2 Department of Radiology, Nanavati Superspeciality Hospital, Mumbai, Maharashtra, India
|Date of Submission||11-Dec-2019|
|Date of Acceptance||13-Dec-2019|
|Date of Web Publication||04-Jun-2020|
Dr. Rutwik Ketkar
Department of Radiology, Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Sella is a small structure in the skull base housing the pituitary gland. Our aim is to show common and not so common lesions in the sellar-suprasellar region and to highlight unique imaging features which can clinch the diagnosis. A study of pituitary should always include the pituitary–hypothalamic axis. Pituitary masses can be divided into various categories, and the focus of this article will be mainly on primary pituitary tumors. Pituitary adenoma is the most common tumor. Based on the size, it is divided into microadenoma (<1 cm) and macroadenoma (≥1 cm). While radiography and computed tomography were used initially for suspected pituitary tumors, magnetic resonance imaging with its multiplanar imaging and an excellent soft-tissue contrast is the investigation of choice. Dynamic imaging is helpful in diagnosing and localizing microadenomas enabling effective surgical management when medical treatment fails. The sellar region is one of the most anatomically complex central nervous system locations. The key to diagnosis lies in understanding the gross and imaging anatomy by dedicated protocols. Structured reporting of pituitary masses ensures a comprehensive analysis of the lesion, based on several imaging characteristics as described in this article, which is finally aimed at dispensing the information required by the treating physician or surgeon. Imaging can now help in predicting surgical outcome, response to medical treatment, and to avoid complications.
Keywords: Adenoma, imaging strategy and reporting, magnetic resonance imaging, pituitary, sella
|How to cite this article:|
Sankhe S, Ambadipudi L, Ketkar R, Susheel Kumar S K. Imaging of sella: Pituitary adenoma and beyond. J Radiat Cancer Res 2020;11:3-16
| Introduction|| |
The pituitary gland is divided into larger anterior adenohypophysis and smaller posterior neurohypophysis, which are embryologically, anatomically, and physiologically distinct. Adenohypophysis develops from Rathke's pouch, an ectodermal derivative of the primitive buccal cavity. Neurohypophysis develops from the neuroectoderm of the diencephalon as an extension of the hypothalamus connected by a stalk.,
A study of pituitary should always include the pituitary–hypothalamic axis. This complex comprises the hypothalamus, stalk, and pituitary gland proper with the hypothalamic neurons and pituitary cells performing a complex regulation of hormonal secretion, connected by the infundibulum.
Adenohypophysis is divided anatomically into the pars tuberalis, the pars intermedia, and the main cellular and functional mass called pars distalis. The anterior pituitary does not have a direct arterial supply and receives blood supply through the hypophyseal portal system. Venous drainage of each half of the gland is into the ipsilateral cavernous sinus and subsequently to the petrosal sinuses.,,
The pituitary in the sella turcica, within the central portion of the sphenoid bone, is bounded superiorly by the diaphragma sellae, suprasellar cistern, optic chiasma, and hypothalamus. Cavernous sinuses, ICAs, and cranial nerves III, IV, VI, and V1 and V2 form the lateral relations [Figure 1]. Anteriorly, it is bounded by the tuberculum sellae, anteroinferiorly by the sphenoid sinus, and posteriorly by dorsum sella, clivus and brain stem.,
|Figure 1: Anatomy. (a) T2-weighted coronal image shows the normal sellar and parasellar anatomical structures. Optic chiasma (1), pituitary stalk (2), pituitary gland (3), ICA (4). (b) Corresponding diagrammatic depiction of sellar and parasellar anatomical structures. Optic chiasma (1), pituitary stalk (2), pituitary gland (3), ICA (4), cavernous sinus (5), sphenoid sinus (6), oculomotor N-Nerve. (7), trochlear N. (8), ophthalmic N. (9), abducens N. (10), maxillary N. (11), third ventricle (12). (c) T1-weighted imaging in sagittal plane showing the normal sellar anatomy. Optic chiasma (1), pituitary stalk (2), posterior pituitary (3), and anterior pituitary (4)|
Click here to view
The pituitary gland is usually 5–7 mm in vertical dimension. Normally, the height of the pituitary is more in females than males. The height of the normal pituitary gland for different age groups is given in [Table 1]. The gland undergoes changes in size and shape throughout life with a physiological increase in size in both sexes during puberty, pregnancy, and perimenopausal period along with a gradual age-related decline in pituitary height proving that the changes in the endocrine milieu correlated with pituitary morphology. The pituitary stalk has a thickness of about 2 mm and it should not exceed 4 mm or the width of the basilar artery.
Pituitary masses can be divided into various categories, as mentioned in [Table 2], and the focus of this article will be mainly on primary pituitary tumors.
Pituitary incidentalomas have increased in incidence owing to improved resolution of modern MRI techniques. Pituitary hyperplasia, besides the physiological enlargement, may also be encountered in end-organ failure (e.g., hypothyroidism), hypothalamic tumors, central precocious puberty, drugs, and tumors secreting hypothalamic-releasing hormones ectopically.,
Pituitary adenomas constitute 10%–15% of all intracranial tumors.,, Pituitary adenomas are classified based on their largest dimension into microadenomas [Figure 2], those that are less than 1 cm, and macroadenomas [Figure 3] which are greater than a cm. Macroadenomas that are greater than 4 cm are referred to as giant adenomas. Giant pituitary tumors are further classified into four grades by Goel et al. Grade 1 giant pituitary tumors are limited superiorly by the lifted diaphragma sellae without cavernous sinus invasion. Grade 2 tumors invade cavernous sinus and Grade 3 tumors elevate the roof of the cavernous sinus. Grade 4 tumors breach the diaphragma sellae extending into the subarachnoid space. This grading helps in surgical planning and also portends incomplete resection, thereby suggesting the need for adjuvant treatment. They can also be classified into functioning and nonfunctioning groups. Functioning adenomas can be further divided into various types based on the hormone(s) secreted.
|Figure 2: Microadenoma. (a and b) T2 and T1 coronal images show the right half of pituitary gland to be slightly bulky with superior and inferior convexity bulging into sphenoid, but no definite lesion is seen. (c) Postcontrast volume-interpolated Gradient recalled echo image shows hypoenhancing microadenoma in the right half of pituitary gland. (d-i) Postcontrast dynamic spin echo images show a well-defined hypoenhancing microadenoma as compared to the normal pituitary gland|
Click here to view
|Figure 3: Typical macroadenoma. (a-c) T2 and T1 isointense figure of eight-shaped sellar suprasellar lesion with homogeneous postcontrast enhancement is seen|
Click here to view
Microadenomas come into light because they are functioning tumors. Prolactinomas are the most common adenomas accounting for about 30% of all pituitary adenomas. Adrenocorticotropic hormone (ACTH) and prolactin-secreting adenomas are usually small in size at the time of presentation, whereas GH-secreting tumors are larger at presentation, although this is not definite. About 25%–30% of pituitary adenomas are nonfunctioning.
Pituitary adenomas are generally soft solid masses, and as they grow bigger, hemorrhage in up to 10%–15% and necrosis in 5%–18% of adenomas are seen within the tumor. They cause sellar enlargement initially and then grow out of the sella turcica extending superiorly, with a constriction at its waist caused by the indentation of diaphragma sellae, into the suprasellar cerebrospinal fluid (CSF) space causing mass effect on the optic chiasm and on the third ventricle. Parasellar extension generally leads to cavernous sinus invasion and carotid encasement. These invasive adenomas are then considered to have an aggressive behavior foreshadowing a poor prognosis due to increased morbidity and difficult surgery, despite the benignity on cytological examination. Adenomas can also erode the floor of sella with infrasellar extension into the sphenoid sinus.
| Imaging|| |
Radiography and tomography were the initial imaging techniques available to evaluate pituitary tumors. Computed tomography (CT) was the investigation of choice in the 70s and 80s for imaging the pituitary., Magnetic resonance imaging (MRI) has now become the gold standard in imaging sellar and juxtasellar regions.
Pituitary adenomas are usually hypodense compared to the normal gland on CT. CT is useful in identifying soft-tissue calcification and bony erosion caused by the invasive adenomas, evaluation of sphenoid sinus anatomy before transsphenoidal surgery, and in those patients where MRI is contraindicated. However, its use is limited due to a lesser soft-tissue contrast as compared to MRI and due to radiation exposure.
MRI with its multiplanar imaging and an excellent soft-tissue contrast is the investigation of choice. The aim of the pituitary imaging protocol is to obtain images with a high spatial resolution with a reasonably good signal-to-noise ratio. The standard MRI sequences and their parameters used as part of the pituitary imaging protocol are given in [Table 3].
Normal anterior pituitary appears isointense on T1 and T2 to the white matter. The MRI signal characteristics of macroadenomas are quite variable.
Plain MRI is adequate to detect most adenomas, and dynamic contrast-enhanced magnetic resonance is particularly useful in imaging microadenomas where the pituitary gland appears normal on plain sequences. Ancillary signs such as lateral deviation of the infundibulum and focal upward convexity of the gland are less reliable and are usually not employed in the diagnosis of microadenomas as there are standard techniques in place to spot the adenoma directly. Most microadenomas are hypointense on T1-weighted precontrast imaging, and bleeding within the adenoma makes it appear hyperintense.
On a dynamic study, the stalk enhancesfirst at 20 s and the anterior lobe attains peak enhancement by 30–60 s. Microadenomas, on the other hand, have a delayed peak enhancement between 60 and 200 s. Microadenomas enhance later than the normal gland and hence appear hypointense on the early phases of a dynamic scan, and the enhancement persists long after washout of contrast from the normal gland. On the delayed scans, 30–60 min after contrast injection, microadenomas appear bright as compared to the rest of the gland. Yuh et al. reported early enhancing microadenomas much before the anterior lobe which was attributed to having a direct arterial blood supply.
Prolactin-secreting pituitary adenomas
Hyperprolactinemia leads to secondary amenorrhea, galactorrhea, and infertility in women. Men usually present at a later stage, with symptoms related to compression rather than with clinical manifestations of elevated prolactin levels which include loss of libido and impotence. Giant prolactinomas can have bizarre and irregular shape, often invading the skull base presenting as nasopharyngeal or sinusoidal mass or with exophthalmos. Most prolactinomas respond to medical treatment with dopamine agonists. This leads to hemorrhage in over half of the cases which are often clinically silent. Cystic degeneration is also common [Figure 4], [Figure 5], [Figure 6]. In our experience, prolactinomas have a high tendency to invade the skull base and undergo shrinkage upon treatment causing CSF leaks.
|Figure 4: Giant prolactinoma. (a-c) T2-weighted images (a and b) show a heterogeneous intensity lesion in the sella with supra- and infrasellar extension and invading the right cavernous sinus, causing encasement of right ICA and its branches. The lesion is isointense on T1-weighted imaging (c) and shows homogeneous postcontrast enhancement. (d-f) Follow-up scan after 6 months of cabergoline therapy shows a significant reduction in size and extent of the lesion which is now predominantly T2 hyperintense and shows peripheral enhancement suggestive of cystic degeneration due to cabergoline treatment|
Click here to view
|Figure 5: Cystic prolactinoma. (a and b) T2-weighted imaging shows hyperintense well-defined lesion in the right half of pituitary gland. (c) Postcontrast T1-weighted GRE image shows the corresponding lesion to be nonenhancing|
Click here to view
|Figure 6: Cystic prolactinoma causing expansion of the sella, (a) T2-weighted imaging showing a sellar suprasellar hyperintense lesion with cystic areas within, (b and c) T1-weighted imaging pre- and postcontrast show the lesion to be isointense with heterogeneous postcontrast enhancement, (d and e) plain computed tomography images show a hypodense sellar suprasellar lesion causing expansion of sella and erosion and thinning of the floor of sella|
Click here to view
Adrenocorticotropic hormone-secreting pituitary adenomas
ACTH-secreting adenomas cause Cushing's disease leading to elevated glucocorticoid levels. Adenomas in Cushing's disease are notoriously small and can escape detection even on a contrast-enhanced dynamic spin-echo sequence. Surgical removal is the treatment of choice. A recent study by Rajeev and Shilpa et al. compared the efficiency of dynamic contrast spin echo and volume-interpolated three-dimensional (3D)-spoiled gradient echo sequences in diagnosis of ACTH-dependent Cushing's syndrome, and it was demonstrated that addition of contrast-enhanced volume-interpolated 3D-spoiled gradient echo sequence increases the yield of MRI in detection of corticotropin-secreting microadenomas and overall accuracy. It could avoid complicated diagnostic interventions such as bilateral inferior petrosal sinus sampling and improve surgical outcome. In addition, it was shown that both the sequences can clearly rule out pituitary disease in cases of ectopic Cushing's syndrome, i.e., 100% specificity.
Growth hormone-secreting pituitary adenomas
Growth hormone (GH)-secreting adenomas cause acromegaly in adults and gigantism before puberty. They tend to be more invasive in men than in women, and in our experience, infrasellar extension is more common than suprasellar growth. These adenomas are generally hypointense on T2-weighted imaging (WI) with low ADC values as compared to the rest of secretory adenomas [Figure 7] and [Figure 8].
|Figure 7: Growth hormone-secreting macroadenoma. (a-c) T2 and T1 isointense sellar lesion without any suprasellar extension with predominantly infrasellar extension. It is invading the left cavernous sinus and shows homogeneous postcontrast enhancement|
Click here to view
|Figure 8: Growth hormone-secreting macroadenoma showing diffusion restriction. (a) T2-weighted axial image shows a sellar, parasellar lesion which is slightly bright in comparison to cortex invading the right cavernous sinus and encasing the cavernous segment of right ICA. (b) T1-weighted postcontrast Fat saturated image shows the lesion to be hypoenhancing. (c and d) Diffusion-weighted imaging and ADC show the corresponding lesion with restricted diffusion|
Click here to view
Hagiwara et al. showed that densely granulated GH-secreting adenomas, containing prominent active Golgi apparatus and numerous secretory granules, are T2 hypointense. Heck et al. showed that these have a better responsiveness to somatostatin analogs as compared to hyperintense GH-secreting adenomas which tend to be larger and sparsely granulated with a blunted response to somatostatin analogs and may, therefore, become candidates for direct surgery. Puig-Domingo et al. reported that T2 hypointense signal of the residual pituitary GH-secreting adenomas predicts a better response to postoperative somatostatin analogs than those with a hyperintense signal.
Nonfunctioning pituitary adenomas
Nonfunctioning pituitary adenomas are usually macroadenomas or giant adenomas presenting with symptoms related to the mass effect. Imaging features are similar to secretory adenomas. Areas of hemorrhage, necrosis, and cystic change are often noted in these large tumors. Large nonsecretory pituitary adenomas can sometimes cause secondary hyperprolactinemia due to pituitary stalk compression syndrome or stalk-section effect, and the reason for this is unclear.,,,
| Preoperative Pituitary Imaging|| |
Preoperative MR assessment of adenomas has assumed a new role of predicting surgical outcome and response to medical treatment.
It has been reported that T2 signal intensity correlates with tumor consistency. Adenomas showing iso- or hypointense T2 signal contained more collagen and are firm in consistency.,,,, Hyperintense tumors are soft and are easily resectable. Nonfunctioning adenomas are usually hyperintense on T2-weighted MRI. On the contrary, Pierallini reported that soft tumors had lower signal intensity than intermediate and hard tumors.
Bahuleyan et al. concluded that tumor consistency cannot be accurately predicted based on MRI T2 signal intensities. Similar observations have been made by several authors that T2 signal does not necessarily correlate with firmness or fibrous tissue in the tumor.,,
The role of diffusion-weighted imaging (DWI) in predicting tumor consistency has gained importance in recent times, but it remains controversial. While according to some studies, DWI and ADC maps correlated well with tumor consistency, other studies reported that there was no significant difference between tumor consistency and ADC values of soft and intermediate groups using line-scan DWI.,,,,
Cavernous sinus invasion
Medial dural reflection of the cavernous sinus, separating it from the pituitary, is not visible on MRI, thus making it difficult to detect early invasion.,, Encasement of intracavernous Internal Carotid Artery (ICA) is the most reliable sign of cavernous sinus invasion [Figure 9]. The presence of abnormal tissue between intracavernous ICA and lateral wall of the cavernous sinus and cavernous sinus expansion are also features of adenoma invading the cavernous sinus. Invasion is less likely when there is intervening normal pituitary gland between tumor and cavernous sinus or if a venous compartment is visible between the tumor and intracavernous ICA.,
|Figure 9: Macroadenoma with cavernous sinus invasion. (a) T2-weighted imaging shows an isointense lesion in the sella invading the left cavernous sinus and encasing the cavernous segment of left ICA. (b) Postcontrast T1 fat sat images show homogeneous enhancement of the lesion|
Click here to view
Knosp et al. classified parasellar growth into five grades (0–4) with ICA as the landmark, and it was reported that cavernous sinus invasion is more likely when the tumor extends beyond the intercarotid line, a line passing through the cross-sectional centers of supra- and intracavernous ICA. Similarly, Cottier et al. published helpful criteria for cavernous sinus invasion in terms of percentage of encasement of carotid, tumor extension across the various venous compartments of the cavernous sinus, and the intercarotid lines.
Pituitary apoplexy is a clinical syndrome characterized by headache, vomiting, visual deficits, ophthalmoplegia, or altered mental status.,, It may present over weeks or may be fulminant leading to coma and death. It is due to infarction or hemorrhage of the pituitary gland and occurs commonly in a preexisting pituitary adenoma. Owing to a relatively tenuous blood supply, pituitary tumors are susceptible to infarction, necrosis, and hemorrhage. Frequently, this will be subclinical and subacute to chronic on MRI or detected at the time of surgery, without culminating in an apoplectic event. Several risk factors for apoplexy have been identified which include trauma, raised intracranial pressure, bromocriptine therapy, pregnancy, diabetic ketoacidosis, anticoagulation, and cardiac surgery.
T1- and T2-weighted MRI is sufficient to diagnose pituitary hemorrhage; however, T2* gradient echo MRI is the most sensitive technique for the detection of intratumoral hemorrhage [Figure 10] and [Figure 11]. Albeit the high sensitivity, T2* GE imaging is not without a caveat. Hypointense signal of hemorrhage can also be seen in the presence of calcification, melanin, or iron deposits. Pituitary hemorrhage undergoes resorption as a long-term effect.
|Figure 10: Macroadenoma with apoplexy. (a and b) T2-weighted images in a patient presenting with acute onset headache and diplopia show a heterogeneously hyperintense sellar suprasellar lesion with a fluid level within. (c and d) T1-weighted imaging shows lesion to be iso- to hypointense with postcontrast enhancement of the isointense solid component|
Click here to view
|Figure 11: Macroadenoma with hemosiderosis. (a) T2-weighted image shows a large hypo- to isointense sellar lesion with supra- and infrasellar extension with hemosiderin staining around. (b) The lesion shows blooming on gradient-weighted image. (c) T1 postcontrast fat sat image shows heterogeneous enhancement of the lesion|
Click here to view
Rogg et al.first reported that in cases of acutely presenting pituitary apoplexy, early detection by diffusion restriction and lack of enhancement on contrast indicating the presence of infarction in the adenoma can lead to early surgical intervention and excellent outcome.
| Postoperative Pituitary Imaging|| |
Postoperative imaging of pituitary adenomas requires a baseline preoperative imaging and details of the surgical procedure. Preoperative imaging gives us information regarding the tumor extension into areas which are difficult to access during surgery such as the cavernous sinus, the posterior clivus, and the suprasellar cistern. A search for residual tumor in these areas will improve detection rates.
Hormonal assays in functioning adenomas and follow-up MRI are used to detect residual tumor in a postoperative sella. Hemorrhage and fat are the most common constituents of a postoperative pituitary mass. Postoperative changes stabilized by 4 months and follow-up MRI for residual tumor are recommended after 4 months in a clinically stable patient., Early postoperative MRI within 48 h and another after 4 months is, therefore, recommended as part of the protocol.
Radiotherapy is an adjunctive treatment given for residual tumors, tumor recurrence, or after failure of medical management. The aim is to control tumor growth and hormonal normalization in secretory tumors. Delayed hypopituitarism is the most common complication.
Postradiotherapy imaging shows the arrest of tumor progression with no significant change in its size.
Imaging strategy and reporting
An optimal imaging strategy has to be devised in conjunction with the referring endocrinologist and the surgeon as treatment protocols vary between different centers. For example, benign, asymptomatic pituitary incidentalomas and functioning adenomas such as prolactinomas may not require surgery and medical treatment may be the initial choice of treatment in case of a functioning adenoma obviating the need for surgery. On the other hand, surgery is thefirst-line therapy for patients with Cushing's disease.
Structured reporting becomes paramount in this age of advanced and varied imaging techniques and protocols. [Table 4] shows a reporting format/model that can be used to provide all the information needed for a complete diagnosis with nature, accurate extent, prognostication, and surgical planning of a pituitary tumor.
| Differential Diagnoses|| |
It is an autoimmune disorder that is seen primarily in women, and it presents in the peri- or postpartum period in 60%–70% of cases. Headache, visual impairment, and diabetes insipidus (DI) are the most common symptoms. The typical MRI findings include a symmetric enlargement of a homogeneously enhancing pituitary gland, a thickened stalk with a diameter >3.5 mm at the level of the median eminence and loss of the normal smooth tapering, loss of posterior pituitary bright spot, and a usually intact sellar floor [Figure 12]. Parasellar T2 dark sign is a characteristic finding in lymphocytic hypophysitis (LYH) helpful in differentiating it from an adenoma. DI corresponds well to pituitary stalk thickening on MRI. It is worth noting that hypopituitarism, which ensues as a result of inflammatory destruction of pituitary parenchyma, often appears disproportionate to the extent of changes on pituitary MRI.
|Figure 12: Lymphocytic hypophysitis. (a) T2-weighted coronal image shows isointense sellar-suprasellar lesion with peripheral T2 dark sign. (b and c) T1-weighted postcontrast image shows intense homogeneous enhancement with stalk thickening. (d) Follow-up scan after corticosteroid therapy shows normal pituitary gland|
Click here to view
Langerhans cell histiocytosis
Langerhans cell histiocytosis has an affinity for the pituitary–hypothalamic axis and affects children. DI is seen in half of these patients, and posterior pituitary bright spot is lost in all the patients affected with DI. Imaging findings are similar to that of LYH. A thickened stalk and hypothalamic lesion in addition to a suprasellar mass are common findings. They appear hyperintense on T2 and hypointense or isointense on T1 and enhance brightly with contrast.,
Sarcoidosis is a systemic inflammatory noncaseating granulomatous disease which may involve the central nervous system (CNS) (neurosarcoidosis) and has a predilection for the leptomeninges, pituitary–hypothalamic axis, and optic chiasm. Radiological findings are indistinguishable from other forms of hypophysitis caused by inflammatory infiltrative processes. Parenchymal and sellar lesions, thickening of the basilar leptomeninges, and dural and bone lesions are seen which are contrast enhancing. The pituitary stalk maybe thickened.,
Basal cisterns are usually involved in tuberculosis and can show leptomeningeal enhancement in the suprasellar cistern. Sellar and suprasellar granulomas may be seen with thickening and enhancement of the pituitary stalk [Figure 13]. Some of them may be calcified [Figure 14]. The presence of other lesions in rest of the brain and pulmonary tuberculosis is helpful in diagnosis.
|Figure 13: Central nervous system tuberculosis with sellar involvement. (a) T2-weighted imaging shows hypointense sellar suprasellar lesions. (b-e) T1-weighted image shows isointense sellar and suprasellar lesions, and postcontrast fat sat images show multiple ring enhancing lesions in the sellar suprasellar region abutting the infundibulum and pituitary. Similar lesions are seen in the left temporal lobe and basal cistern|
Click here to view
|Figure 14: Calcified sellar tuberculoma. (a) T2-weighted imaging shows a hypointense suprasellar lesion. (b and c) T1-weighted pre- and postcontrast images show a nonenhancing isointense lesion without any enhancement abutting the pituitary gland superiorly and just anterior to the infundibulum. (d) On plain computed tomography image, the corresponding lesion appears calcified|
Click here to view
Although rare, pituitary abscess is a potentially life-threatening disease. It usually develops by hematogenous seeding or direct spread of adjacent infection. It shows typical MR features of a round sellar mass, being hyper- to isointense on T2 and hypo- to isointense on T1 with postcontrast rim enhancement and a central nonenhancing portion.
Meningioma is the second most common tumor after pituitary adenomas in this region originating from the tuberculum sella, diaphragma sellae, anterior clinoid processes, planum sphenoidale, dural covering of cavernous sinuses, and upper clivus. On CT, meningiomas are hyperdense lesions with intense homogeneous enhancement and show osseous changes in the form of hyperostosis or erosion.
On MRI, they are isointense to slightly hypointense as compared to cortex on T1WI. They are isointense to slightly hyperintense on T2WI and show intense homogeneous enhancement with an enhancing dural tail. CSF cleft with vessels seen as flow voids on T2WI is seen around them [Figure 15]. Meningiomas show calcification in up to 25% of the cases. The sella turcica is normal in size or is mildly enlarged as compared to macroadenomas, and the pituitary gland is visualized separately in many cases.
|Figure 15: Meningioma. (a and b) T2 and T1 isointense sellar suprasellar lesion arising from tuberculum sellae compressing the pituitary gland which is seen in the left half. (c and d) It shows intense homogeneous postcontrast enhancement with dural tail. However, note the differential enhancement of meningioma with respect to the pituitary gland|
Click here to view
Tuberculum sellae meningioma with intrasellar extension causes compression of pituitary parenchyma which may not be seen separately. However, “dural tail” sign is an important diagnostic clue.
When meningiomas invade the cavernous sinus, they tend to constrict the lumen of the carotid artery which is not usually seen in case of adenomas.,
Craniopharyngiomas are uncommon tumors arising from the squamous cell rests in the remnant of Rathke's pouch along the craniopharyngeal duct, anywhere from the nasopharynx to the third ventricle. They show bimodal age distribution with thefirst peak in children and a second smaller peak in older adults.
Adamantinomatous and squamous papillary are the two main histological subtypes. The adamantinomatous type is the most common, mainly affecting children and adolescents. It is a predominantly suprasellar solid-cystic lesion with necrotic debris, fibrous tissue, and lobulated calcification. The solid component is almost always calcified and is usually inferior to the cystic component. The cystic components show variable T1 intensity depending on the amount of protein content [Figure 16]. The squamous papillary subtype presents more frequently in adults and is predominantly solid and rounded. Calcifications are rare.,,
|Figure 16: Craniopharyngioma. (a-d) T2 and T1 heterogeneous intensity sellar suprasellar solid cystic lesion is seen compressing the pituitary gland but separates from it and showing heterogeneous postcontrast enhancement|
Click here to view
Often, craniopharyngiomas cause a compression of the pituitary gland; however, a compressed, displaced gland can be identified separately.
Metastases to this region are rare. Breast and lung cancers are the most common primary tumors causing metastases to this region in females and males, respectively. Metastasis involves the posterior pituitary or the stalk initially and spreads to the anterior pituitary later. CSF seeding of primary brain tumors to suprasellar and infundibular locations can also occur.
A hyper- or isodense mass, with homogeneous or heterogeneous enhancement, is seen on CT. On MRI, they are usually hyperintense on T2 and appear iso- or hypointense on T1 with enhancement on contrast. The metastatic deposit is usually a small enhancing pituitary lesion with lack of sellar enlargement. Bony erosion may occur [Figure 17]. Loss of posterior pituitary bright spot and stalk thickening are other nonspecific findings.,
|Figure 17: Metastasis to sella. (a-c) T2 and T1 isointense sellar lesion with supra- and infrasellar extension and infiltration of stalk. It shows cavernous sinus invasion encasing both ICAs with narrowing of left ICA. The lesion shows heterogeneous postcontrast enhancement. (d and e) Contrastenhanced computed tomography images show a large heterogeneously enhancing lesion in the sella with supra and infrasellar extension and eroding the surrounding bones|
Click here to view
Rathke's cleft cyst
Rathke's cleft cysts (RCCs) are nonneoplastic epithelial cysts, lined by a single layer of columnar or cuboidal cells, arising from remnants of Rathke's pouch along the craniopharyngeal duct. They are usually intrasellar in location, between anterior and posterior pituitary lobes, in the region of pars intermedia. They can have a suprasellar extension or originate anterior to the infundibulum. CT attenuation and MRI signal intensities of the cyst vary greatly depending on the protein content. RCCs contain serous or mucinous fluid along with cellular debris, and lack of calcification differentiates them from craniopharyngiomas. The cyst fluid never enhances on contrast; however, a thin peripheral rim of enhancement of the cyst wall may be seen in few cases. The presence of a nonenhancing intracystic nodule, which is hypointense on T2 and hyperintense on T1, composed of protein and cellular debris is virtually pathognomonic for the RCC.
Arachnoid cysts can occur in the suprasellar or sellar compartment and are thought to arise from the herniation of an arachnoid diverticulum through an incomplete diaphragma sellae. These are smoothly marginated lesions which follow CSF imaging characteristics on CT and MRI without any enhancement [Figure 18]. Although they may appear similar to RCCs [Figure 19], the anterior lobe and the infundibulum are typically displaced posteriorly.
|Figure 18: Arachnoid cyst. (a and b) T2 hyperintense T1 hypointense well-defined sellar suprasellar lesion following cerebrospinal fluid signal intensity is seen. (c) T1-weighted postcontrast image shows the lesion to be nonenhancing with enhancement of the laterally compressed pituitary parenchyma|
Click here to view
|Figure 19: Rathke's cleft cyst. (a) T2-weighted imaging shows a hyperintense sellar lesion with isointense nodule within. (b) T1-weighted imaging shows the lesion to be isointense with hyperintense nodule within. (c) T1 postcontrast image shows peripheral enhancement around the lesion|
Click here to view
Intracranial germinomas or extra-gonadal seminomas are a type of germ cell tumour which are predominantly seen in pediatric populations. They usually occur in midline, either in pineal region (majority) or along the floor of third ventricle/suprasellar region. They commonly present with diabetes insipidus due to pituitary stalk involvement. On CT, they appear hyperdense due to high cellularity. Calcifications are common. On MRI, they appear as soft tissue masses, ovoid or lobulated in contour with homogenous post contrast enhancement [Figure 20].
|Figure 20: Germinoma. (a) T2-weighted imaging shows a lobulated sellar lesion with supra- and infrasellar extension which is T2 isointense with few hyperintense foci within suggestive of microcysts. (b and c) The lesion is isointense on T1 and shows homogeneous postcontrast enhancement. (d) On susceptibility-weighted imaging, the lesion shows foci of calcification and hemorrhage within|
Click here to view
| Conclusion|| |
The sellar region is one of the most anatomically complex CNS locations. The key to diagnosis lies in understanding the gross and imaging anatomy by dedicated protocols. Structured reporting of pituitary masses ensures a comprehensive analysis of the lesion, based on several imaging characteristics as described in this article, which is finally aimed at dispensing the information required by the treating physician or surgeon. Imaging can now help in predicting surgical outcome, response to medical treatment, and to avoid complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Elster AD. Modern imaging of the pituitary. Radiology 1993;187:1-4.
Ikeda H, Suzuki J, Sasano N, Niizuma H. The development and morphogenesis of the human pituitary gland. Anat Embryol (Berl) 1988;178:327-36.
Colombo N, Berry I, Kucharczyk J, Kucharczyk W, de Groot J, Larson T, et al
. Posterior pituitary gland: Appearance on MR images in normal and pathologic states. Radiology 1987;165:481-5.
Elster AD. Imaging of the sella: Anatomy and pathology. Semin Ultrasound CT MR 1993;14:182-94.
Johnsen DE, Woodruff WW, Allen IS, Cera PJ, Funkhouser GR, Coleman LL. MR imaging of the sellar and juxtasellar regions. Radiographics 1991;11:727-58.
Elster AD, Chen MY, Williams DW 3rd
, Key LL. Pituitary gland: MR imaging of physiologic hypertrophy in adolescence. Radiology 1990;174:681-5.
Tsunoda A, Okuda O, Sato K. MR height of the pituitary gland as a function of age and sex: Especially physiological hypertrophy in adolescence and in climacterium. AJNR Am J Neuroradiol 1997;18:551-4.
Serhal D, Weil RJ, Hamrahian AH. Evaluation and management of pituitary incidentalomas. Cleve Clin J Med 2008;75:793-801.
Steiner E, Imhof H, Knosp E. Gd-DTPA enhanced high resolution MR imaging of pituitary adenomas. Radiographics 1989;9:587-98.
Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P. Giant pituitary tumors: A study based on surgical treatment of 118 cases. Surg Neurol 2004;61:436-45.
Rennert J, Doerfler A. Imaging of sellar and parasellar lesions. Clin Neurol Neurosurg 2007;109:111-24.
Kricheff II. The radiologic diagnosis of pituitary adenoma: An overview. Radiology 1979;131:263-5.
Donovan JL, Nesbit GM. Distinction of masses involving the sella and suprasellar space: Specificity of imaging features. AJR Am J Roentgenol 1996;167:597-603.
Syvertsen A, Haughton VM, Williams AL, Cusick JF. The computed tomographic appearance of the normal pituitary gland and pituitary microadenomas. Radiology 1979;133:385-91.
Sakamoto Y, Takahashi M, Korogi Y, Bussaka H, Ushio Y. Normal and abnormal pituitary glands: Gadopentetate dimeglumine-enhanced MR imaging. Radiology 1991;178:441-5.
Yuh WT, Fisher DJ, Nguyen HD, Tali ET, Gao F, Simonson TM, et al
. Sequential MR enhancement pattern in normal pituitary gland and in pituitary adenoma. AJNR Am J Neuroradiol 1994;15:101-8.
Kasaliwal R, Sankhe SS, Lila AR, Budyal SR, Jagtap VS, Sarathi V, et al
. Volume interpolated 3D-spoiled gradient echo sequence is better than dynamic contrast spin echo sequence for MRI detection of corticotropin secreting pituitary microadenomas. Clin Endocrinol (Oxf) 2013;78:825-30.
Hagiwara A, Inoue Y, Wakasa K, Haba T, Tashiro T, Miyamoto T. Comparison of growth hormone-producing and non-growth hormone-producing pituitary adenomas: Imaging characteristics and pathologic correlation. Radiology 2003;228:533-8.
Heck A, Ringstad G, Fougner SL, Casar-Borota O, Nome T, Ramm-Pettersen J, et al
. Intensity of pituitary adenoma on T2-weighted magnetic resonance imaging predicts the response to octreotide treatment in newly diagnosed acromegaly. Clin Endocrinol (Oxf) 2012;77:72-8.
Puig-Domingo M, Resmini E, Gomez-Anson B, Nicolau J, Mora M, Palomera E, et al
. Magnetic resonance imaging as a predictor of response to somatostatin analogs in acromegaly after surgical failure. J Clin Endocrinol Metab 2010;95:4973-8.
Kinoshita Y, Hama S, Tominaga A, Arita K, Sugiyama K, Sakoguchi T, et al
. Masked hyperprolactinemia: Tumor-derived factors inhibiting prolactin secretion caused by pituitary-stalk damage. J Clin Neurosci 2011;18:1651-5.
Kruse A, Astrup J, Gyldensted C, Cold GE. Hyperprolactinaemia in patients with pituitary adenomas. The pituitary stalk compression syndrome. Br J Neurosurg 1995;9:453-7.
Skinner DC. Rethinking the stalk effect: A new hypothesis explaining suprasellar tumor-induced hyperprolactinemia. Med Hypotheses 2009;72:309-10.
Smith MV, Laws ER Jr., Magnetic resonance imaging measurements of pituitary stalk compression and deviation in patients with nonprolactin-secreting intrasellar and parasellar tumors: Lack of correlation with serum prolactin levels. Neurosurgery 1994;34:834-9.
Iuchi T, Saeki N, Tanaka M, Sunami K, Yamaura A. MRI prediction of fibrous pituitary adenomas. Acta Neurochir (Wien) 1998;140:779-86.
Snow RB, Johnson CE, Morgello S, Lavyne MH, Patterson RH Jr., Is magnetic resonance imaging useful in guiding the operative approach to large pituitary tumors? Neurosurgery 1990;26:801-3.
Snow RB, Lavyne MH, Lee BC, Morgello S, Patterson RH Jr., Craniotomy versus transsphenoidal excision of large pituitary tumors: The usefulness of magnetic resonance imaging in guiding the operative approach. Neurosurgery 1986;19:59-64.
Naganuma H, Satoh E, Nukui H. Technical considerations of transsphenoidal removal of fibrous pituitary adenomas and evaluation of collagen content and subtype in the adenomas. Neurol Med Chir (Tokyo) 2002;42:202-12.
Ishii K, Ikeda H, Takahashi S, Matsumoto K, Ishibashi T, Tazawa S. MR imaging of pituitary adenomas with sphenoid sinus invasion: Characteristic MR findings indicating fibrosis. Radiat Med 1996;14:173-8.
Pierallini A, Caramia F, Falcone C, Tinelli E, Paonessa A, Ciddio AB, et al
. Pituitary macroadenomas: Preoperative evaluation of consistency with diffusion-weighted MR imaging – Initial experience. Radiology 2006;239:223-31.
Bahuleyan B, Raghuram L, Rajshekhar V, Chacko AG. To assess the ability of MRI to predict consistency of pituitary macroadenomas. Br J Neurosurg 2006;20:324-6.
Chakrabortty S, Oi S, Yamaguchi M, Tamaki N, Matsumoto S. Growth hormone-producing pituitary adenomas: MR characteristics and pre- and postoperative evaluation. Neurol Med Chir (Tokyo) 1993;33:81-5.
Mohamed FF, Abouhashem S. Diagnostic value of apparent diffusion coefficient (ADC) in assessment of pituitary macroadenoma consistency. Egypt J Radiol Nucl Med 2013;44:617-24.
Boxerman JL, Rogg JM, Donahue JE, Machan JT, Goldman MA, Doberstein CE. Preoperative MRI evaluation of pituitary macroadenoma: Imaging features predictive of successful transsphenoidal surgery. AJR Am J Roentgenol 2010;195:720-8.
Suzuki C, Maeda M, Hori K, Kozuka Y, Sakuma H, Taki W, et al
. Apparent diffusion coefficient of pituitary macroadenoma evaluated with line-scan diffusion-weighted imaging. J Neuroradiol 2007;34:228-35.
Mahmoud OM, Tominaga A, Amatya VJ, Ohtaki M, Sugiyama K, Sakoguchi T, et al
. Role of PROPELLER diffusion-weighted imaging and apparent diffusion coefficient in the evaluation of pituitary adenomas. Eur J Radiol 2011;80:412-7.
Scotti G, Yu CY, Dillon WP, Norman D, Colombo N, Newton TH, et al
. MR imaging of cavernous sinus involvement by pituitary adenomas. AJR Am J Roentgenol 1988;151:799-806.
Cottier JP, Destrieux C, Brunereau L, Bertrand P, Moreau L, Jan M, et al
. Cavernous sinus invasion by pituitary adenoma: MR imaging. Radiology 2000;215:463-9.
Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: A magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993;33:610-7.
Bonicki W, Kasperlik-Załuska A, Koszewski W, Zgliczyński W, Wisławski J. Pituitary apoplexy: Endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas. Acta Neurochir (Wien) 1993;120:118-22.
Dubuisson AS, Beckers A, Stevenaert A. Classical pituitary tumour apoplexy: Clinical features, management and outcomes in a series of 24 patients. Clin Neurol Neurosurg 2007;109:63-70.
Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA. Classical pituitary apoplexy: Clinical features, management and outcome. Clin Endocrinol (Oxf) 1999;51:181-8.
Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry 2001;71:542-5.
Tosaka M, Sato N, Hirato J, Fujimaki H, Yamaguchi R, Kohga H, et al
. Assessment of hemorrhage in pituitary macroadenoma by T2*-weighted gradient-echo MR imaging. AJNR Am J Neuroradiol 2007;28:2023-9.
Rogg JM, Tung GA, Anderson G, Cortez S. Pituitary apoplexy: Early detection with diffusion-weighted MR imaging. AJNR Am J Neuroradiol 2002;23:1240-5.
Rodríguez O, Mateos B, de la Pedraja R, Villoria R, Hernando JI, Pastor A, et al
. Postoperative follow-up of pituitary adenomas after trans-sphenoidal resection: MRI and clinical correlation. Neuroradiology 1996;38:747-54.
Rajaraman V, Schulder M. Postoperative MRI appearance after transsphenoidal pituitary tumor resection. Surg Neurol 1999;52:592-8.
Caturegli P, Newschaffer C, Olivi A, Pomper MG, Burger PC, Rose NR. Autoimmune hypophysitis. Endocr Rev 2005;26:599-614.
Nakata Y, Sato N, Masumoto T, Mori H, Akai H, Nobusawa H, et al
. Parasellar T2 dark sign on MR imaging in patients with lymphocytic hypophysitis. AJNR Am J Neuroradiol 2010;31:1944-50.
Lury KM. Inflammatory and infectious processes involving the pituitary gland. Top Magn Reson Imaging 2005;16:301-6.
Kaltsas GA, Powles TB, Evanson J, Plowman PN, Drinkwater JE, Jenkins PJ, et al
. Hypothalamo-pituitary abnormalities in adult patients with langerhans cell histiocytosis: Clinical, endocrinological, and radiological features and response to treatment. J Clin Endocrinol Metab 2000;85:1370-6.
Lury KM, Smith JK, Matheus MG, Castillo M. Neurosarcoidosis-review of imaging findings. Semin Roentgenol 2004;39:495-504.
Kumar J, Kumar A, Sharma R, Vashisht S. Magnetic resonance imaging of sellar and suprasellar pathology: A pictorial review. Curr Probl Diagn Radiol 2007;36:227-36.
Zhang YQ, Wang CC, Ma ZY. Pediatric craniopharyngiomas: Clinicomorphological study of 189 cases. Pediatr Neurosurg 2002;36:80-4.
Zada G, Lin N, Ojerholm E, Ramkissoon S, Laws ER. Craniopharyngioma and other cystic epithelial lesions of the sellar region: A review of clinical, imaging, and histopathological relationships. Neurosurg Focus 2010;28:E4.
Karavitaki N, Brufani C, Warner JT, Adams CB, Richards P, Ansorge O, et al
. Craniopharyngiomas in children and adults: Systematic analysis of 121 cases with long-term follow-up. Clin Endocrinol (Oxf) 2005;62:397-409.
Kaltsas GA, Evanson J, Chrisoulidou A, Grossman AB. The diagnosis and management of parasellar tumours of the pituitary. Endocr Relat Cancer 2008;15:885-903.
Freda PU, Post KD. Differential diagnosis of sellar masses. Endocrinol Metab Clin North Am 1999;28:81-117, vi.
Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, et al
. Surgical treatment of symptomatic Rathke cleft cysts: Clinical features and results with special attention to recurrence. J Neurosurg 2004;100:33-40.
Byun WM, Kim OL, Kim D. MR imaging findings of Rathke's cleft cysts: Significance of intracystic nodules. AJNR Am J Neuroradiol 2000;21:485-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]
[Table 1], [Table 2], [Table 3], [Table 4]

domain: medical


text:
In her recently published book, Paisley Rekdal argues that, in accepting our dual condition, the adventurous artist, regardless of race or other identity, must be willing to brave criticism; she insists that all creative writers, both fledgling and veteran, search within to find their own ethics of literary invention.
Matt W. Miller’s fourth book chronicles in documentary poetics the history of the Merrimack River, braiding together its many voices from the perspective of the twenty-first century, when the insistence of memory resides everywhere and in everything: people, the river, the land, industry, relationships—in short, in one’s spirit.
Ethel Rohan’s stories are expertly laced with opposition and convergence, a curled fist and an open palm. Her most recent collection—out this week—features relationships rife with both dissonance and confluence, characters in pairs and triads stretching away and snapping back together.
Lilly Dancyger’s just-released mixed media memoir is a story of two artists, forever separated, and the history and symbols that provide an artistic shorthand able to move past the boundaries of shared experiences and meet again.
Gabriela Garcia’s non-chronological debut novel, built on glimpses of memory and history, digs into issues of cultural identity, social and political unrest, and the complexities of lives informed by migration, oppression, and racial inequality.
J. Robert Lennon’s new novel and short story collection, both released last week, offer up an aesthetic of the uncompromising, the surprising, and the fantastic, either cloaked in the everyday or surreally spread.
Reading Cárdenas’s second novel, with its intricately patterned sentences circling obsessively around an absent center, it’s hard to shake the feeling that the author has done something remarkable, inventing an entirely original language for representing the fractured sensation of being conscious in the twenty-first century.
Hobson’s latest novel is a brilliant, artfully crafted story of Native heritage, family dynamics, and ancestral hope.
Bible is a careful craftsman, cutting his new novel down to its core without losing a diverse cast of characters, a clearly rendered town, and wholly realized emotional resonance. He doesn’t overexplain, doesn’t excessively detail, and doesn’t deviate from the novel’s heart.
Russell’s most recent book, chronicling a walk from the panhandle of Florida to the celestial city of Miami, comes to the conclusion that a walking journey should not only be a journey about the self, but also about how the self exists in a built environment.

domain: library


text:
GEORGE TOWN, Nov 4 — News that three premier and prominent schools on the island are facing closure, has shocked former students.
The SK Convent Light Street, SMK Convent Light Street (CLS) and SMK Convent Pulau Tikus (CPT) will see a reduction in student intake beginning next year heading towards closure.
Sharon Selvarani, 34, who used to be a trainee teacher in SK Convent Light Street in 2000 said she is saddened to say goodbye to the school.
“The school is close to my heart as I embarked on my teaching journey there and the senior teachers there have instilled copious amounts of knowledge into me.
“I made sure I stopped and took pictures outside the school building every time I visit Penang,” said the teacher, who is now serving in a school in Rawang, Selangor.
“I am sad and I hope the school is kept and refurbished because the nation needs more schools like this,” she said.
The chairman of Stella Maris primary school in Jalan Hulu Klang, Dr Christine Chow, 67, who was a former student of SMK Convent Light Street, expressed her disappointment over the closure of the school.
“I’m not only a former student, but was an orphan there too,” she told Malay Mail.
“I studied and grew up in the school and I feel devastated knowing the school is going to be closed.”
Christine, who is also a lecturer at Berjaya University College of Hospitality, said the school had provided a good education for many students, including orphans like her.
“The teachers, especially Khor Chin-Kee, always motivated us and gave us the confidence to perform better in the class,” said Christine, who is from the batch of 1968.
Christine also said the thing that she remembered the most in the school was the kindness showed by the nuns, who were looking after the orphans.
“I valued them and they never treated us in a harsh manner,” she said.
Fellow former student Teow Min Yee said the school held much memories.
“It was my secondary school and I boarded in the school for one year when I was in Form 5. It was a beautiful school and the place is peaceful,” said Teow, who is from the batch of 1967.
“The building of the school is also historical. It’s sad to hear that the management is closing the school. The teachers in the school are knowledgeable and they have imparted a lot of moral values. Most of the school leavers are doing good now,” said the former physiotherapist.
Khaw Chia Hui, 34, who attended CLS from Primary Two to Form 5, said the school has historical value and was so beautiful that she opted to take her pre-wedding photos there.
“I have great memories there, such as using Francis Light’s office as a classroom, and contributing to fundraisers to help renovate the school.
“Being by the sea, the school was also beautiful and I even snuck in to take pre-wedding photos,” said the alumnae of class 2000.
Kim Danker-Ooi, 34, who attend CLS from Primary 4 to Form 5 and graduated in 2000, said the school and its educators have played a significant role for many of them.
“I have heartfelt gratitude for the school’s contribution,” she said.
Another CLS alumnae of class 2000, S. Sivagami said the school should be gazetted as a heritage site.
“I’m perplexed over the decision for the Sisters of the Infant Jesus to take back the school. All I wish is that the school be gazetted as a heritage site given its rich and long history,” said the alumnae who attended the school from removed class to Form 5.
CLS alumnus of 1981, Rani Grantham, 53, said she had fond memories of the school.
“My memories of that school is having classes overlooking the sea. It always had a peaceful atmosphere. The Irish nuns looked strict but were in fact very approachable,” she said.

domain: sociology


text:
When a company has employees that are problems to work with, it can create a hostile work environment that drains productivity. Some general categories of behaviors exhibited by problem employees include bullying, gossiping, insolence and insubordination.
Managers and business owners must deal with employees who violate company rules or engage in some type of misbehavior. However, dealing with problem employees can be stressful and awkward. To demonstrate leadership, employers need to deal with problem employees directly and discuss behavioral and performance issues.
Below are actionable tips for dealing with problem employees.
Workplace gossip isn’t the best source of information about problem employees. If you know very little about the person in question, start talking to them so they are at ease when speaking with you. This is a crucial part of finding the truth.
You might not want to jump right into a discussion about work difficulties or personal problems with someone who isn’t comfortable talking with you. This may not be the right way for identifying the problem. Although it may take you several conversations before bringing up the issues, it’s often worth it.
Take time to assess and reflect on the problems. This will help you determine what you need or expect your employees to do to bridge the gap between their behavior and the business’s expectations. This may help you figure out and design an appropriate course of action.
Listen to Them
Oftentimes, when employees are a problem in the workplace, people rarely pay attention to them. A good number of managers become irritated and lose hope in the employee. Some turn their attention to other things out of a combination of self-protection and avoidance.
While you might want to decide on what to think about problem employees, it’s always good practice to pay attention to someone who’s not doing well. You can start by arranging for a private conversation with them.
Your best shot at solving the situation lies in having a clear understanding of what’s going on. Difficult employees may start behaving differently once they realize they’re being heard. This may include accommodating a problematic employee’s point of view.
You may find out about real issues (that need to be addressed) that aren’t a tough employee’s fault.
Implement Preventative Training
Continuous preventive training can lay the foundation for employees to recognize their behavioral expectations. It also helps employers to be ready to act when workers fall short of those expectations.
Most businesses these days include civility training for all employees. These trainings often include components like business etiquette, diversity awareness and cultural sensitivity.
Facilitating goal-oriented teamwork activities can encourage better understanding between employees. Workplace testing modules provide a great way to help co-workers understand that they may have different tendencies and different work styles. This helps them find ways to interact with each other better.
In most cases, the understanding that one’s own behaviors and style are just as efficient as a co-worker’s opposite tendencies and style can help diffuse previously frustrating interactions. You can create a less hostile work environment in general with these types of workshops.
Critique Behavior, Not Employees
It’s important that you don’t make communication too emotional or personal. The aim is to find a solution to a workplace problem yet not to ignite a confrontation. To achieve this, it’s important to concentrate specifically on undesirable or inappropriate behavior a worker has demonstrated and not attacking them personally.
While there might be harmful intentions behind their unacceptable actions, it could have stemmed from fear, confusion or personal issues that you know little about.
Create a Solution Together
The end goal of engaging with problem employees is an agreed-upon solution. Talk about specific goals with the employee and be sure to monitor their input.
If possible, let the employees decide goals for themselves. This provides them with a stake in their own transformation process. It’s also a good way to know if they’re interested in improving.
After uncovering an employee’s issues, having a conversation and implementing a customized plan, you need to step back and monitor the worker’s progress. Establish feasible and measurable targets and time frame for completing them. The key is that the employee and the manager agree upon a concrete goal and timeline.
Also, how often you monitor their progress should be tailored to the activity. If the unacceptable behavior continues, then you should consider executing a disciplinary action. Depending on the severity of the misdemeanor, an employee could be transferred to a different business unit or department.
Then again, transfers aren’t the best ways on how to deal with problem employees. In persistent or more extreme cases, terminating an employee may be the right course of action.
As you evaluate your employee’s performance, you may as well consider the kind of support you should provide. You can help the difficult worker get back on track and become better in the areas they’re lagging in. Research professional development resources.
Also, you may want to link them up with training that could be useful for them to improve or turn the situation around.
Give Constructive Feedback
While it can be awkward to give negative feedback, you should do it in a constructive manner. Don’t make it personal and try not to belittle the, with your feedback. Just keep your advice positive and offer pointers that will help the worker better their behavior and become more productive.
Deal With Problem Employees Accordingly
Dealing with employees is never easy as not all workers are reasonable and rational. As the manager or employer, you will almost always have to deal with workers who are labeled problem employees. While some employers choose to ignore the problem, it’s worth taking the bull by the horns and take it on head first.
By taking on the difficult employee, you’ll not only help them improve but also send a message to other employees that you’re a capable person who encourages handwork and positivity. For more tips and advice, check out our blog.

domain: psychology


ZIP Countertop Reverse Osmosis Water Filter Is The Best Choose For Your Home Dupure International Water Filters
Countertop reverse osmosis systems are gradually becoming the backbone of water purification industry as a result of their ease of use as, their reliability and total purification efficiency. They are also not so costly as the other bigger versions.
Countertop reverse osmosis systems are ideal for people who just rent their houses or people who want a handy system. Typical reverse systems need permanent modifications to be done to your cabinets so they may be set up easily and also correctly.
The countertop system joins to a present sink faucet very quickly and easily. Once the machine is connected, it moves water through several phases of purification in order to provide you with clean, top quality water.
If you are searching for the very best countertop reverse osmosis systems, then you are at the ideal location. ZIP system is not only very effective but also sleek-looking. It normally uses 24 watts while it has 50 percent healing rate. With this system it’s possible to become almost five gallon of water over 10 to 15 minutes. It does not feature hoses or diverter valves which usually flow, therefore so it occupies less space and it’s also tidy. Dupure International Water Filters
The machine moves tap water through four stages so as eliminate up to 99percent of contaminants in the water. The machine does not need to be installed as it merely needs to be removed out of the box and plugged in. It functions in the same way for a coffee machine.
The system measures 9.5″by.5″by16.25″ and it’s also quite amazing for a water filtration system. You will need to change your filters after every twelve weeks. The cost of a comprehensive set is roughly $50. You will also need to modify the reverse osmosis membrane after every two to four years. The price of the membrane is almost $50 as well.
Zip is probably one of the best countertop reverse osmosis systems that are available on the market now.
Puricom ZIP’S Patented Technology Dupure International Water Filters
Pure water made easy: you do not need to waste your precious time simply waiting for filtering procedure to complete. With zip you only have to Fill out the bottom container with one gallon of tap water, then press the button and simply walk away. Within 10 to 15 minutes the top container will be full of approximately 0.5 gallons of distilled water and ZIP will automatically turn itself off.
- BPA-Free: it is easy to remove the top and underside containers and easily wash them with clean dish soap.
- Efficiency: it only requires 24W less than a bulb and also has 50percent (1:1) recovery rate which is best among reverse filters.
- Design: the system will definitely look great within your kitchen. It does not have leaky diverter valves or bulky pads to secure to a faucet.
- Simple To Change Replacement Filters: it will alert you for recommended filter switch through red blinking light after every twelve months.
Usage, Maintenance & Filter Changes
This system was created putting in mind ease of use in addition to practicality. The system also has a very simple user interface. With a twist of a dial Water comes out whereas there’s not any requirement for a complicated user manual. The system is mobile and it only has to be plugged to a power supply. The machine doesn’t need to be installed to some household plumbing.
Altering the procedures filters is very quick and also easy. The filters come off and go back on using an easy twist function. The system has an indicator light that lets you know the ideal time to modify the filters. The LED light port offers you color coded management of the filter condition. There are No special tools which are needed so as to alter the filters. Dupure International Water Filters
The LED light that is colour coded instantly shows you if filtration process is complete. The system provides you immediate supply of distilled water.
The unit is also easy to work: you can select the temperature by means of a selector lever and then temporarily press on the selector lever: 3-hundred tsp fresh osmosis water has been drawn from the inbuilt 1.5 ltr tank. Keeping up the unit is very simple, membranes as well as pre-filters are so-called Quick Change filters, along with also the after-filter is a slide-in filter. Both the Filter and the diaphragm can be exchanged with a couple of motions of the hand.
The system only needs to be plugged into a normal power source. Just a power connection through a very simple plug socket is necessary.
The unit comes with an automatic shutdown manner; this usually means that the device turn off automatically after 1hour in order to save power.
Other Features of This ZIP Countertop Unit
ZIP filter has the power to remove up to 99 percent of contaminants . The machine’s Alkaline Post Filter usually adds a tiny quantity of Calcium as well as Magnesium so as to give you a taste that is similar to that of the most expensive bottled water.
Beautiful Convenience Dupure International Water Filters
The unit functions like a coffee maker. It does not have messy hoses as well as leaky diverter valves that usually neglect. You only need to fill out the container with water from the kitchen faucet and you’ll be able to get 1/2 gallon of quite clean alkaline water following 10-15minutes.
ZIP System Characteristics
The unit is designed with, durability, usability, high quality in addition to efficiency in your mind and it features many incredible capabilities. The device is made with green, recyclable materials which are environmentally friendly like ABS, and PP, in order to ensure suitability for recycling as well as to minimize the usage of Earth’s resources.
The sleek European design of ZIP can work together with the modern design of European as well as the American style kitchens and homes. The unit includes Practical internal design that divides water and electric parts in order to extend the product’s lifetime and ensure your security.
WATER PURITY – 4 STAGES OF ADVANCED FILTRATION
STAGE 1 — 5 Micron Sediment Filter
This entails unique gradient pore structure, in which the outer segment traps larger particles and the inner part traps smaller particles. The stage effectively removes dirt and rust.
STAGE 2 — The Activated Carbon Block Filters
The stage removes harmful chemical residues along with carcinogens like THM’s and pesticides. The massive adsorption capability effectively eliminates odors and VOC’s.
STAGE 3 — The Reverse Osmosis Membrane Dupure International Water Filters
The 75 Gallon A Day Reverse Osmosis Membrane usually purifies water out of all of the contaminants found on the periodic table’s elements. It is the heart of this reverse osmosis system.
STAGE 4 — The High Quality Alkaline Post Filter
The Polishing Carbon’s Alkaline Post Filter usually adds beneficial minerals –Magnesium and potassium into the purified water to get the ideal taste. It also increases the alkalinity of water into healthy level of between 7 and 8 pH.
- The unit is excellent for apartments, condos and RV’s.|}
- The system comes with a one Year money-back guarantee.
- It also comes with a 1 Year guarantee.
- The unit is among the very best among reverse filters.
- Water is of Delicious purity.
- The device is also very convenient
- Water passes through four stages of advanced filtration.
- It’s easy to Easy to Change the unit’s Replacement Filters.
- The system increases the purified water Magnesium and Magnesium that are valuable and give water the best taste.
- The unit includes a design that is not only Modern but also Fashionable and streamlined
The aforementioned review points out a few of the very best Countertop Reverse osmosis systems you will ever get on the market in the event your concern is obtaining a countertop system that’s very powerful and also portable. It’s known to be among the highest quality systems based on consumer reviews along with the consumer ratings. Dupure International Water Filters
The ZIP Countertop Reverse Osmosis Water Filter is lightweight, portable, simple to install and it eliminates up to 99.9 percent of harmful chemicals found in water. It is therefore, a recommended water filtration system.


Nationality and Borders Bill Will Harm Children
20 September 2021
Immigration solicitors at the Children’s Law Centre have raised serious concerns around the Nationality and Borders Bill. The solicitors have said the Bill will harm children, increase the risk of child trafficking and encroach on devolved matters in relation to trafficking and child protection.
The concerns have been raised ahead of the Westminster committee stage of the Bill, starting on Tuesday 21 September. The committee is expected to report to the House by Thursday 4 November 2021.
Barbara Muldoon, Immigration Solicitor at the Children’s Law Centre said: “The Children’s Law Centre remains deeply concerned about the wide-ranging impact the Nationality and Borders Bill will have on vulnerable children in this jurisdiction. We have made some good progress in relation to tackling trafficking over the last decade, but this will undo that progress.
“The Bill, as it stands, represents a major departure from long-standing international obligations and domestic law. Yet the consultation process fell massively short of basic standards. It’s notable that the vast majority of immigration practitioners have been critical to date.
“When it comes to vulnerable children and child victims of trafficking, the matter should be dealt with as a child safe-guarding issue. Yet the Nationality and Borders Bill seeks to weaken child safeguarding duties. Children will be put at increased risk of trafficking and re-trafficking, at risk of being criminalised and at risk of being detained in adult detention centres. This is far from acceptable.
“With child protection and the prevention of trafficking both being devolved matters, the Bill also massively over-reaches. We have heard concerns from practitioners in other jurisdictions concerning this already. It’s likely we are going to see decades of litigation in relation to this matter.
“We need to see a concerted effort to amend the Bill during the committee stage. As a minimum, it must remain compatible with the 1951 Refugee Convention and other domestic and international commitments. We also need to ensure mitigations are put in place by the NI Executive to protect our devolved powers and ultimately to protect children from the worst reaches of the changes.”


FP3 is a new condominium project in the rapidly changing Seaport District / Fort Point Channel neighborhood of Boston. The building is actually made up of an existing building with several floors of new construction, on top.
The Clarendon is now open.
This is a brand-new condominium project in the heart of the Back Bay neighborhood of Boston.
The Clarendon is designed by world-renowned Robert A.M. Stern Architects, LLP.
Details on new Boston condos for sale coming on the market in downtown Boston during the past 24 hours, including this property at 25 Channel Center PH #201, Seaport District, Boston, MA.
The closing on purchase of a home in The Clarendon condominium project in the Back Bay neighborhood of Boston was recorded today at the Suffolk County Registry of Deeds.
This was a 21st-floor three-bedroom three and ½-bath condo with approximately 1,967 square feet of space. It was the 23rd closing in the 103-unit building.
Boston condo sales and real estate data for the period ending March 13, 2010.
A complete analysis of the past thirty-days of under agreement and closed sales data for the Downtown Boston condo market.
Notice: Undefined index: num_larger_page_numbers in /home/content/87/10698787/html/wp-content/themes/wp-creativix/scripts/wp-pagenavi.php on line 44
Notice: Undefined index: larger_page_numbers_multiple in /home/content/87/10698787/html/wp-content/themes/wp-creativix/scripts/wp-pagenavi.php on line 45


text:
NooCube is a newly launched brain supplements in Indianapolis US that declares to improve cognitive functions by utilizing the herbal formulation. It is expected to be very reliable, as the compounds included in it have been medically confirmed as advantageous for the mind. Noocube is extremely risk-free. Since although it is a nootropic, NooCube drugs does not consist of one of the most popular energizer, caffeine. This should make it unable to generate one of the most usual side results connected with nootropics, including jitteriness as well as insomnia. Nootropics is herbal and also the opportunity to produce adverse effects are very unusual.
Do deny any type of drugs to improve cognitive function before you review this Noocube review: capsules to improve mind power that will provide you details concerning exactly what is Noocube and also the factors to utilize it, the formula, how you can use Noocube and how to order drugs to improve cognitive function Noocube available online in Indianapolis US.
What is mind stimulant drugs Noocube
Noocube is a daily pills developed to boost mind function by supporting focus, psychological rate as well as mind. It is the best blend of mind vitamins, amino acids, and also other building blocks vital for healthy and balanced as well as well working neurotransmitters. Given that Noocube has tested formula and no high levels of caffeine, it is an excellent choice for both brand-new and also knowledgeable brain tablets users in Indianapolis US. It needs to execute well for lots of people, as well as at the exact same time it is not most likely to create negative effects. This is because high levels of caffeine is one of the most usual cause for unwanted reactions experienced by customers of nootropics, as well as Noocube does not include high levels of caffeine in it’s formula.
The components of Noocube products
Every one of NooCube’s ingredients list have been rigorously tested for safety and also are backed by substantial professional research studies. Noocube manufacturer has undoubtedly chosen one of the most promising natural materials, so NooCube has a fantastic factor in it’s favor right from the beginning. Certainly, not all the studies are considered as precise proof by the clinical neighborhood. However they are appealing however, and future individuals in Indianapolis US have a good need to expect great outcomes.
Below are the details of Noocube components:
Alpha Glycerylphosphorylcholine (Alpha GPC)
This is an all-natural compound included in many mind booster as it is believed that it could enhance mind and also discovering. It operates by increasing the level of acetylcholine, which is neurotransmitter. Neurotransmitters are chemicals that help with communication between mind cells, and each of them has different features. Acetylcholine in certain is associated with cognitive procedures. There are some studies which show alpha GPC are able to enhance cognitive features in both healthy people and individuals who experience dementia. In one of the most location of the globe consisting of Europe, this material is used in the treatment of Alzheimer’s disease.
It is a compound that is drawn out from the Chinese moss plant. Huperzine is identified as an effective therapy for Alzheimer’s illness. It is incredibly popular active ingredient in brain boosters. Huperzine A raises the level of acetylcholine and enhance all cognitive functions.
Cat’s Claw (Uncaria tomentosa)
This plant is utilized in the therapy of several conditions, as it includes substances that are able to promote the body immune system, secure cells from damages or even eliminate infections and also bacteria. It appears that Cat’s Claw could be utilized for the whole body, including mind cells. It can protect nerve cells from damages, which is really handy. Although it is not a stimulant, antioxidants are a wonderful addition to any brain tablets.
This is another ingredient that is extremely usual in nootropics. This plant is made use of in the treatment of a number of loves, yet usually for those that damages reasoning skills. A variety of research studies reveal it as able to enhance cognitive functions, and also it appears that it functions by enhancing the degree of natural chemicals. It is also believed that it could protect nerve cells from damage.
Oat straw or Avena Sativa has many great properties as well as it is able to lower cholesterol and blood sugar. It is utilized in the treatment of lots of wellness problems, but hardly ever as a brain stimulant. The studies regarding Oat Straw as offered in Noocube site look appealing.
This substance is an amino acid discovered in green and black tea, and it has a structure that resembles glutamate. Glutamate jobs as a neurotransmitter, so it is necessary for healthy and balanced brain functions. Given that theanine has a comparable structure, it is believed that it could be utilized by the body similarly. Although it is not yet verified that theanine has a similar impact, but it looks very encouraging.
Unlike theanine it could not perform as a natural chemical, but it is consisted of in the creation of noradrenaline and dopamine. These compounds are neurotransmitters that are crucial for emphasis and awareness, especially in demanding conditions. Tyrosine is not just very valuable for those who are functioning or researching under anxiety, but likewise for those that endure from stress and anxiety and also associated mental conditions.
Ways to make use of brain drugs Noocube
You are advised to take in 2 NooCube capsules with morning meal every early morning. Because neurochemistry is different for everyone, the results could distinctive in between every individual. The recommended dose is start with consuming 2 tablets, prior to looking for the best dosage. Boosting dose could be 3 or 4 NooCube capsules every day. Do not exceed 4 capsules for eventually.
Best place to acquire pills to improve cognitive ability in Indianapolis US
NooCube capsules is available in capsule form and also is manufactured as well as sold by ERGO Group Limited, a company based in United Arab Emirates. This firm probably has actually begun its activity in the service of wellness supplements. NooCube is most likely it wases initially launch, but this firm seem to be completely legit.
It is asserted that Noocube can boost emphasis, memory, psychological energy and also all other cognitive processes. Which is exactly just what it is promised for all various other mind stimulant readily available on the market. However the Noocube website really supplies evidence for these statements. Site site visitors can read papers regarding scientific researches executed on the majority of the formulation. As well as all of them reveal extremely positive findings.
If you have an interest in purchasing Noocube, right here are the rate of Noocube in Indianapolis US:
|Noocube Product||Best offer price||Buy Now|
|2 bottles + 1 free bottle||
|Buy Now||3 bottles + 3 free bottles||
Make certain to acquire Noocube from the official web site. There are numerous benefits if you purchase from there. You will have premium quality tablets to enhance cognitive ability. You will also get multi get deals, buy 2 Get 1 Cost Free and also buy 3 Get 3 Cost Free to make you save even more fund. There is also refund warranty in situation Noocube does not work for you.


Full-stack Web Developer, Digital Learning - For Helping Save Lives
Do you want to use your full-stack web development skills to help save lives? Then come help us make our powerful digital learning platform even more impactful.
Laerdal Medical is a world-leading provider of medical and educational products, helping doctors and nurses around the world save lives. We do so with both screen-based advanced e-learning, physical skills training on manikins, and insightful analytics. We have more than a million healthcare providers using our products and services.
The Laerdal office in Copenhagen is the center of excellence for Laerdal's digital learning solutions and has a unique mix of dedicated people ranging from medical doctors and user experience designers to highly skilled software engineers within app development, 3D and data. Watch our introduction to Laerdal Copenhagen.
The Laerdal training and simulation products are making healthcare professionals better at saving lives all over the globe. To respond fast and influentially to new learning needs, we are developing a strong digital learning platform based on the open-source framework Adapt Learning, enabling our learning experts to author digital learning products that hit the mark.
As a full-stack developer on our Laerdal Adapt Platform team, you will play a vital role in evolving our platform to new levels. Things like incorporating adaptive learning capabilities, the next level of user behavior tracking, and integrating new 3rd party frameworks are all on our schedule. So, if you are thriving to use your full-stack web application competencies to make a real difference, then you are the one we are looking for.
You will work closely with colleagues locally in our Copenhagen office and team members in both Bangalore and Stavanger.
Your primary tasks and areas of responsibility:
- Extend and enhance the Laerdal Adapt platform and ecosystem: evolve the platform by adding new components and features requested by product teams.
- Work with the backend of the Adapt platform to ensure the authoring tools and deployment pipelines are continuously improved.
- Add new features to the frontend of the platform, including new themes, components, extensions, and menus.
- Integrate 3rd party systems and component libraries to easily incorporate new functionality and expand the territory of the Laerdal Adapt platform
Skills and experience
We expect an educational background in Computer Science, IT, or equivalent at bachelor or master level and preferably 5+ years of development experience.
The ideal candidate has the following experience
- Expert in full-stack development of web applications
- Specialist in tools and framework such as
- Less CSS
- Former experience in extending/customizing open-source frameworks such as Adapt, Umbraco etc. to tailor specific needs
- Identify technical debt in code bases and provide solutions to eliminate these
- Debug and problem solve critical issues across the entire Adapt platform
- Participate in technical design- and code discussions with colleagues
- Break down User Stories into concrete developer tasks
As a person you are self-motivated with a forward leaning go-do attitude, are a team player, and you enjoy working in a multidisciplinary cooperative environment. Furthermore, you strive to be the best in your field, you wish to learn more, and are not afraid to explore new areas & technologies.
If this has spawned your interest, then reach out to us. Call Jeppe Klingberg on +45 2891 1949 with questions or to hear more about the possibilities. And if you think the job sounds right to you, send us your application by using the application button below: “Apply online”.
We will be conducting interviews on a running basis, so send your application today.
We look forward to hearing from you.
Laerdal is a global company with 1600 employees, with corporate headquarter in Stavanger and development sites in Stavanger, Copenhagen, Washington DC, and Bangalore. The Laerdal Copenhagen office is the global center for research and development of digital learning and analytics. See more about working in Laerdal Copenhagen on our website and introduction video.
Laerdal Medical offers a competitive work package, flexible working conditions and a casual office environment with company-sponsored social activities and perks.


text:
- 100% Original Templates
- 100% Working Download Files
- UnTouched Fresh Files
- No Malware & Virus
- Free Feature Updates
MaMaHosT is an Single WebHosting Company HTML Template. We have created the Template with real life experience. With Multiple Color Switcher, Fully Responsive & many more. Right fit for Selling your Domain Hosting, Software, IT Enable Service’s. Also useful for IT Solution Companies.
ThemeForest MaMaHosT – Modern WebHosting Business Responsive Template is an elegant, modern, stylish and unique Web Hosting Template. It is packed with awesome features and its main focus is to make your website stand out while keeping it extremely easy to use and maintain.
Unique Home Pages.
2 Different Blog Single Page.
2 Different Contact Page.
Clean & Modern Design.
Valid HTML5 & CSS3.
Valid Bootlint Bootstrap.
Sticky Menu When Scrolling Down.
OWl Slider Use.
Smooth transition effects.
Cross Browser Optimization.
Standerd custom code Created.
All files are well commented.
Download All Premium Original Web Hosting Templates and Premium PHP Scripts only at DevelopLikePro.
MaMaHosT – Modern WebHosting Business Responsive Template v1 – Premium Web Hosting Template Tested by DevelopLikePro and 100% Working.
|Last updated:||22 November 2017|
|Release date:||22 November 2017|
|Current Download Version:||v1|
|Item Type:||Web Hosting Template|
|Download Link:||Download Link 1 Download Link 2 Download Link 3|

domain: design


text:
When your child has fallen asleep, you will end up taken to the waiting room. There are no shots or needles used while your kid is still awake. Your own child may choose a favorite scent to taste the air flowing from the mask. In the two hours before the scheduled arrival time, give nothing to be able to eat or drink.
Many of the time, this specific muscle is contracted, which often closes off the oesophagus from the stomach. Your surgeon will always discuss these in more details before your operation in addition to give you a way to ask questions. The fundoplication is then performed around a 56 bougie taking a distal and proximal bite of the esophagus. You need to discuss to your doctor about the advantages and disadvantages in your current situation to decide regardless of whether surgery is a fine choice for you.
LINX decreases acid exposure to your current esophagus meaning you may be able to decrease or get rid of the use regarding GERD medications. Each time a sufferer swallows food, LINX extends and allows it to be able to enter the stomach. Individuals experience a faster healing, since there is no internal cutting and experience fewer complications than traditional fundoplication surgery. Although effective, it has a number of negative effects which is usually why the St George’s upper gastrointestinal surgical group investigated new approaches to be able to develop less invasive medical treatments for reflux.
Thank you thus much for your wonderful overview on ” Reflux” in addition to “surgical intervention for reflux”. The LINX procedure exhibits promise being a highly successful and optimal treatment regarding uncontrolled GERD symptoms. Postoperative ambulation is important to aid expel the CO2 air used during the laparoscopic procedure and to stop venous thrombosis. Explain to patients that after surgical procedure they may experience some mild discomfort, including pain on the port sites, gas pain, or a “sore throat” related to temporary intubation for anesthesia.
Is there an operation to stop acid reflux?
Fundoplication. This is the standard surgical treatment for GERD. It tightens and reinforces the LES. The upper part of the stomach is wrapped around the outside of the lower esophagus to strengthen the sphincter.2 Mar 2016
Nissen R, The Treatment of Hiatal Hernia and Esophageal Reflux by Fundoplication. Acid suppressing drugs (such as Omeprazole or Lansoprazole) to be able to reduce acid reflux (these work by reducing or even neutralizing the acid in the stomach or producing the stomach empty faster). Damage to the oesophagus, stomach or lung coating, resulting in leakage from this area and sometimes necessitating the further laparoscopic procedure, upper body drain, or an open functioning, to address the problem.
Because associated with the insufficient any hurt pain, when you proceed home you may nicely think you are capable to act as if you have not had a good operation. Most patients carry out not have pain as a result after laparoscopic surgery, instead just some abdominal and chest discomfort. Life design changes for example losing pounds, avoiding foods that lead to acid reflux and stopping smoking. Some patients experience a feeling of indigestion after surgery plus are advised to carry on taking medications to decrease stomach acid for some several weeks after surgery.
In a laparoscopic procedure, surgeons use tiny incisions (1/4 to .5 inch) to the belly through trocars (narrow tube-like instruments). After midnight typically the night before the operation, you should not consume or drink anything other than medications that the surgeon has told you are permissible to take with the sip of water typically the morning of surgery. After your surgeon reviews together with you the potential hazards and benefits of typically the operation, you will need to provide created consent for surgery. Although laparoscopic anti-reflux surgery provides many benefits, it may not be appropriate for some sufferers.
With regard to any GERD treatment in order to be worth trying, it needs to be very safe. Examples of these types of symptoms are asthma, hoarseness, or cough together with poisson.
For many people, the side effects associated with surgeryâ€”bloating due to gas build up, swallowing problems, pain in the surgical siteâ€”are as bothersome as GERD signs. Outcomes of the laparoscopic technique are best any time the surgery is completed by a surgeon with experience using this procedure. Prilosec and Zantac both lessen acid levels in the stomach to alleviate symptoms of acid reflux. Having a good upset stomach several periods per week might be IRRITABLE BOWEL SYNDROME or acid reflux. The laparoscopic fundoplication surgery requires just a few days within the hospital with the patient in a position to return to job after 1 week.


text:
Jelly Roll Quilts book
- Good to Know
by Pam and Nicky Lintott
The original book of the Jelly Roll series. This book still continues to be a best seller and is the one we recommend for quilters just starting out on their jelly roll journey. The book contains sixteen patterns and one bag pattern suitable for quilters of all skill levels.
Clear step by step instructions, clear diagrams and fantastic photography - this is the perfect book to get you unravelling those deliciously looking jelly rolls!
Be the first to review this product!

domain: hobby


text:
Jeremy McGoran starting a conversation about mental health in the Penticton community.
The family of Penticton Vees defenceman Dante Fabbro is soaking up their time at the NHL Entry Draft
Okanagan Skaha School District trustees voted to apply for new funding for West Bench and Trout Creek Elementary Schools.
- Impress Branded Content
- updated Jun 20, 2016 at 9:58 AM
Work done without a licence or permit can lead to six times as many safety hazards, according to the BC Safety Authority
Markets reel as world absorbs shock of UK vote for Brexit

domain: news


text:
A special fermented black tea which we've partnered with Jing Wei Fu Tea to sell. This tea is special, and quite unlike any Puer or fermented tea you may be familiar with. The process of making "Fu tea" is sophisticated, involving a triple fermentation process which results in the natural growth of a healthy new probiotic spores called "Golden Flowers" which is internaitonally recognized and patented by multiple organizations, including the HACCP. It has been scientifically dubbed Eurotium Cristatum. The "Golden Flowers" are actually large and prominent that you can see them in the tea itself, like little yellow flowers which accompany your tea.
This is the tea bag version.

domain: food


text:
Added Oct 23, 2012
by Delphine C.
Port Au Prince, ...
As soon as I saw this pattern I decided to make, especially since it was available in size 34 and I didn’t have to grade it down. It’s easy to make, super comfortable to wear (thanks to the panel on the bias) and was definitely a show stopper at the office !
More details and my alterations on my blog !
Wool blend remnants from Paron NYC (I think). I actually had 1 1/2 yards left from a pair of pants I made last year and did not even remember.
Invisible zipper and poly seam binding.


Separate names with a comma.
100 LC 30/60 $30
100 commercial 30/06 $20
100 7mm08 $30
29 35 Remington $18
27 257 Roberts $20
45 220 Swift brass $25
100 30/30 $22
CCI Ammo 22 Long Rifle 40 Grain Red White Blue Coated - MPN: 921RWB
Complete .308 reloading kit with lots of extras for sale. $550 for everything. Open to trades.
Hornady L'N'L Iron Press with automatic primer...
Powder[ATTACH] [ATTACH] [ATTACH]
N340, 7oz, $12
Titegroup, 15oz, $17
Reloader 15, 14 oz, $17
I have just started going through an uncles remaining things, and have these things that I have no use for.
3 1 pound cans of FFg Superfine...
I have a barely used jug of Ramshot Tac. Born date of 02.28.13. Used about 500 grains for test loads before deciding to stick with my tried and...
***Edited to add case gauges, modified cartridge, pictures, individual prices etc.***
Just traded my .270 win rifle that I was going to reload...
For sale is my Pietta made 1858 NEW MODEL ARMY revolver chambered in .36 caliber for BLACK POWDER LOADS. Gun remains in very good, pre-owned...
I don't know how I do it. Why did I buy this? I must have had a plan.
The new plan is to get rid of it.
This is sealed, new, with the exception...
So I recently bought a used lnl ap press from a member on here, and when I started loading 223 a few months back and have had this problem...
RAMSHOT TAC - Powder Valley
Also, if you order $250 worth, they cover haz mat charge through tomorrow, so hurry!
My favorite .223/5.56 powder...
I’m not new to reloading just new to loading .45 ACP. Looking for a clean burning, good metering from a Dillon 550, and accurate powder with good...
All sealed and new, kept in dry climate controlled room. I have quite a bit of each up for sale. Pick up in St Helens Oregon
RETUMBO - $180 per...
As the title says
Hi everyone. First time on this forum about the black powder firearms. My good friend has an old Charles Daley 10 gauge double barrel. It's got...
I have the following, all new and sealed:
Ramshot TAC, 8lb Jug -$125
SOLD Reloader 15, 2lbs -$30 SOLD
Unique, 1lb - $15
Possible trade for 9mm...
[ATTACH] [ATTACH] hi there! Looking to sell this powder and bullets pretty cheap. Good deal for the right guy who re loads for the .308 Win
powder and primer lot $100
1 lb Unique
1 lb H110
1 lb HS6
80% full HS6
80% full Trailboss


BIVc Remote-Controlled Demolition
ETO ORDNANCE TECHINICAL INTELLIGENCE REPORT NO. 126A
Intel Report on the Borgward BIVc, with 6 photos.
This a supplement to report no. 126. The photos included are of the interior and engine area.
"A further examination of the German B IV c remote-controlled demolition vehicle described in ETO Ord Technical Intelligence Report No. 126 has been made and the additional information obtained is given to supplement that report."
|File Size: <10 MB|