Extended approach or usage of nasoseptal flap is a risk factor for olfactory dysfunction after endoscopic anterior skullbase surgery: results from 928 patients in a single tertiary center.

BACKGROUND: The aim of this study was to compare olfactory function change in patients who underwent endoscopic skull-base surgery. METHODOLOGY: A total of 928 patients were included in this retrospective study. Olfactory function was measured using the non- validated Likert scale (0â€"100), the Cross-Cultural Smell Identification Test (CC-SIT) and the butanol threshold test (BTT). Patients were divided into two groups: an endoscopic trans-sellar approach group (ETA, n = 768) and an extended endoscopic endonasal approach group (EEEA, n = 160). The ETA group was sub-divided into Nasoseptal flap (NSF) and no NSF groups. RESULTS: Non-validated olfactory function significantly worsened in the EEEA and ETA-NSF groups compared with that in the ETA- no NSF group for at least 6 months post-operatively. Validated olfactory impairment (BTT and CC-SIT) was also significantly worse in the EEEA and NSF groups compared with that in the ETA-no NSF group 3 months post-operatively. Additionally, the degrees of non-validated and validated olfactory deterioration were not significantly different between the EEEA and ETA-NSF groups. We also found that CC-SIT score changes were significantly impaired in tuberculum sellae meningioma patients than in craniopharyn- gioma patients. CONCLUSIONS: We conclude that NSF was the key factor that led to olfactory impairment after endoscopic skull-base surgery.

Forkhead box M1 (FOXM1) transcription factor is a key oncogenic driver of aggressive human meningioma progression.

AIMS: Aggressive meningioma remains incurable with neither chemo- nor targeted therapies proven effective, largely due to unidentified genetic alterations and/or aberrant oncogenic pathways driving the disease progression. In this study, we examined the expression and function of Forkhead box M1 (FOXM1) transcription factor during meningioma progression. METHODS: Human meningioma samples (n = 101) were collected, followed by Western blotting, quantitative PCR, immunohistochemical and progression-free survival (PFS) analyses. For in vitro assays, FOXM1 was overexpressed or knocked-down in benign (SF4433 and SF4068) or malignant (SF3061 and IOMM-Lee) human meningioma cell lines respectively. For in vivo studies, siomycin A (a FOXM1 inhibitor)-pretreated or control IOMM-Lee cells were implanted subcutaneously in nude mice. RESULTS: FOXM1 expression was increased in higher grades of meningioma and correlated with the mitotic index in the tumour tissue. Moreover, FOXM1 was increased in recurrent meningioma compared with the matched primary lesions. The patients who had higher FOXM1 expression had shorter PFS. In the subsequent in vitro assays, knockdown of FOXM1 in malignant meningioma cell lines resulted in decreased tumour cell proliferation, angiogenesis and invasion, potentially via regulation of ß-catenin, cyclin D1, p21, interleukin-8, vascular endothelial growth factor-A, PLAU, and epithelial-to-mesenchymal transition-related genes, whereas overexpression of FOXM1 in benign meningioma cell lines had the opposite effects. Last, suppression of FOXM1 using a pharmacological inhibitor, siomycin A, decreased tumour growth in an in vivo mouse model. CONCLUSIONS: Our data demonstrate that FOXM1 is a key transcription factor regulating oncogenic signalling pathways in meningioma progression, and a promising therapeutic target for aggressive meningioma.

[Clinical effects of microsurgery in spinal cord anaplastic astrocytoma].

Objective: To investigate the surgical outcomes and prognosis of spinal cord anaplastic astrocytoma (AA). Methods: A total of 27 consecutive patients diagnosed as spinal cord AA between January 2008 and May 2015 in Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. There were 18 males and 9 females, the mean age was (30.7±13.0) years (ranging from 5 to 52 years). The lesions were located at cervical level in 8 patients, at thoracic level in 9 patients, at cervicothoracic level in 3 patients, and at thoracolumbar level in 7 patients, the average number of vertebral was 3.3±1.3.The median time from onset of symptom to surgery was 4 months, ranging from 3 days to 48 months. The clinical presentations were weakness (23 cases), paresthesia (22 cases), pain (20 cases), sphincter disorder (15 cases) and paralysis (7 cases). The preoperative modified McCormick scale was as follows: grade Ⅱ for 6 cases, grade Ⅲ for 7 cases, grade Ⅳ for 7 cases, grade Ⅴ for 7 cases. The tumors were surgically removed via posterior median approach with the monitoring of the somatosensory-evoked potentials to minimize the neurological injury. All of the patients were recommonded to receive adjuvant chemotherapy and radiotherapy postoperatively after pothological verified and followed up by clinic interview or telephone postoperatively. Log-rank test was used to calculate the survival rate. Results: Gross total resection and subtotal resection were achieved in 18 patients and partial resection in 9. Twenty patients received adjuvant chemotherapy and (or) radiotherapy, 7 patients did not received chemoradiation postoperatively. Nineteen patients died and 8 were alive at the last follow-up. The median survival time was 23 months with 1 and 2-year survival rates of 85.2% and 50.0%.There was no statistical significance between subtotal resection group and partial resection group(χ(2)=0.089, P=0.880), the survival rates of patients in chemotherapy group and radiotherapy group were increased significantly(χ(2)=6.687, P=0.001; χ(2)=14.887, P=0.002). Conclusions: Spinal cord AA is a rare spinal high-grade astrocytoma with aggressive nature, the prognosis remains poor even after comprehensive treatments. Microsurgery followed by adjuvant chemoradiation is recommended for the treatment.

Mass cytometry identifies a distinct monocyte cytokine signature shared by clinically heterogeneous pediatric SLE patients.

Systemic Lupus Erythematosus (SLE) is a heterogeneous autoimmune disease with heightened disease severity in children. The incomplete understanding of the precise cellular and molecular events that drive disease activity pose a significant hurdle to the development of targeted therapeutic agents. Here, we performed single-cell phenotypic and functional characterization of pediatric SLE patients and healthy controls blood via mass cytometry. We identified a distinct CD14hi monocyte cytokine signature, with increased levels of monocyte chemoattractant protein-1 (MCP1), macrophage inflammatory protein-1ß (Mip1ß), and interleukin-1 receptor antagonist (IL-1RA). This signature was shared by every clinically heterogeneous patient, and reproduced in healthy donors' blood upon ex-vivo exposure to plasma from clinically active patients only. This SLE-plasma induced signature was abrogated by JAK1/JAK2 selective inhibition. This study demonstrates the utility of mass cytometry to evaluate immune dysregulation in pediatric autoimmunity, by identification of a multi-parametric immune signature that can be further dissected to delineate the events that drive disease pathogenesis.

Differentiation of Hemangioblastoma from Metastatic Brain Tumor using Dynamic Contrast-enhanced MR Imaging.

PURPOSE: The aim of this study was to differentiate hemangioblastomas from metastatic brain tumors using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and compare the diagnostic performances with diffusion-weighted imaging (DWI) and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI). METHODS: We retrospectively reviewed 7 patients with hemangioblastoma and 15 patients with metastatic adenocarcinoma with magnetic resonance imaging (MRI) including DWI, DSC-MRI, and DCE-MRI. Apparent diffusion coefficient (ADC), relative cerebral blood volume (rCBV), and DCE-MRI parameters (K trans, k ep, v e, and v p) were compared between the two groups. The diagnostic performance of each parameter was evaluated with receiver operating characteristic (ROC) curve analysis. RESULTS: v p, k ep, and rCBV were significantly different between patients with hemangioblastoma and those with metastatic brain tumor (p < 0.001, p = 0.005, and p = 0.017, respectively). A v p cutoff value of 0.012 and a rCBV cutoff value of 8.0 showed the highest accuracy for differentiating hemangioblastoma from metastasis. The area under the ROC curve for v p and rCBV was 0.99 and 0.89, respectively. A v p > 0.012 showed 100 % sensitivity, 93.3 % specificity, and 95.5 % accuracy and a rCBV > 8.0 showed 85.7 % sensitivity, 93.3 % specificity, and 90.9 % accuracy for differentiating hemangioblastoma from metastatic brain tumor. CONCLUSION: DCE-MRI was useful for differentiating hemangioblastoma from metastatic brain tumor.

Differentiation of tumor progression from pseudoprogression in patients with posttreatment glioblastoma using multiparametric histogram analysis.

BACKGROUND AND PURPOSE: The multiparametric imaging can show us different aspects of tumor behavior and may help differentiation of tumor recurrence from treatment related change. Our aim was to differentiate tumor progression from pseudoprogression in patients with glioblastoma by using multiparametric histogram analysis of 2 consecutive MR imaging studies with relative cerebral blood volume and ADC values. MATERIALS AND METHODS: Thirty-five consecutive patients with glioblastoma with new or increased size of enhancing lesions after concomitant chemoradiation therapy following surgical resection were included. Combined histograms were made by using the relative cerebral blood volume and ADC values of enhancing areas for initial and follow-up MR imaging, and subtracted histograms were also prepared. The histogram parameters between groups were compared. The diagnostic accuracy of tumor progression based on the histogram parameters of initial and follow-up MR imaging and subtracted histograms was compared and correlated with overall survival. RESULTS: Twenty-four pseudoprogressions and 11 tumor progressions were determined. Diagnosis based on the subtracted histogram mode with a multiparametric approach was more accurate than the diagnosis based on the uniparametric approach (area under the receiver operating characteristic curve of 0.877 versus 0.801), with 81.8% sensitivity and 100% specificity. A high mode of relative cerebral blood volume on the subtracted histogram by using a multiparametric approach (relative cerebral blood volume ×ADC) was the best predictor of true tumor progression (P < .001) and worse survival (P = .003). CONCLUSIONS: Multiparametric histogram analysis of posttreatment glioblastoma was useful to predict true tumor progression and worse survival.

Stem cell transcription factor NANOG controls cell migration and invasion via dysregulation of E-cadherin and FoxJ1 and contributes to adverse clinical outcome in ovarian cancers.

Ovarian cancer is the most lethal of all gynecological malignancies, and the identification of novel prognostic and therapeutic targets for ovarian cancer is crucial. It is believed that only a small subset of cancer cells are endowed with stem cell properties, which are responsible for tumor growth, metastatic progression and recurrence. NANOG is one of the key transcription factors essential for maintaining self-renewal and pluripotency in stem cells. This study investigated the role of NANOG in ovarian carcinogenesis and showed overexpression of NANOG mRNA and protein in the nucleus of ovarian cancers compared with benign ovarian lesions. Increased nuclear NANOG expression was significantly associated with high-grade cancers, serous histological subtypes, reduced chemosensitivity, and poor overall and disease-free survival. Further analysis showed NANOG is an independent prognostic factor for overall and disease-free survival. Moreover, NANOG was highly expressed in ovarian cancer cell lines with metastasis-associated property and in clinical samples of metastatic foci. Stable knockdown of NANOG impeded ovarian cancer cell proliferation, migration and invasion, which was accompanied by an increase in mRNA expression of E-cadherin, caveolin-1, FOXO1, FOXO3a, FOXJ1 and FOXB1. Conversely, ectopic NANOG overexpression enhanced ovarian cancer cell migration and invasion along with decreased E-cadherin, caveolin-1, FOXO1, FOXO3a, FOXJ1 and FOXB1 mRNA expression. Importantly, we found Nanog-mediated cell migration and invasion involved its regulation of E-cadherin and FOXJ1. This is the first report revealing the association between NANOG expression and clinical outcome of patients with ovarian cancers, suggesting NANOG to be a potential prognostic marker and therapeutic molecular target in ovarian cancer.

Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch.

OBJECTIVE: The aim of this study was to evaluate the efficacies and compare the outcomes of targeted and blind epidural blood patch (EBP) treatments of spontaneous intracranial hypotension (SIH). METHODS: Between January 1999 and December 2009, 56 patients who were diagnosed with SIH received either a targeted or blind EBP. The efficacies of targeted and blind EBPs were evaluated based on degree and duration of symptom relief and on the need for repeat EBP. RESULTS: Fifty-six patients (23 men and 33 women; mean age, 39.6 years; age range, 22-69 years) were included in this study. Thirty-one patients received EBP that targeted CSF leak segments, and 25 received a blind EBP because primary CSF leak sites were not identified (19 patients via a lumbar epidural route, mainly the L 3-4 level, regardless of primary CSF leak site, and 6 patients via upper thoracic epidural spaces, mainly the T4-6 level). In the 31 patients who received a targeted EBP, 27 (87.1%) exhibited clinical improvement after first administration. In contrast, 13 of the 25 patients (52%) who received a blind EBP via a lumbar or upper thoracic epidural route achieved complete recovery. Targeted EBPs were more effective than blind EBPs for the treatment of SIH (p < 0.05). CONCLUSIONS: EBPs targeting CSF leaks can be safely placed under fluoroscopic guidance in patients with SIH and are more likely to be effective than blindly placed EBPs.

Diagnostic dilemma of pseudoprogression in the treatment of newly diagnosed glioblastomas: the role of assessing relative cerebral blood flow volume and oxygen-6-methylguanine-DNA methyltransferase promoter methylation status.

BACKGROUND AND PURPOSE: Methylation of the MGMT gene promoter is associated with a favorable prognosis in adult patients with GBM treated with TMZ. We determined the incidence of pseudoprogression according to the MGMT methylation status and the potential value of DSC perfusion MR images for predicting pseudoprogression. MATERIALS AND METHODS: New or enlarged enhancing lesions after CCRT in adult patients with newly diagnosed GBMs were prospectively assessed by measuring their rCBV by using DSC perfusion MR images. Tumor tissue was assayed to determine MGMT promoter methylation status. All patients were regularly followed up at an interval of 2 months by MR images, including DSC perfusion MR images. RESULTS: Ninety eligible patients were enrolled in this study. After CCRT, new or enlarged enhanced lesions were found in 59 of 90 patients, which were subsequently classified as pseudoprogression (26 patients, 28.9%) and real progression (33 patients, 36.7%). Overall, there was a significant difference in the mean rCBV between pseudoprogression and real tumor progression (P = .003). The ROC curve revealed that an rCBV ratio >1.47 had an 81.5% sensitivity and a 77.8% specificity. The unmethylated MGMT promoter group had a significant difference of mean rCBV between pseudoprogression and real progression (P = .009), though the methylated MGMT promoter group had no significant difference (P = .258). CONCLUSIONS: The current study suggests that rCBV measured by DSC perfusion MR images has a differential impact on the predictability of pseudoprogression in patients with GBM.

Characteristic features of unruptured intracranial aneurysms: predictive risk factors for aneurysm rupture.

BACKGROUND AND PURPOSE: The purpose of this study was to identify the risk factors predisposing to aneurysm rupture and to provide a reliable estimation for likelihood of rupture in unruptured intracranial aneurysms. METHODS: The authors performed a nested case-control study of 290 aneurysms (123 unruptured aneurysms and 167 ruptured aneurysms) occurring during a prospective cohort study in 1493 consecutive patients with newly diagnosed intracranial aneurysm and were treated in a single institute between January 1995 and December 2006. Controls were matched for age, treatment group, number of lesion, sex, region and study period in which the incidence of ruptured and unruptured intracranial aneurysm was equivalently balanced. The authors assessed the predictive risk factors associated with aneurysmal rupture based on the clinical and angiographic findings reported in the patients' medical records. RESULTS: Between January 1997 and December 2002, 167 patients with ruptured intracranial aneurysms were assigned to group 1, and 123 patients with unruptured intracranial aneurysms during the same period were assigned to group 2. Aspect ratio (OR 3.76), maximum diameter of neck (N(max)) < or =3 mm (OR 2.56) and family history of cerebrovascular disease (OR 5.63) were strongly correlated with aneurysm rupture (p<0.05). CONCLUSIONS: There are differences between the clinical and intrinsic characteristics of patients with unruptured and ruptured intracranial aneurysm. It will be helpful to make rational decisions regarding the optimal therapeutic strategy for unruptured intracranial aneurysm.

Use of synchronous fluorescence spectra to estimate biochemical oxygen demand (BOD) of urban rivers affected by treated sewage.

Synchronous fluorescence spectra and the first derivative spectra of urban rivers affected by treated sewage were studied to find the optimum index for biochemical oxygen demand (BOD) estimation. In addition, various sample treatment methods as well as the multiple regression method using available monitoring parameters were examined to improve the BOD estimation capability of the indices. From July to November 2006, grab samples were collected from three rivers in the city of Seoul, Korea, which included one receiving effluent from a municipal wastewater treatment facility. The BOD values of the samples ranged from 0.4 to 28.0 mg l(-1). Out of the many fluorescence characteristics observed, the relative fluorescence intensity at 283 nm to 245 nm from the synchronous spectra was selected as the optimum fluorescence estimation index because it had the highest positive correlations with the BOD values (r = 0.910). The filtration process, using GF/F filter prior to the fluorescence measurement, resulted in an enhanced correlation demonstrating that the removal of suspended solids from the samples helps alleviate, to some extent, the interference of light scattering. In contrast, the same correlation was not enhanced by the pH adjustment of the sample to minimize the complexation of organic matter with cations. The multiple regression method, using either light scattering intensity at 633nm or turbidity, greatly enhanced the correlation between measured and predicted BOD values. The correlation was even higher than that obtained for filtered samples, thus suggesting that the multiple regression method based on the original sample is more effective than sample treatment in enhancing BOD estimation.

Pseudomonas fluorescens HYK0210-SK09 offers species-specific biological control of winter algal blooms caused by freshwater diatom Stephanodiscus hantzschii.

AIMS: The study of an algicidal activity and mechanism of the isolated Pseudomonas fluorescens HYK0210-SK09 (SK09) against a winter bloomed harmful diatom, Stephanodiscus hantzschii. METHODS AND RESULTS: SK09 was isolated from the Paldang reservoir, Korea and used to biological control of S. hantzschii. The inoculation of SK09 at the final density of 5 x 10(6) cells ml(-1) caused degradation of >90% of S. hantzschii cells within 5 days. The algal cell lysis was achieved by a direct attack of the bacteria to the diatom cells, and the algicidal compound was located in the cytoplasm of the cell. As SK09 did not suppress Microcystis aeruginosa, Anabaena cylindrica, Coelastrum astroideum or Cyclotella meneghiniana, it appeared to attack S. hantzschii in a species-specific manner. Testing in an indoor mesocosms confirmed that SK09 effectively reduced S. hantzschii cells by 88% within 9 days. CONCLUSIONS: This bacterium is useful in regulating blooms of S. hantzschii. However, it should be studied in the future that their impact in shaping phytoplankton community and their activity in natural environments. SIGNIFICANCE AND IMPACT OF THE STUDY: The bacterium enabled us to develop a new strategy, to understand the interaction for anthropogenic control of harmful algal blooms in nature.

Hemifacial spasm: neurovascular compressive patterns and surgical significance.

BACKGROUND: The aim of this study was to report further investigation of neurovascular compression as a cause of hemifacial spasm (HFS) and to provide useful surgical guidelines by describing the compression patterns. MATERIAL AND METHODS: From January 2004 to February 2006, 236 consecutive patients with HFS underwent microvascular decompression (MVD) in a single centre. Based on the operation and medical records, the intraoperative findings and post-operative outcomes were obtained and analysed. RESULTS: We found that 95.3% of lesions had accompanying causative factors that made the neurovascular compression inevitable. Based on the contributing factors, compression patterns were categorised into six different types including: loop (n = 11: 4.6%), arachnoid (n = 66: 27.9%), perforator (n = 58: 24.6%), branch (n = 18: 7.6%), sandwich (n = 28: 11.9%), and tandem (n = 52: 22.0%). The compression patterns were significantly correlated with the compressing vessels involved. Thirty-two (86.5%) of 37 lesions where the vertebral artery was the compressing vessel involved the tandem type. Anterior inferior cerebellar artery was the compressing vessel involved in 49 (84.5%) of 58 perforator type compressions, while posterior inferior cerebellar artery was the compressing vessel involved in 8 (72.7%) of 11 loop type compressions. CONCLUSIONS: Once the compressing vessel responsible for the neurovascular compression are identified, the probable pattern of compression can be anticipated; this knowledge could facilitate the application of the appropriate operative procedures and minimise post-operative complications.

Frequency and prognosis of delayed facial palsy after microvascular decompression for hemifacial spasm.

BACKGROUND: Microvascular decompression (MVD) for hemifacial spasm (HFS) provides a long-term cure rate. Delayed facial palsy (DFP) is not an unusual complication, but it has only been sporadically described in the literature. The purpose of this report is to evaluate the incidence of delayed facial palsy after MVD and its clinical course and final results. METHODS: From January, 1998 to April, 2004, 410 patients underwent microvascular decompression for hemifacial spasm at our Institute. During this time, 21 patients (5.4%) developed delayed facial weakness; eighteen of them were given steroid medication and they were followed up in the out-patient clinic. FINDINGS: Twenty-one patients developed DFP after microvascular decompression an incidence of 5.4%. There were seventeen women (81.0%) among the 21 patients with DFP who were included in this study. In twenty of them, the symptoms of HFS improved completely after the operation, but the spasm remained with one of them. The onset of palsy occurred between postoperative day 7 and 23 (average: 12.1 days). The palsy was at least Grade II or worse on the House-Brackmann (HB) scale. The time to recovery averaged 5.7 weeks (range: 25 days-17 weeks); 20 patients improved to complete recovery and 1 patient remained with minimal weakness, as Grade II on the HB scale, at the follow-up examination. CONCLUSION: Our findings demonstrated that the incidence of DFP was not so low as has been reported the literature, and it did not have any striking predisposing factors. Even though the degree of facial palsy was variable, almost all patients exhibited a complete recovery without any further special treatment. The etiology of DFP and its association with herpes infection should be further clarified.

Isolation and characterization of a bio-agent antagonistic to diatom, Stephanodiscus hantzschii.

AIMS: Identification of bacterium HYK0203-SK02 and its lysis of Stephanodiscus hantzschii. METHODS AND RESULTS: In an effort to identify a bio-agent capable of controlling S. hantzschii blooms, we used the algal lawn method to identify 76 bacteria in relevant water samples. Of these, the seven isolate showed algicidal activity against S. hantzschii; isolate HYK0203-SK02 exhibited the strongest algicidal activity, and was used for further analysis. 16S rDNA sequencing of this isolate allowed us to identify HYK0203-SK02 as a strain of Pseudomonas putida (99.2%). Growth of S. hantzschii was strongly suppressed by bacteria in all growth phases, with the strongest algicidal activity noted against diatoms in the exponential stage (5-18 days). Host range assays revealed that isolate HYK0203-SK02 also strongly inhibited the growth of Microcystis aeruginosa, but stimulated growth of the diatom Cyclotella sp., which has a similar structure to that of S. hantzschii. Biochemical assays revealed that the algicidal substance seemed to be localized in the cytoplasmic membrane of this newly identified algicidal bacterium. CONCLUSION: The algicidal bacteria P. putida HYK0203-SK02 caused cell lysis and death of not only diatom S. hantzschii but also cyanobacteria M. aeruginosa, dramatically. Algicidal substance might be located at the compartment of cytoplasmic membrane. SIGNIFICANCE AND IMPACT OF THE STUDY: Taken together, our results indicate that P. putida HYK0203-SK02 may be a potential bio-agent for future use in controlling freshwater diatomic blooms.

Surgical tactics and outcome of treatment in jugular foramen schwannomas.

Seven patients with schwannomas of the jugular foramen were included our study in Samsung Medical Center between 1995 and 1999. Patients with neurofibromatosis were excluded. The records of the seven patients (six surgical case and one nonsurgical case) were retrospectively reviewed. There were six women and one man (mean age, 47 years) with a symptom duration ranging from 3 months to 14 years (mean, 47 months). The predominant symptoms were hearing difficulty, hemifacial spasm and hoarseness. Preoperative audiologic evaluation, computerised tomography (CT), magnetic resonance (MR) imaging, and angiography were performed in most patients. We classified tumours into four types using Kaye and Pellet classification on the basis of radiological and surgical findings. The tumours were: Type A (at cerebellopontine angle) in one; Type B (foraminal) in two; Type C (extracranial and/or foraminal) in two; and Type D (intra- and extracranial) in two cases. We used various surgical approaches such as retrosigmoid suboccipital craniectomy for Type A tumours, infratemporal fossa type A approach (ITFA) for Type C tumours, petro-occipital transsigmoid approach or modified transcochear approach for Type D tumours and ITFA with partial labyrinthectomy for Type B. In the selection of surgical approaches, we took consideration of tumour extension, tumour size, and preoperative hearing function. Facial nerve transposition was not used only in one case of ITFA because of small tumour size (1.5cm). Gross total removal was achieved in five cases, and subtotal removal in one case (Type D tumour) with a single-stage operation. Stereotactic radiosurgery was performed on residual mass in the subtotally removed case. Follow-up period ranged from 13 to 49 months (mean, 27.5 months). There was neither postoperative mortality nor recurrence on follow-up MR imaging. There were two cases of temporary facial nerve palsy and one aggravation of pre-existing low cranial palsy. Two case of sustained vocal cord palsy underwent thyroplasty, but there was no aspiration pneumonia. Persistent cerebrospinal fluid collection was improved with lumboperitoneal shunt. The surgical approaches of each case should be tailored according to their shape and the clinical manifestation. We obtain acceptable outcomes from one-stage operation.

Psychiatric disorders in pre-schoolers.

The psychiatric disorders seen in preschoolers are reviewed. Behaviour problems are the most commonly seen. These may be due to reaction to stress, developmental problems of attachment and temperamental characteristics such as shyness and aggressiveness. Related to behavioural problems are the developmental disorders of enuresis, encopresis and constipation. The rate of behaviour problems in Singapore was found to be 7% which compares favourably with studies overseas. Disorders that have their onset in the preschool period include Attention Deficit Hyperactivity Disorder (ADHD) and Pervasive Developmental Disorders. ADHD is increasingly important because of the response to Ritalin and pervasive disorders because of the recognition that autistic states probably cover a spectrum of disorders. Aetiological factors of preschool psychiatric disorders include biological and psychosocial contribution. The latter is associated with the quality of the home environment and quality of care experienced by the child. Assessment methods include the gathering of developmental data such as the IQ and appropriate behavioural checklists. Direct observation is increasingly practised. Management methods range from drug therapy (mainly in ADHD), to traditional psychodynamic, family and behavioural therapy.

Biofeedback and stress management strategies.

The concept of stress management was reviewed in this paper. Stress was conceptualised as a perception of inability to cope with its attendant emotional and psychophysiological responses. Management of stress then has to do with altering environmental triggers where possible. Alteration to more realistic mode of perception, adoption of more adaptive means of emotional response as well as the modulation of the body's psychophysiological state through the use of various relaxation techniques would all help to reduce stress and enable the individual to cope with it. The role of biofeedback in promoting the relaxation response as well as training the individual to adapt to better means of coping was discussed. Thirty-three anxious patients who were treated with biofeedback assisted relaxation training were studied for their response on EMG reading and heart rate. Their psychosocial functioning on an experiential index also showed an improvement. It was concluded that whatever techniques are used, a multi-modal approach to stress management is probably the more effective in helping people to cope with the variety of stress faced in life.

An open clinical trial with the long-acting neuroleptics flupenthixol decanoate and fluphenazine decanoate in the maintenance treatment of schizophrenia.

An open clinical trial was carried out in 21 chronic schizophrenics to assess the effectiveness and side-effects of treatment with depot neuroleptics. All patients had been stabilized on fluphenazine decanoate for at least 6 months and on entry to the study were given the choice of continuing with this treatment or changing over to flupenthixol decanoate. Sixteen patients chose to receive flupenthixol decanoate (40 mg) and the other 5 fluphenazine decanoate (25 mg). Doses were given every 4 weeks during the 12-week study period. Clinical assessments were carried out every 4 weeks (Weeks 0, 4, 8 and 12) using the Brief Psychiatric Rating Scale and a side-effects checklist, and the Hamilton Rating Scale for Depression, the Schedule for Affected Disorders and Schizophrenia--Change Version, and the Global Assessment Scale were completed on entry (Week 0) and at the end of the study (Week 12). The results indicated that symptoms of depression, withdrawal, worrying, and psychomotor retardation were improved significantly (p less than 0.05) more with flupenthixol than with fluphenazine. The frequency of side-effects decreased during treatment with flupenthixol and there was a tendency towards fewer side-effects in the flupenthixol group than in the fluphenazine group after 8 weeks of treatment. It is concluded that a group of schizophrenic patients characterized by depressive symptoms or side-effects attributable to a prescribed neuroleptic might benefit from a switch to flupenthixol treatment.