Atypical meningioma with nodal metastasis: A case report.

INTRODUCTION: Meningiomas are common and usually benign central nervous system neoplasms. These neoplasms are graded into three groups which differ in biological behaviour. Atypical meningioma is an intermediate grade (Grade 2) tumour that is rarely associated with metastases compared to higher grade (Grade 3) meningiomas. CASE REPORT: A 68-year-old lady with a history of multiple craniotomies and hemifacial resections for meningothelial meningioma currently underwent orbital exenteration, tumour debulking and cervical nodal excision for tumour recurrence. Histopathological examination of the tumour showed atypical meningioma, with cervical nodal metastasis. DISCUSSION: This case report presents a rare finding of lymph node metastasis associated with atypical meningioma. The previous history of surgical resection is a known risk factor for metastasis for low to intermediate grade meningioma. Tumour biology and histology are predictors of metastasis. Haematogenous dissemination is the commonest route of metastasis. No standardised management protocol has been developed and the prognosis remains unknown.

The use of magnetic resonance phase-contrast cine in Chiari malformation with syringomyelia.

INTRODUCTION: Chiari malformation (CM) is a disorder of mesodermal origin and is commonly associated with syringomyelia. Foramen magnum decompression is the first-line of standard treatment in symptomatic patients with a confirmed radiographic diagnosis. Magnetic resonance (MR) cine allows accurate evaluation of cerebrospinal fluid (CSF) physiology at the craniovertebral junction but often this is under-utilised in Malaysia. METHODS: In this series, we looked into nine cases of CM with syringomyelia from clinical and radiological perspective before and after surgery. The radiological parameters were herniated tonsillar length, syrinx: cord ratio, syrinx length and diameter. Flow velocity and morphologic changes in Chiari were illustrated. RESULTS: Seven patients showed either reduction in syrinx length, syrinx: cord ratio or both postoperatively. Clinical recovery somewhat varied in motor and sensory symptoms. Four patients gained better functional grade in modified Rankin scale (MRS) while the rest remained similar. The study highlighted the advantage of CSF flow dynamics information over MR anatomical radiographic improvement in addressing the neurologic and functional recovery. We also discussed the practicality of cine sequence in preoperative patient selection, syrinx analysis and postoperative flow evaluation in anticipation of clinical outcome. CONCLUSION: Phase-contrast cine MRI is a useful tool dictated by resource availability. We recommend its routine use in preoperative analysis and subsequent observational follow-up after surgery.

Dedifferentiated endometrioid adenocarcinoma of the uterus: A case series and review of literature.

Introduction Dedifferentiated endometrioid adenocarcinoma (DEAC) was first described in 2007. However, it has only been recognised as a distinct subtype of endometrioid adenocarcinoma in the last 1-2 years. DEAC is a more aggressive histological subtype and carries a poorer prognosis. Patients with DEAC tend to present with advanced disease compared the other endometrioid adenocarcinomas. Methodology The study is a retrospective review of patients with DEAC diagnosed in two institutions in Singapore between January 2012 and October 2017. Results 7 patients were diagnosed with DEAC. The mean age was 56.4 years. All patients presented with either abnormal uterine bleeding or post menopausal bleeding. Out of the 7 patients, one was diagnosed with Stage 2 disease, 5 were diagnosed with Stage 3 disease and 1 was diagnosed with Stage 4 disease. One patient had neoadjuvant chemotherapy, followed by surgery, and completion chemotherapy post surgery. The other 6 patients (87.5%) underwent primary debulking surgery. Out of these 6 patients, 5 patients had adjuvant chemotherapy post surgery and one patient had both adjuvant chemotherapy and radiotherapy. Lymphovascular invasion was found in 71.4% of the cases. Conclusion DEAC is a more aggressive histological subtype of endometrioid adenocarcinomas. Better awareness of this condition can lead to proper diagnosis and treatment.

Comparing the outcome of monitored anaesthesia care and local anaesthesia for carpal tunnel syndrome surgery by neurosurgeons.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy of the hand, up to 90% of all nerve compression syndromes. The disease is often treated with conservative measures or surgery. The senior author initially intended to treat his own neurosurgical patients concurrently diagnosed with carpal tunnel syndrome in 2014, subsequently, he began to pick up more referrals from the primary healthcare group over the years. This has led to the setup of a peripheral and spine clinic to act as a hub of referrals. OBJECTIVE: Department of Neurosurgery Sarawak aimed to evaluate the surgical outcome of carpal tunnel release done over five years. METHODS: The carpal tunnel surgeries were done under local anaesthesia (LA) given by neurosurgeons (Bupivacaine 0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC) was later introduced by our hospital neuroanaesthetist in the beginning of 2018 (Target-controlled infusion propofol and boluses of fentanyl). We looked into our first 17 cases and compared these to the two anaesthesia techniques (LA versus MAC + LA) in terms of patient's pain score based on visual analogue scale (VAS). RESULTS: Result showed MAC provided excellent pain control during and immediately after the surgery. None experienced anaesthesia complications. There was no difference in pain control at post-operation one month. Both techniques had equal good clinical outcome during patients' clinic follow up. CONCLUSION: Neurosurgeons provide alternative route for CTS patients to receive surgical treatment. Being a designated pain free hospital, anaesthetist collaboration in carpal tunnel surgery is an added value and improves patients overall experience and satisfaction.

Evaluation of visual outcomes after toric intraocular lens implantation.

PURPOSE: To evaluate postoperative visual acuity, refractive status and rotational stability of toric intraocular lens (IOL) in correcting pre-existing corneal astigmatism. METHODS: A total of 69 patients with topographic corneal astigmatism of 1.0 Diopter (D) and above who underwent cataract surgery between June 2015 and December 2016 were included in this retrospective observational study. All preoperative toric IOL calculations were performed using immersion biometry. Appropriate formula to calculate toric IOL power was applied (SRK/T, Holladay 1 or Hoffer Q formula). All patients undergone similar uncomplicated phacoemulsification with implantation of AcrySoft IQ SN6AT toric IOL of different powers. Visual outcome, refractive status and axis of lens were evaluated at six weeks postoperatively. Ethical approval from the Ministry of Health Medical Research Ethics Committee was obtained prior to commencement of study. RESULTS: The mean refractive astigmatism decreased from 1.69 D ±1.10 (SD) to 0.81 D ± 0.40 (SD) at six weeks postoperatively. The mean postoperative spherical equivalent was at -0.37 D ±0.64 (SD). Mean LogMAR for uncorrected and corrected distance visual acuity in six weeks postoperative patients was at 0.29 ±0.16 (SD) and 0.12 ±0.12 (SD) respectively. Intraoperative to 6 weeks of postoperative comparison of IOL axis alignment showed low levels of rotation (mean 3.21 ±2.52 degrees). CONCLUSION: Cataract surgery with implantation of toric IOL was stable and effective in improving pre-existing regular corneal astigmatism.

Biphasic motion of the median nerve in the normal Asian population.

BACKGROUND: The biomechanical interaction between the median nerve and the flexor tendons is an important consideration in Carpal tunnel syndrome (CTS). We aim to quantify the displacement and compressive deformation pattern of the median nerve in various stages of finger flexion in the normal population at the inlet of the carpal tunnel. METHODS: Transverse ultrasounds images were taken at the carpal tunnel inlet during full-extension, mid-flexion and full flexion. The displacement, distance, Feret's diameter, and perimeter of the median nerve were calculated and compared between each position. RESULTS: Biphasic median nerve motion was observed, with a displacement of 2.84 ± 3.49 mm in the ulnar direction from full-extension to mid-flexion (Phase I) and a further 0.93 ± 3.04 mm from mid-flexion to full flexion (Phase II). Of 49 hands, 37 (75.5%) exhibited ulnar displacement in Phase I while 12 (24.5%) exhibited radial displacement. Feret's diameter (5.95 ± 1.08 mm) and perimeter (13.28 ± 2.09) of the median nerve were greatest in the mid-flexed position. CONCLUSION: In a healthy Asian population, the median nerve has a biphasic motion during finger flexion, with maximal deformation in the mid-flexed position.

Brain and spinal tumour.

This study reviewed the epidemiology of brain and spinal tumours in Sarawak from January 2009 till December 2012. The crude incidence of brain tumour in Sarawak was 4.6 per 100,000 population/year with cumulative rate 0.5%. Meningioma was the most common brain tumour (32.3%) and followed by astrocytoma (19.4%). Only brain metastases showed a rising trend and cases were doubled in 4 years. This accounted for 15.4% and lung carcinoma was the commonest primary. Others tumour load were consistent. Primitive neuroectodermal tumour (PNET) and astrocytoma were common in paediatrics (60%). We encountered more primary spinal tumour rather than spinal metastases. Intradural schwannoma was the commonest and frequently located at thoracic level. The current healthcare system in Sarawak enables a more consolidate data collection to reflect accurate brain tumours incidence. This advantage allows subsequent future survival outcome research and benchmarking for healthcare resource planning.

Obstructive sleep apnoea in a case of thyroglossal duct cyst carcinoma.

OBJECTIVES: To report a rare case of thyroglossal duct cyst carcinoma which presented with obstructive sleep apnoea, and to highlight the difficulties in making this clinical diagnosis. METHOD: Case report and review of the English language literature concerning thyroglossal duct cyst carcinoma. RESULTS: Thyroglossal duct cyst carcinoma is a rare clinical entity found in only approximately 1 per cent of all patients operated upon for thyroglossal duct cyst. This condition usually presents in an identical manner to its benign counterpart; atypical presentations have not previously been reported. Our patient is the first reported case of a thyroglossal duct cyst carcinoma first presenting with symptoms of obstructive sleep apnoea, without a neck mass. Complete surgical excision with total thyroidectomy and lymph node clearance was performed, in view of the positive lymph node metastases (seen on imaging) and the need for post-operative radioiodine therapy. CONCLUSION: Thyroglossal duct cyst carcinomas may present atypically, posing a diagnostic dilemma for the clinician. For patients diagnosed with obstructive sleep apnoea, it is imperative that a thorough otolaryngological examination be performed to exclude any underlying pathology.

Cloning of a Zoysia ZjLsL and its overexpression to induce axillary meristem initiation and tiller formation in Arabidopsis and bentgrass.

Zoysia grass and creeping bentgrass are important turf grasses used in parks, gardens and playing fields. Development of grasses with increased tiller formation will enhance their commercial cultivation. To investigate the regulatory mechanism of tiller formation, we cloned the Zoysia japonica Lateral suppressor-like (ZjLsL) gene. The Lateral suppressor (Ls) gene encodes a transcriptional regulator belonging to the plant-specific GRAS protein family of putative transcription factors, and regulates axillary meristem initiation. A full-length DNA of the ZjLsL gene was isolated by 5'/3' DNA walking. Phylogenetic analysis showed that ZjLsL is closely related to Ls genes. Southern blot analysis revealed that zoysia grass has two copies of the ZjLsL gene. ZjLsL expression was detected in all organs of zoysia grass but was most highly expressed in culms. Overexpression of ZjLsL in creeping bentgrass and Arabidopsis plants promoted axillary bud formation. These results suggest that ZjLsL plays an important role in axillary meristem initiation and tiller formation.

Identification of unique and common low abundance tumour-specific transcripts by suppression subtractive hybridization and oligonucleotide probe array analysis.

Most human cancers are characterized by genetic aberrations accompanied by altered expression and function of numerous genes. Applying genome-wide, microarray gene expression analysis to identify deregulated genes in different tumour types can provide potential gene candidates as diagnostic and prognostic tools and promising targets for drug development. However, the detection of deregulated genes with low levels of expression remains a major challenge. In this study, we have designed a strategy, termed modified suppression subtractive hybridization (mSSH), to identify genes encoding rare transcripts. The strategy entails incorporating the T(7)-promoter sequence at the 5' end of the noncoding cDNA strand during first strand cDNA synthesis to generate unidirectional antisense RNA from the resultant cDNA following conventional SSH. These transcripts are subsequently analysed by Affymetrix oligonucleotide gene arrays. Here, we have used five hepatocellular carcinoma (HCC), five breast carcinoma and four nasopharyngeal carcinoma (NPC) biopsies separately as testers and their corresponding normal biopsies as drivers to enrich for low abundance tumour type-specific transcripts. The total detectable number of probe sets following mSSH was reduced almost 10-fold in comparison to those detected for the same resected tumour tissues without undergoing subtraction, thus yielding a subtraction efficacy of over 90%. Using this experimental approach, we have identified 48 HCC-specific, 45 breast carcinoma-specific, and 83 NPC-specific genes. In addition, 115 genes were upregulated in all the three cancer types. When compared to gene-profiling data obtained without mSSH, the majority of these identified transcripts were of low abundance in the original cancer tissues. mSSH can therefore serve as a comprehensive molecular strategy for pursuing functional genomic studies of human cancers.

Enlarged cervical sympathetic ganglion: an unusual parapharyngeal space tumour.

Primary parapharyngeal space tumours are rare, but they pose not only diagnostic but also therapeutic challenges in head and neck surgery. Imaging studies, in particular magnetic resonance (MR) imaging, play a central role in the diagnosis of parapharyngeal space (PPS) tumours. Besides schwannomas, primary lesions arising from the sympathetic chain within the PPS are extremely rare. We describe a 49-year-old man in whom the cervical sympathetic ganglion became enlarged after radiotherapy for nasopharyngeal carcinoma, and appeared as a parapharyngeal mass. This phenomenon has not been reported in the literature. We also discuss the features of the enlarged cervical sympathetic ganglion on MR imaging.

Metastatic angiosarcoma to the thyroid.

BACKGROUND: Angiosarcoma (AS) in non-alpine areas is exceptionally rare, and so is metastatic AS to the thyroid. The difficulties and controversies associated with its diagnosis and management are highlighted in this case report. METHOD: Case report. RESULTS: A Chinese gentleman with AS metastatic to the thyroid presented a year after radiotherapy to his scalp AS. There was rapid expansion of the metastasis over 2 weeks and invasion of the pyriform fossa caused dysphagia and haemoptysis. The diagnosis was established by paraffin histology of the tumour post-hemithyroidectomy, after repeated fine-needle aspiration cytology was not diagnostic. Patient opted for external beam radiotherapy to the pyriform fossa instead of pharyngolaryngectomy. Residual pyriform tumour was treated with brachytherapy delivered via nasogastric tube. Unfortunately, the patient died 4 months later due to cardiac failure which was unrelated to his oncologic condition. CONCLUSION: AS metastatic to the thyroid is possible. The unexpectedly acute presentation and difficulties associated with diagnosis and management are highlighted. A useful method of delivering brachytherapy to the pyriform fossa is described.

Nasopharyngeal carcinoma in young patients.

Nasopharyngeal carcinoma (NPC) is rare in under 20-year-olds. Early diagnosis greatly improves survival. A retrospective review of 12 young NPC patients (seven males, five females, mean age 16 years) was performed to identify differing patient and tumour characteristics from adult NPC. Seventy-five per cent presented with neck lumps and 25% with headache. None had a family history of NPC or epistaxis. One patient had early stage NPC, and 11 had late stage NPC. Three late stage patients who received chemoradiotherapy had better clinical outcomes than six late stage patients receiving only radiotherapy. There were six deaths, five bony recurrences and one postnasal space recurrence. The 11 late stage patients' five-year actuarial survival was only 29%. Headache is an important symptom for young NPC. Late stage presentation and distant recurrences are also more common, supporting an increased role of chemotherapy.

Osmotic stress induces inactivation of photosynthesis in guard cell protoplasts of Vicia leaves.

Guard cell protoplasts isolated from Vicia leaves showed a strong suppression of the photosynthesis under hypotonic conditions, as reflected by changes in the chlorophyll fluorescence characteristics. The response was reversible as well. Mesophyll cell protoplasts did not show any lowering of photosynthetic activity under hypo-osmotic conditions. This result indicates that the response was guard cell specific.

Adverse drug reactions in patients admitted to hospital identified by discharge ICD-10 codes and by spontaneous reports.

AIMS: We studied the international classification of disease (ICD) hospital discharge codes to find unreported adverse drug reactions (ADRs), and asked doctors about their attitudes to reporting some of these cases. METHODS: We examined the ICD codes assigned on discharge to identify ADRs and compared these with spontaneous reports made to the Committee on Safety of Medicines (CSM). Doctors involved were sent brief résumés of cases and asked if they would report them. RESULTS: 49 of 21 365 patient episodes were coded on discharge as ADRs, of which 33 were 'reportable'. Fourteen spontaneous reports were received by the CSM during the same period. The two groups did not overlap. 25 of 60 doctors responded to our questionnaire, and would have reported only 8 of 75 cases outlined. CONCLUSIONS: The ICD coding allowed us to identify important ADRs which most doctors would not report spontaneously.

The suprahyoid neck: normal and pathological anatomy.

The suprahyoid neck can be divided into fascia-bound spaces. These spaces, which are readily demonstrated on computed tomography (CT) and magnetic resonance imaging (MRI), form the anatomical framework for generating differential diagnosis and assessing disease extent. By correlating the radiological features with clinical information, the diagnostic possibilities of demonstrated lesions could be narrowed down considerably. Multiple space involvement is common in inflammatory and neoplastic processes and the full extent of these lesions should be outlined to facilitate surgical or radiotherapy planning.

The pattern of nodal recurrence following definitive radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: The pattern of nodal metastasis in previously untreated nasopharyngeal carcinoma (NPC) has been studied and reported. In order to analyse the pattern of recurrent nodal disease in previously treated NPC, a retrospective study on 68 patients who underwent radical neck dissection for regionally recurrent NPC was conducted. METHODS: Seventy-four neck dissections were performed on 68 patients who developed nodal recurrence after a mean disease-free interval of 39.2 months. None of the patients had evidence of local or systemic disease at the time of surgery. Histopathological reports of the 74 neck dissections were analysed with regard to the number of positive nodes as well as the number of involved nodal levels. RESULTS: Of the 65 neck dissection specimens with analysable data, 31 showed metastatic disease at a single nodal level with a mean number of positive nodes of 1.2, while 34 showed metastatic disease at multiple levels with a mean number of positive nodes of 6.6. Nodal recurrence occurred at level II with the greatest frequency (78.5%). Of the 31 specimens with single level nodal involvement, 21 (67.7%) occurred at level II. Isolated involvement at the other levels did occur, but was uncommon (range 3-16%). Of the 34 specimens with multiple level nodal involvement, 30 (88.2%) showed involvement at level II. Once more than one level was involved, the frequency of involvement at any given level was at least 30%. CONCLUSION: The predominant involvement at level II and the high frequencies of involvement at all levels support the use of a classical radical neck dissection in treating recurrent nodal disease in NPC.

Inhibition of Blue Light-Dependent H+ Pumping by Abscisic Acid in Vicia Guard-Cell Protoplasts.

Blue-light (BL)-dependent H+ pumping in guard-cell protoplasts (GCPs) from Vicia faba was inhibited by 65% in the presence of abscisic acid (ABA). The inhibition increased with the time after application of ABA and was concentration dependent with a saturating concentration of 1 [mu]M at pH 6.2. The inhibition was nearly independent of the pH of the medium in the range 5.4 to 7.2 when ABA was applied at 10 [mu]M, whereas it was dependent on pH when the ABA concentration was decreased. The protonated form of ABA was saturating at 40 nM in inhibiting BL-dependent H+ pumping under various experimental conditions, whereas the dissociated form at 500 nM had no inhibitory effect on the pumping, suggesting that the protonated form of ABA is the form active in inhibiting the pumping. Fusicoccin (10 [mu]M), an activator of plasma membrane H+-ATPase, induced H+ pumping from GCPs, and the rate of H+ pumping was decreased to 70% by ABA. In contrast, ABA did not inhibit H+ pumping in isolated microsome vesicles from GCPs. These results suggest that the inhibition of BL-dependent H+ pumping by ABA in GCPs may be due to indirect inactivation of plasma membrane H+-ATPase and/or inhibition of the BL-signaling pathway. The pump inhibition by ABA causes membrane depolarization and can be an initial step to induce stomatal closure and reduces the transpirational water loss under drought stress in the daytime.

Properties of Proton Pumping in Response to Blue Light and Fusicoccin in Guard Cell Protoplasts Isolated from Adaxial Epidermis of Vicia Leaves.

Guard cell protoplasts (GCPs) were isolated from the adaxial epidermis of Vicia leaves. The properties of isolated adaxial GCPs (ad GCPs) were compared with those of abaxial GCPs (ab GCPs) with respect to H+-pumping activity. A saturating pulse of blue light (200 [mu]mol m-2 s-1, 30 s) induced H+ pumping in both ad GCPs and ab GCPs under red light. The maximum rate of blue-light-dependent H+ pumping was slightly higher in ad GCPs than in ab GCPs, but the magnitude of H+ pumping in ad GCPs was 68% of that in ab GCPs. H+ pumping was responsive to the second pulse, and the rate and magnitude of the pumping increased with the time between two pulses. The periods required to achieve 50% of the maximum rate were 12 and 22 min for ad GCPs and ab GCPs, respectively. The rates of blue-light-dependent H+ pumping were saturable, with half-saturation at 630 [mu]mol m-2 (21 [mu]mol m-2 s-1, 30 s) for ad GCPs and 105 [mu]mol m-2 (3.5 [mu]mol m-2 s-1, 30s) for ab GCPs. In contrast, fusicoccin, an activator of the plasma membrane H+- ATPase, induced H+ pumping with a slightly higher rate in ad GCPs than in ab GCPs. Both types of protoplast swelled similarly in response to fusicoccin. These results suggest that ad GCPs have almost the same activity for H+ pumping as ab GCPs, whereas ad GCPs require a larger number of photons to activate the H+ pump than ab GCPs.