IntroductionThe prevalence, disease progression, and treatment outcomes for patients with type 2 diabetes vary significantly between ethnic groups. The Bihari community constitutes one of the most vulnerable populations in Bangladesh on the basis of access to health services and other fundamental rights. Our study aimed at finding out the prevalence and risk factors of type 2 diabetes among the Bihari adults in Dhaka city.MethodsThis cross-sectional community-based study was carried out among stranded Pakistanis (known as Bihari) living in camps in the Mirpur area from July 2014 to June 2015. Laboratory-based oral glucose tolerance test (OGTT) was the basis for the diagnosis of type 2 diabetes mellitus (DM). Anthropometric measurements, blood pressure, biochemical tests, family history, and socioeconomic information were obtained to determine the risk factors.ResultsThe prevalence of diabetes mellitus (DM), impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) were estimated at 10.11%, 8.74%, and 4.55%, respectively. Increased diastolic blood pressure, serum triglyceride, and cholesterol level were observed to be significantly (p < 0.05) associated with diabetes. Also, the presence of diabetes, high blood pressure, and obesity among relatives significantly increased the probability of diabetes.ConclusionsTo the best of our knowledge, this is the first study on diabetes prevalence among the Bihari community in Bangladesh. The prevalence of type 2 diabetes mellitus was found to be higher among the Bihari community compared to the general population in Bangladesh. Health planners and policymakers should realize the alarming situation and identified risk factors and consider the minor ethnic groups during decision-making regarding prevention and control of diabetes and other noncommunicable diseases. Diabetes is one of the four major types of noncommunicable diseases (NCDs) that make the largest contribution to morbidity and mortality worldwide . In 2016A recent population-based study on the Santhal tribe (an ethnic group) of Bangladesh published in 2014 revealed that the prevalence of type 2 diabetes mellitus (DM) was only 0.6% and hyperglycemia (fasting plasma glucose > 5.5 mmol/l) was 10% [The Bihari people in Bangladesh, also known as non-Bangladeshi or stranded Pakistanis, are an ethnic minority, and at present over 250,000 Biharis live in 66 squalid refugee camps across the country . They arStudy designThis was a cross-sectional community-based study carried out from July 2014 to June 2015.Study settings, sample size, and study populationThe study was carried out among the Bihari communities living in the Mirpur area of Dhaka North City Corporation (DNCC). Apparently healthy adult volunteers of the seven camps  of the study area were randomly selected as study participants.The calculated sample size was 284 by considering the prevalence rate at 6.1% of type 2 diabetes mellitus among the general population of Bangladesh  and erroInclusion CriteriaPeople  aged ≥ 30 years who agreed to participate voluntarily were selected as study participants.Exclusion CriteriaSubjects aged < 30 years and not willing to participate were excluded from the study.Data collection procedureFour trained data collectors were assigned to prepare a list of eligible subjects (≥ 30 years) of the selected camps. After random selection of the participants from the camp dwellers’ list, written informed consents were taken from each individual and they were given a study-specific identification number and card. Face-to-face interviews were conducted using pretested semi-structured questionnaires, and each interview session took around 45 minutes. Nutritional status was assessed by anthropometric measurement of weight, height, hip and waist circumference. Basic information such as age, sex, educational status, occupation, family income, food intake pattern, smoking and alcohol consumption history as well as information about the various factors that affect the blood glucose level were also collected. During the interview, the participants were requested to provide a sample for measuring their blood glucose level using the oral glucose tolerance test (OGTT) and lipid profile on a specific date with clear instruction. All tests were performed in the biochemistry laboratory of the Bangladesh Institute of Health Sciences (BIHS) and the study participants were informed about the test results. The data were checked meticulously after collection to avoid errors or inconsistencies.Data analysisData analysis was performed using Stata 13 . The prevalence rate of diabetes was determined by percentage. Values were reported as the mean ± standard deviation (SD). Statistical comparisons between different groups were made using the t-test and χ² test. Logistic regression was applied to calculate the crude odds ratio and adjusted odds ratio to identify risk factors. Stepwise model selection using the Akaike information criterion (SWAIC model)  was usedOperational definitionsThe World Health Organization (WHO) 2006 criteria  were folDiabetes Mellitus (DM)It has been determined by measuring the venous plasma glucose level by OGTT at 0 minute and 120 minutes. If the 0 minute glucose level is ≥ 7.0 mmol/l and the 120 minute glucose level is ≥ 11.1 mmol/l, the person is considered as diabetic.Impaired Glucose Tolerance (IGT)It has been determined if the 0 minute glucose level is < 7.0 mmol/l and the 120 minute glucose level is between 7.8 to < 11.1 mmol/l.Impaired Fasting Glucose (IFG)When the 0 minute glucose level is 6.1 to < 7.0 mmol/l and the 120 minute glucose level is < 7.8 mmol/l.Normal Glucose Tolerance (NGT)If the 0 minute glucose level is < 6.1 mmol/l and 120 minute glucose level is < 7.8 mmol/l.EthnicityA complex multidimensional construct reflecting the confluence of the biological factors and geographical origins, culture, economic, political and legal factors, as well as racism .Anthropometric AssessmentThe measurement of the physical dimension and the gross composition of the body. In this study, the body mass index (BMI) and waist-hip ratio (WHR) have been used.Body Mass Index (BMI)It is calculated by the formula: weight in kilogram divided by height in meter squared. It helps to grade the obesity. A BMI ≥ 25 is graded as overweight.Hypertension (HTN)Defined as a systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure of ≥ 90 mm Hg.Lipid ProfileBased on the criteria described by ES Ford et al. .HypercholesterolemiaFasting venous blood cholesterol level ≥ 200 mg/dl.Triglycerides LevelFasting venous blood triglycerides level considered abnormal if it is > 150 mg/dl.Total Monthly IncomeIt includes pay and allowances drawn by the respondent plus any income from other family members.Vigorous Intensity Physical ActivitiesActivities that require hard physical effort and cause large increases in respiratory or heart rate.Moderate Intensity Physical ActivitiesActivities that require moderate physical effort and small increases in respiratory or heart-rate.Sedentary/Mild Intensity Physical ActivitiesSitting or reclining at work, at home, getting to and from places, or with friends, including time spent sitting at the desk, sitting with friends, traveling in the car, bus, train, reading, playing cards, or watching television, but not including time spent sleeping.Sociodemographic informationThe mean age of the male subjects was 47.7 years and that of the female participants was 41.8 years, whereas about 41% of the total study participants were between 30-39 years of age. There were no formal years of schooling among 85% of the participants. The types of occupation varied among the participants. Most of the male respondents (60%) were involved in business, whereas the females were mostly (61%) engaged in household activities. Monthly income ranged between Bangladeshi Taka (BDT) 5001 to 10,000 for more than half of the respondents. However, monthly income ≤ 5000 BDT constituted about 30% of the study population, which indicates low socioeconomic status  were engaged in moderate physical activities. Smoking habit among the males and females was 71% and 32%, respectively. Around 20% of the male respondents used to consume alcohol Table .Prevalence of type 2 diabetesThe overall prevalence of type 2 diabetes, impaired glucose tolerance, and impaired fasting glucose was estimated at 10.11%, 8.74%, and 4.55%, respectively. Increased diastolic blood pressure, serum triglyceride, and cholesterol level were observed to be significantly  associated with diabetes , moderate intensity activity, and use of salt in regular meals, it was observed that the presence of relatives with diabetes, high blood pressure, and obesity significantly affected the probability of type 2 diabetes Table .Differences in the prevalence, risk factors, and other adverse health conditions among specific population groups exist in type 2 diabetes mellitus throughout the world. There are multiple factors that contribute to these disparities, including biological, clinical, health system, and social factors . Our stuThere is an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life . A studyMost studies reported a twofold to sixfold increased risk of type 2 diabetes associated with a positive family history compared to a negative family history of diabetes. These estimates are consistently elevated across different study designs and in several ethnic groups . Our stuMinorities commonly live in substandard neighborhood environments with the lack of healthy food stores, lack of places to exercise, and increased psychosocial stressors related to crime or limited social cohesion that results in poor health outcomes -24. EvidAbout 41% of the respondents in our study were known to be smokers. It was alarming that 32% female participants gave the history of tobacco consumption. Although we did not find a significant association between smoking and diabetes, previous study findings showed that diabetes incidence was higher among smokers who used to smoke cigarettes ≥ two packs/day compared to those who had never smoked . ConsideThe findings of this study may not be generalizable to all ethnic communities or the whole Bihari population in Bangladesh as the data was collected only from Dhaka city. Therefore, the prevalence and risk factors for diabetes might not be similar among the other Bihari camp residents in different parts of the country. As self-reported information was collected from the patients, there might be a chance of interviewer bias and recall bias. Other limitations include small sample size, cross-sectional study design, and the lack of follow-up, though we made suggestions to the respondents with positive findings to consult with clinicians.The Bihari community constitutes one of the most vulnerable populations in Bangladesh on the basis of access to health care services and other fundamental rights. This study reveals the high prevalence of type 2 diabetes mellitus among the Bihari communities compared to the general population. Health planners and policymakers should realize the alarming situation and identified risk factors and should consider the minority ethnic groups during decision-making regarding prevention and control of diabetes and other noncommunicable diseases.


BackgroundMeningiomas follow schwannomas as the second most common cerebellopontine angle (CPA) tumors. We investigate the diagnosis, management, and prognosis of this disease.MethodsWe reviewed the cases with the CPA meningiomas in our institution in Shaanxi, China from January 2012 to December 2015. Charts were retrospectively examined and patients were divided into two groups: 1) surgical treatment with a retrosigmoid approach for tumor resection and 2) stereotactic radiosurgery treatment only. Patients were followed up and outpatient records were also reviewed.ResultsForty-nine patients underwent surgical resection via the retrosigmoid approach, while the other four underwent Gamma Knife® stereotactic radiosurgery  only. The most common presenting symptoms included hearing loss/tinnitus, vertigo, and headache; only 8.2% were asymptomatic. The largest diameter and base of each tumor varied from 4.0 to 5.5 cm and 3.0 to 5.0 cm, respectively. The tumors extended into different directions, mainly towards the tentorium and internal acoustic meatus (IAM). Eighty-three percent of surgical patients had a gross total resection. One death occurred due to pulmonary inflammation. Tumor recurrence was noted in 6.1% of patients. Postoperative trigeminal disturbance, facial nerve palsy, and hearing deterioration or loss were the most common immediate and delayed postoperative complications; most patients partially or completely recovered after hospital discharge. Intraoperative neuro-electrophysiological monitoring, complete resection, and postoperative radiation were key factors for reducing complications and recurrence.ConclusionsThe retrosigmoid approach offers an ideal visual field for exposing and resecting CPA meningiomas in a large series of cases. In our experience, it is one of the most useful and commonly used surgical approaches for removing meningiomas of this region. Cerebellopontine angle (CPA) meningiomas account for 1.5% of intracranial meningiomas and dominated 58.3%) in a series of meningiomas of the posterior skull base . Of all % in a seThough full of challenges, surgical resection remains the main strategy to cope with this disease at present. Considering the slow growth of the tumor and the possible complications secondary to intraoperative insult and damage to vital anatomical structures, such as the cranial nerves, the decision on the necessity of complete surgical resection remains critical. What’s more, meningiomas occupying the same CPA region may have quite different origins. The relative locations of the meningiomas to the surrounding crucial organs determine whether surgical resection or conservative management is favored. Postoperatively, how additional non-surgical treatments assist in the prevention of recurrence is also important. As the knowledge related to the clinical anatomy of the skull base increases, more surgical approaches for CPA meningiomas have been developed and widely applied. Similar to other intracranial tumors, the indications for surgery alone or combining with adjuncts, such as radiation therapy, also need to be carefully balanced by the neurosurgical team. Without a doubt, these considerations will be universal to all intracranial meningiomas, and even other benign tumors.This study analyzes the surgical results from a group of patients with initial radiographic diagnoses of CPA meningioma, confirmed by postoperative pathologies. A retrosigmoid approach was used in all surgical cases. Clinical parameters, such as symptoms/syndromes, radiographic characteristics, surgical strategies, and other comprehensive treatments, were also investigated to obtain insight into the factors that affect prognosis.Patient populationThis study was approved by the Ethics Committee of Xijing Hospital, Fourth Military Medical University. Patient consents were waived. All the radiographic imaging studies, including magnetic resonance imagings (MRIs), were reviewed by independent radiologists. Patients with bilateral meningiomas were excluded for the purity of the sample. A total of 53 patients, consecutively admitted to Xijing Hospital, Fourth Military Medical University from January 2012 to December 2015 with an initial radiographic diagnosis of CPA meningioma, were included in this study . An “S”-shaped scalp incision about 8 - 10 cm was made behind the ear. The incision was long enough to allow an ideal craniotomy to obtain a large bone flap. In order to get the largest exposure for the convenience of surgery, the mastoid air cells were opened and the sigmoid sinus was partially exposed. Sealing air cells with bone wax helped to avoid postoperative leakage of cerebrospinal fluid (CSF). The dura was incised in a radial fashion and the cerebellar hemisphere was gently retracted to expose and open the cerebellomedullary cistern. The CSF was released in a great degree to ensure a wider operative space. A serpentine retractor was used to get a stable operative window. Difficult exposures were encountered in three patients who had large tumors (> 5 cm) due to intraoperative cerebellar protrusion and the lateral one-third of the cerebellar hemispheres on the tumor side were removed. Ventricular puncture and CSF drainage were performed before craniotomy in two cases who demonstrated severe obstructive hydrocephalus and evidence of chronic foramen magnum herniation. Preoperatively, 26 cases were analyzed angiographically for the assistance of predicting tumor attachments. The tumors were debulked in a piecemeal fashion under an operative microscope. Coagulating and carbonizing the tumor tissues fruited bloodless resection. Ultrasonic aspiration (USA) was applied in 19 cases to ease the operative process when fragmentation, emulsification, and aspiration of soft and firm tumor tissue were desirable intraoperatively.Neuroelectrophysiological monitoringNeuroelectrophysiological monitoring  of the cranial nerves and brainstem functions included spontaneous electromyogram for cranial nerve V , evoked electromyogram for facial nerve CN VII, spontaneous electromyogram for accessory nerve CN XI, and brainstem auditory evoked potential (BAEP). An alarm would notify the surgeons if these nerves and brainstem were disturbed during intraoperative retracting, bisecting, or tumor resection. If an alarm was triggered, the ongoing manipulation would be halted immediately until the neuroelectrophysiological monitoring confirmed the nerves to be stable.Stereotactic radiosurgeryGamma Knife® stereotactic radiosurgery  was utilized for either a treatment for small, asymptomatic CPA meningiomas or as a prevention of recurrence postoperatively. The radiation doses of 12-15 Gy were applied depending on the volumes of the target .Data accumulation and statistical analysisDetailed clinical materials were obtained from the clinical data bank in our hospital. The data, collected by complying with national laws on ethics, was summarized and processed using the Statistical Package for Social Sciences (SPSS)  software. Non-parametrical tests were performed with statistically significant differences defined as p value < 0.05.Demographic informationWithin this series of 53 cases, 49 underwent surgical resection and the other four were treated with stereotactic radiotherapy (Gamma Knife) based on the sizes of the tumors (< 2 cm diameter). The clinical characteristics of the population are listed in Table Tumor extension and originBesides dominating mainly the posterior aspect of the petrous part of the temporal bone, the meningiomas also extended into other directions, including the tentorium (32/53), internal acoustic meatus (IAM) (16/53), clivus (8/53), jugular foramen (3/53), and cavernous sinus (3/53). Ten cases involved tumors with extensions in two or more directions. Among all operated patients, enhanced magnetic resonance imaging (MRI) revealed the largest diameter and base varying from 4 to 5.5 cm and 3.0 to 5.0 cm, respectively. There were 28 cases with left CPA meningioma and 21 cases with right-sided CPA meningioma. Three patients presented with a meningioma with the largest diameter over 5 cm and obstructive hydrocephalus. According to computerized tomography (CT) window data, 14 patients had a dilated IAM with an opening of 1 to 2 cm, and 32 had reactive thickening of the petrous bone.Three types of relationships were observed between the tumor and dura: attached but not adhered, tightly adhered but easily separated, and invading with impaired dura. The last was considered to indicate the origin of the meningioma. In this surgical group, the tumor originated from the petrous part of the temporal bone in 42 patients , on the IAM in three, and on the cerebellar tentorium in four . Preoperative radiographic examination served as an invaluable guide in the intraoperative identification of the tumor origin  of the cranial nerves and brainstem functions was performed in 40 cases where the tumors were of close locations to the CNs. There were 21 patients who had abnormal electrophysiological changes to CN V, 29 patients to CN VII, and five patients to CN XI. Anatomical preservation of the trigeminal nerve (CN V) was achieved in 47 patients, accounting for 95.9% of the total cases , 12 had facial nerve palsy (24.5%), 29 had hearing deterioration or loss (59.2%), and 10 had dysphagia and cough weakness (20.4%). Though not totally disappeared, these symptoms resolved to different degrees after discharge (10 to 20 days following admission). In this series, one death occurred due to aspiration pneumonia, which might be the result of functional deterioration of either CN IX, CN X, or CN XII. Thus, the mortality rate of all was 2.0% (1/53). No case of CSF leakage was observed in this series.Of the 12 who had facial nerve palsy, five had House-Brackmann (HB) Grade 2 facial nerve palsy and recovered to Grade 1  within 20 days. Four had HB Grade 3 facial nerve palsy and recovered to Grade 2 within three weeks and recovered to Grade 1 at the three to six-month follow-up. Three patients had HB Grade 4-5 facial nerve dysfunction and recovered to Grade 3 at the six-month follow-up.Additional treatmentsIn this clinical series, Leksell Gamma Knife stereotactic radiosurgery was used as an important adjunct for the purpose of reducing postoperative recurrences and morbidities. This adjunct therapy was used in patients who had tumor invasion of the bone or extended dura, five patients who had an intraoperative residual tumor < 1.5 cm in diameter, and in 27 patients after total removal Figure . It was Follow-upDespite the aforementioned single mortality, 52 patients were successfully discharged. Forty patients (81.6% of the whole series) achieved postoperative follow-up from six to 42 months. The four cases treated with radiation were followed up for 25 to 34 months. Detailed follow-up was accomplished in 39 cases with a duration of three to 34 months (average: 24.5 months). The follow-up demonstrated a 98.1% survival rate (51/52) with one patient deceased from a non-operative cause (traffic accident). Three cases complained of facial numbness, five had mild hemifacial paralysis (HB Grade 2), 18 had hearing deterioration, two had hearing loss, and four had mild dysfunction of CN IX, CN X, and CN XI. Two cases with tumor pathologically classified as CPA meningioma WHO Grade II  radiographically recurred, respectively, at the two and 2.5-year follow-ups despite early postoperative Gamma Knife intervention. One other patient with a pathological diagnosis of mixed tumor (WHO Grade I), who had no postoperative radiation, had a tumor recurrence 2.6 years later with the presentations of headache and gait instability. The other patients with small residuals had no tumor regrowth at the 34-month follow-up. Based on the high progression-free survival rate (approaching 100%), the Kaplan-Meier curve was not generated.Analysis of the clinical presentations of the CPA meningiomasCPA meningiomas often present with complicated symptoms. Common early symptoms, including hearing loss/tinnitus, headache, and vertigo, are often neglected by the patients. Inquiring about the early symptoms is crucial for evaluating the tumor origin. In this series, with an average duration of 19.4 months from the onset of initial symptoms to admission, early symptoms included hearing loss/tinnitus, vertigo, headache, gait instability, extremity numbness/weakness, facial pain/numbness, nausea/vomiting, facial palsy, hemifacial spasm, throat discomfort, swallowing disorder, and ptosis . Among these, hearing disturbance, vertigo, and headache were the three most commonly seen complaints with occurrences of 42.9%, 40.8%, and 38.8%, respectively. A previous study reported that patients with CPA meningioma mainly complained of unsteadiness 54%), hearing loss (52%), vertigo (35%), and tinnitus (23%) [4%, heariSurgical strategy optionsBecause of the small sizes at early stages and slow growth, CPA meningiomas usually cause no apparent symptoms or neurologic deficits. Within this population, non-surgical interventions instead of radical operations should be first considered. In our group, four cases with the tumor size < 2 cm were treated with Gamma Knife stereotactic radiotherapy. They developed no indications for advanced surgical intervention in the follow-up periods (up to 25-34 months). MRIs revealed evidence of tumor shrinkage in some three out of the four cases Figure . ClinicaWe want to emphasize that the retrosigmoid approach used in our series is perhaps one of the most commonly used surgical approaches for removing CPA meningiomas. However, in deciding which surgical approach is the best, considerations need to be given to tumor invasion of the cavernous sinus, to their expansion to the IAM, to their tentorial attachment, and to their forward expansion towards the jugular foramen -6. The cAlthough the meningiomas in this series were of various pathological subtypes and different sensitivities to radiation, subtotal or partial tumor removal for the protection of the cranial nerves and brainstem was possible. Jeopardizing a patient’s quality of life for the sake of total removal is not worthwhile. A small residual tumor could be well controlled via conservative treatments, such as radiotherapy. However, it should be emphasized that CPA meningiomas with WHO Grade II or higher levels of morphological evidence have a higher risk of recurrence in a relatively shorter period of time. Gross total resection is extremely important for these patients, and postoperative radiation should not be neglected.Among the three patients who developed recurring tumors after the operation, two were confirmed pathologically as WHO Grade II  and one was a WHO Grade I (mixed subtype). Even though the former two patients received stereotactic radiation treatment early postoperatively, the tumors recurred in less than three years in accordance with the strong biological activities. Hardesty, et al.  did a reThe surgeon’s choice of surgical approach depends mainly on the characteristics of the tumor, and his/her personal preferences. In this series, the retrosigmoid approach was chosen based on our understanding of the following parameters: tumor origin, growth direction, form and size, and the main symptoms and syndromes indicative of the invaded vital structures. Most neurosurgeons prefer a single approach, while others use certain combinations of the following approaches: retrosigmoid, transpetrosal, and transcochlear approaches. Leonetti, et al. reported a series of 29 patients with large CPA meningiomas (> 3 cm) treated surgically using a combined retrosigmoid-transpetrosal-transcochlear approach . This coSurgical techniquesGenerally, CPA meningiomas grow along the posterior aspect of the petrous part of the temporal bone in various directions and even extend into the cavernous sinus and the middle cranial fossa. However, the interface to which the tumor tightly adheres was often observed at the posterior surface of the petrous bone (from the tip to the root) in 85.7% of our cases, at the internal acoustic meatus in 6.1% of cases, and at the tentorium in 8.2% of cases. The fact that the majority of CPA meningiomas have originated from the posterior surface of the petrous bone provided a valuable clue for surgical separation. The first step for this kind of operation was to cut the blood supply to the tumor at its base using a bipolar electric coagulator, thus making it easier to separate the tumor from its base. After the tumor base—the most vascularized attachment (MVA)—had been well controlled, it was easier to separate the tumor body from the surrounding tissues because of its relatively loose connections therein.Although difficult, there are many ways to distinguish the MVA from other contact surfaces. Based on operative findings from 34 consecutive patients with CPA meningiomas, Kunii, et al.  classifiIn order to reduce retraction injuries, a “piece by piece” method for removing the tumor under an operative microscope should be employed. The strategy requires that the tumor tissues be coagulated and even carbonized in advance, with an aim of obtaining tumor shrinkage and then bloodless resection. A cavitron ultrasonic surgical aspirator (CUSA®)  was convenient for removing deep parts of CPA meningiomas. In our group of 49 cases, total removal was achieved in 41 83.7%), subtotal in six (12.2%), and partial in two (4.1%). In another study, total removal was reported in 19 of 29 patients (67%) [3.7%, subPreservation of cranial nervesCPA meningiomas are usually found to arise from cells lining the arachnoid villi, which are occasionally observed close to nerve roots and their foramina, such as the IAM, compared with their predominant location adjacent to the dural sinuses. In our experiences, although the meningiomas tend to more loosely adhere to these often-inflicted cranial nerves  than acoustic neuromas are, separating them from cranial nerves is still challenging, especially when the tumor is located close to the foramina where the nerves enter or exit.The trigeminal, facial, acoustic, and accessory nerves were among those usually monitored during operations. Considering the slow growth of meningiomas and for the purpose of protecting and preserving the cranial nerves to the best of our abilities, we left a small part of the tumors untouched  in some cases, which were later treated with additional managements  or staged operations. In the present group with intraoperative monitoring by neuroelectrophysiological techniques, 93.9% of cases (46/49) had anatomical preservation of the inflicted CN V, CN VII, and CN VIII. Although postoperatively, the functional status of these nerves initially revealed a disturbance to different degrees, each gradually recovered to a satisfactory level in 10 or more days. One patient (aged 64) suffered a severe disturbance postoperatively in the function of his posterior CN’s and later died of pulmonary inflammation. The part of the CPA meningioma compressing and adhering to the posterior CNs should be intentionally left behind to keep the nerves’ functions intact. Postoperative stereotactic radiosurgery can be a good remedial measure. Kane, et al. adopted a retrosigmoid approach for 22 cases with CPA meningioma and observed that 13 had an internal auditory canal (IAC) extension . IAC driNeuroelectrophysiological monitoringIn the majority of cases, because of various tumor extensions, several cranial nerves (CN V through CN XI) were at risk of being touched, shifted, or even compressed, potentially leading to a variety of symptoms and syndromes. The facial nerve was most frequently involved in surgical complications, followed by the trigeminal and accessory nerves. In many instances, the facial nerve was torn in order to partially or completely disconnect the tumor from its surroundings. A small residual was permitted for protecting the functions of the CNs and brainstem. Intraoperative neuroelectrophysiological monitoring provided neurosurgeons with ongoing feedback regarding the cranial nerves. Warning signals from neuroelectrophysiological monitoring were immediately heeded since even anatomical preservation of the CNs did not guarantee intact functions. Due to certain practical problems, not all CN’s were monitored intraoperatively. In one case of this series, the abducens nerve was clearly exposed and confirmed to be intact after being separated from the tumor but ended up functionally impaired postoperatively Figure . In thisRemedial measuresBecause of the possible complications following surgical manipulation, cautions should be exercised when choosing to operate on a tumor of small size or to perform a complete removal of a small-sized residual. The difficulty and danger arise during surgery of a tumor involving the dura anterior to the IAM, in comparison with the treatment of the part posterior to the IAM . Under tThe meningotheliomatous meningioma was the main subtype in this series, dominating 59.2% (29/49) of the whole group. Another 22.5% (12/49) had a fibrous subtype. The other eight cases  exhibited transitional (3/49), angiomatous (1/49), syncytial (1/49), mixed (1/49), clear (1/49), and atypical (1/49) subtypes. Our follow-up suggested that there was a greater tendency for recurrence in less than three years with subtypes of clear, atypical, and mixed, even though two Grade II patients received postoperative Gamma Knife stereotactic radiosurgical intervention early. The recurrence rate in our series was 6.1% (3/49). The clear, atypical subtypes are classified as WHO Grade II, and the mixed type is classified as WHO Grade I. Hence, the biological characteristics were in accordance with the recurrence. Clear cell meningiomas (CCM), a rare histological subtype of meningioma, have a high recurrence rate and aggressiveness. A study with a series of 15 patients harboring intracranial CCM (mainly located at the CPA) demonstrated that immunohistochemistry played a vital role in differentiating CCM from other tumors. Brain invasion, atypia, and MIB-1 labeling index were likely to predict the recurrence. The extent of resection could be associated with the prognosis as well . An extrIn one case, stereotactic radiosurgery was reported to be effective for treating CPA meningioma . An oldeReinert, et al. analyzed a total of 201 operated cases with an intracranial meningioma with diameters ≤ 3 cm. According to tumor locations, patients were classified as group I , group II , and group III  . RadicalLimitationsWe recognize that this study is limited by the inherent problem of a retrospective analysis. In addition, every surgeon's experience and technique skills vary, influencing the outcomes of the patients.In this study, we reviewed a large sample size of 53 patients with CPA meningioma. Though generally considered as a big challenge to resect tumors at this location, retrosigmoid approach yielded satisfactory results with an excellent extension of resection, preservation of cranial nerves, and low complication rates in our institution. Meanwhile, stereotactic radiation therapy can be used as an adjunct for small or high-grade tumors. Thus, we advocate this approach for CPA meningiomas that are surgically resectable.


Deaf children who receive a cochlear implant early in life and engage in intensive oral/aural therapy often make great strides in spoken language acquisition. However, despite clinicians’ best efforts, there is a great deal of variability in language outcomes. One concern is that cortical regions which normally support auditory processing may become reorganized for visual function, leaving fewer available resources for auditory language acquisition. The conditions under which these changes occur are not well understood, but we may begin investigating this phenomenon by looking for interactions between auditory and visual evoked cortical potentials in deaf children. If children with abnormal auditory responses show increased sensitivity to visual stimuli, this may indicate the presence of maladaptive cortical plasticity. We recorded evoked potentials, using both auditory and visual paradigms, from 25 typical hearing children and 26 deaf children (ages 2–8 years) with cochlear implants. An auditory oddball paradigm was used (85% /ba/ syllables vs. 15% frequency modulated tone sweeps) to elicit an auditory P1 component. Visual evoked potentials (VEPs) were recorded during presentation of an intermittent peripheral radial checkerboard while children watched a silent cartoon, eliciting a P1–N1 response. We observed reduced auditory P1 amplitudes and a lack of latency shift associated with normative aging in our deaf sample. We also observed shorter latencies in N1 VEPs to visual stimulus offset in deaf participants. While these data demonstrate cortical changes associated with auditory deprivation, we did not find evidence for a relationship between cortical auditory evoked potentials and the VEPs. This is consistent with descriptions of intra-modal plasticity within visual systems of deaf children, but do not provide evidence for cross-modal plasticity. In addition, we note that sign language experience had no effect on deaf children’s early auditory and visual ERP responses. Congenital deafness leads to significant language delays in children acquiring spoken language. Cascading effects of impoverished linguistic knowledge impact a wide range of psychological and cognitive behaviors including self-regulation , workingThe interplay of factors contributing to this lack of success is poorly understood . One incEarly studies of animal models of deafness provide evidence supporting the idea that CMP is present in humans . For exaRecent work has reported evidence of CMP in pre- and post-lingually deaf adults with CIs which has been suggested to be maladaptive. In studies that have reported maladaptive CMP, the research often makes use of a neural marker of visual processing , and relates this signal to a behavioral processing deficit such as identification of speech in noise . The infThere are several weaknesses in this line of reasoning, the foremost of which is that a high-level auditory function like the recognition of words is a multi-component process that encompasses many distinct processing stages. This involves not only fundamental elements of acoustic processing, but mechanisms of speech segmentation, phonemic identification, and lexical recognition, as well as other cognitive properties such as attention to the stimuli, and in the context of multi-modal testing, integration of visual speech information. Thus behavioral performance draws on many cognitive systems that extend beyond the function of primary auditory cortex alone.A second weakness is that the methods that are used to assert that auditory cortex capabilities have been usurped by visual processing rely on source localization of ERP signals such as sLORETA . Such meFurthermore, few published studies have directly evaluated physiological measures of auditory and visual function in a pediatric population with congenital deafness. The use of pediatric populations is especially important as children in their formative years of language development may be at greatest risk of developing maladaptive CMP. This also highlights the active role of the language acquisition process, as the question has been raised as to whether language input itself may play a role in maladaptive CMP. For instance, The present study addresses these concerns by collecting both auditory and visual evoked potentials (VEPs) in a pediatric population in the early and middle stages of language development, including children exposed to sign language and those enrolled in aural/oral-only programs. We begin with an experiment designed to elicit a cortical auditory evoked potential, the auditory P1, which has been described as biomarker of primary auditory cortex development in deafness . Next, w = 4.10), who received CIs, served as subjects. Twenty-five normally hearing children, ages 2.4–8.3 years ( = 5.2), served as controls. Table 1 presents the subject characteristics and demographics of the deaf children involved in the present study. Shown in Table 1 is the child’s age at time of testing, age of first implant (in days) , gender, cochlear implant(s) , time in sound (in days for the first implant) , and language inventory scores (spoken and sign language production). Auditory data from two subjects (S13 and S22) was corrupted and therefore not used in the analysis of the auditory results.Twenty-six congenitally deaf children with severe-to-profound sensorineural hearing loss, ages 2.0–8.5 years  while auditory stimuli were presented.Auditory stimuli were presented in an oddball paradigm designed to elicit a P1 cortical auditory evoked potential. The stimuli consisted of either a synthesized speech syllable (/ba/) which served as a standard (85%) or a frequency modulated tone (600–1200 Hz) which served as a deviant (15%), both of which were 100 ms in duration. Auditory stimuli were presented free-field at 65 db for deaf children and 60 db for hearing controls using AUVIO 05A13 speakers located approximately 45° degrees to left and right of the subject and powered by a NuForce Icon amplifier driven by the laptop’s audio output. Stimuli presentation was jittered between 2 and 4 s to reduce expectancies. A total of 202 trials per subject were presented, lasting approximately 4.5 min.ERPs were collected using a Biosemi Active Two recording system . Recordings were taken at 22 electrode sites, using standard 10/20 system. Three additional external electrodes were used to record data from left and right mastoids and the third was placed below the left eye to monitor eye movements. The eye electrode was used to assist in eliminating trials where blinks or horizontal eye movements occurred and trials where participants were looking away. Voltage offsets between each active electrode and CMS (common mode sense -the online reference) were below 20 μV, before the start of data collection. Offsets were checked again at the end of the recording session.SD 10.85) of deaf subjects trials were rejected, while 15.07%  of hearing children’s trials were rejected. T-test indicated that the numbers of auditory trails rejected across groups did not differ . For visual data 10.72%  of deaf subjects trials were rejected, while 8.6%  of hearing children’s trials were rejected. T-test indicated that the number of visual trails rejected across groups did not differ .Sampling rate during recording was 512 Hz. Oﬄine, continuous data was downsampled to 256 Hz, and bandpass filtered at 0.1–30 Hz. Data from scalp and eye electrodes were re-referenced oﬄine to the average of left and right mastoids. Initial analysis of the EEG data was performed using the ERPLAB plugin  for EEGLAuditory data was collected with CIs functioning. In 11 children with CI, we were unable to establish contact at lateral temporal or parietal sites due to the location of the implanted receiver/stimulator. In these cases, we eliminated the affected channels prior to data analysis. ICA analysis was used to remove CI artifact from the deaf participant data. Between 1 and 5 components per subject were removed in auditory data set. Auditory data reported here represent responses only to the standard /ba/ stimuli. For all analysis, automatic peak detection [most positive (P1) or negative peak (N1)] was taken using ERPLAB’s, ERP measurement tool .post hoc testing, better modeling where assumptions of sphericity are violated , and analyses that are robust in cases with missing data and where cells are not completely balanced  random intercepts.All models were initially estimated with the maximum available fixed effects structure with factors iteratively assessed for significance. Individual factors were removed by excluding the factor with the lowest Figure 1). This morphology is consistent with cortical auditory evoked potential P1–N1 complex. Deaf children showed more variable responses both in latency and in waveform morphology. To quantify the observed patterns across groups we measured both peak amplitude and latency of the most positive peak between 70 and 175 ms at frontal midlines sites Fz and Cz for all subjects.In control subjects, the electrophysiological response to auditory standards produced a positive peak between 100 and 200 ms, followed by a negative peak around 300 ms post stimulus. This was most prominent over fronto-central sites . This effect is illustrated in Figure 1. No other factors were significant.A main effect of Group indicated that hearing controls showed a larger P1 compared to the deaf children with CIs  and a significant Age × Group Interaction . The Age × Group interaction is depicted in Figure 2. The scatter plot shows that while hearing children show expected age-related changes (latencies decrease with age), this pattern is not observed in the deaf children with CIs . No other factors were significant.We observed a main effect of Age .Following participation in the passive auditory task, subjects watched a silent cartoon presented in the middle of the screen against a dark gray background. A radial black and white checkerboard  intermittently replaced the background and lasted for 2, 3, or 4 s. There were a total of 60 trials, which lasted approximately 6 min. This peripheral visual stimulus was designed to elicit a pattern-onset and a pattern-offset VEP. Based on previous reports of differences between deaf and hearing subjects observed during visual processing we focused on the expression of the P1 and N1 visual components .EEG procedures and analysis are identical to that of Experiment 1.Post hoc testing used Tukey’s HSD, corrected for multiple comparisons, implemented by the lsmeans package , Group, Age, and Gender, as well as by-subject and by-site  random effects.  package  in R.Figures 3 and 4). To quantify observed VEP differences we examined the window of 70–200 ms post stimulus to characterize effects related to the P1 component. The window of measurement used for the N1 was 175–325 ms. Analysis of the visual data included posterior electrode sites O1, O2, Pz, and fronto-central sites Cz and Fz.Visual inspection of the data revealed a P1, peaking at approximately 165 ms followed by an N1, peaking about 250 ms, in both onset and offset of the checkerboard pattern. The effects were most robust at posterior parietal and occipital sites (Automatic peak detection [most positive (P1) or negative peak (N1)] was taken using ERPLAB’s measurement tool .t = -2.58, p = 0.01; Hearing:  onsets = 8.83 μV,  offsets = 6.55 μV; Deaf:  onsets = 7.88 μV,  offsets = 7.26 μV).Examining data from the visual VEP responses we find a main effect of Pattern, showing overall larger responses to pattern onsets than offsets  or offset amplitude .No other factors were significant predictors of P1 amplitude, and t = -1.18, p = 0.24; Hearing:  onsets = 144.47 ms,  offset = 140.59 ms; Deaf:  onsets = 143.55 ms,  offsets = 144.35 ms). Post hoc testing revealed no significant differences between Group for pattern offset  or onset latencies  .Looking at P1 latencies, we find no significant differences between onset and offset within Groups . Post hoc testing showed no significant amplitude difference between Groups for either onsets  or offsets .Examining visual N1 amplitude, we observed a trend in Pattern which showed that N1 was larger to offset relative to onset in both groups . A significant Pattern × Group interaction  showed that in deaf subjects, offset latencies were shorter than onset latencies . Post hoc testing further revealed a significant Group difference for offset latencies , but not onsets . These differences are illustrated in Figure 5, right panel.Assessment of N1 latency showed a significant difference in Pattern for the control group with offset latencies longer than onset latencies . A post hoc analysis using Pearson’s product-moment correlation provides further confirmation of the lack of relationship between auditory and visual latencies observed in deaf subjects at site O2  and at site Cz . However, in hearing subjects, a significant correlation between auditory and visual latencies is observed at Cz , but not O2 . These differences are illustrated in Figure In evaluating these models, no significant effects beyond those already discussed were observed , Age of Implantation , and Time in Sound (measured by days since implantation).We constructed two new models using only the deaf CI data, and modeled auditory P1  and visual N1 response latencies  with factors for Age, Gender, Signs and Words Produced (derived from our modified MacArthur inventories), Age of Implantation , and Time in Sound (measured by days since implantation). Measures of language production, as well as age of implantation, and time in sound, were highly correlated with chronological age. To avoid colinearities in the data, these were each residualized against Age. Both models also included random effects for subject and site, as in previous analyses.p-values were >0.25).We found no differences in response latencies as a function of language exposure, signs produced, words produced, age of implantation, or time in sound, in either of the latency models  and central site (Cz) showed no systematic relationship between evoked-potential latencies across these two sensory domains in the deaf subjects. We observed that variability associated with auditory P1 latencies was not effectively modulated by a high-contrast visual pattern in deaf children. Our data would indicate that auditory cortex does not become responsive to the low level visual signals induced by the stimuli used here as a result of early auditory deprivation in children who have received a cochlear implant early in life. The lack of a trade-off between auditory and visual processing at this level accords with physiological data from deaf cats that show functional changes in visual processing does not come at the cost of auditory function . These dIt is interesting to note that we did observe a relationship between auditory P1 latencies and visual N1 latencies recorded at central site Cz but not at occipital site O2 for the hearing children. These data may reflect a coupling between auditory and visual sensory systems that is present in typically developing hearing children that is not observed in the deaf children. Further work is needed to understand the development and scope of such interactions.Finally, we assessed whether the observed latency differences in the auditory P1 and visual N1 components were affected by early exposure to a signed language, age at first implantation, or time since implantation. None of these factors were shown to influence auditory P1 or visual N1 latencies. We especially note that we observed no differences in the auditory and visual responses of deaf children who have been exposed to sign language and those who have elected an oral-based rehabilitative strategy. These data directly challenge claims that exposure to a visual language in the formative stages of language acquisition in deaf children with CIs locks the language system into a vision-only configuration that prevents possible future acquisition of auditory language .Statements involving human subjects. This study was carried out in accordance with the recommendations of UC Davis Human Subject Institutional Review Board following the Human Research Protection Program Plan. The protocol was approved by the Human Subject Institutional Review Board. Written informed consent was acquired from the parents of all subjects prior to beginning the experiment. This study involved hearing and deaf children 2–8 years old. Parents were informed that they could stop testing at any time and their children were not required to participate. All subjects gave written informed consent in accordance with the Declaration of Helsinki.DC and SC-C designed the experiment. TL and SB created in-house behavioral measures. DC, SC-C, TL, and SB collected the data. LL did the statistical analysis of the data. SC-C analyzed the ERP data. DC, SC-C, and LL drafted the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The absence of major progress in the treatment of glioblastoma (GBM) is partly attributable to our poor understanding of both GBM tumor biology and the acquirement of treatment resistance in recurrent GBMs. Recurrent GBMs are characterized by their resistance to radiation. In this study, we used an established stable U87 radioresistant GBM model and total RNA sequencing to shed light on global mRNA expression changes following irradiation. We identified many genes, the expressions of which were altered in our radioresistant GBM model, that have never before been reported to be associated with the development of radioresistant GBM and should be concertedly further investigated to understand their roles in radioresistance. These genes were enriched in various biological processes such as inflammatory response, cell migration, positive regulation of epithelial to mesenchymal transition, angiogenesis, apoptosis, positive regulation of T-cell migration, positive regulation of macrophage chemotaxis, T-cell antigen processing and presentation, and microglial cell activation involved in immune response genes. These findings furnish crucial information for elucidating the molecular mechanisms associated with radioresistance in GBM. Therapeutically, with the global alterations of multiple biological pathways observed in irradiated GBM cells, an effective GBM therapy may require a cocktail carrying multiple agents targeting multiple implicated pathways in order to have a chance at making a substantial impact on improving the overall GBM survival. ASAH1) and sphingosine-1-phosphate (S1P) [ASAH1 is a lysosomal cysteine amidase that converts ceramides, which trigger senescence and apoptosis, into sphingosine and free fatty acids [SPHK1) or 2 (SPHK2) to form a tumor promoter, S1P [Glioblastoma (GBM), with an overall survival of less than 1.5 years and a 5-year survival rate of 5%, is the most common, malignant primary cancer of the central nervous system in adults, with an estimated 12,120 new diagnoses in the United States alone in 2016 . The curte (S1P) , 9. ASAHty acids –17. Subster, S1P –15. HoweRNA sequencing (RNA-seq) has become a powerful technique for transcriptome profiling of cell lines of interest to explain phenotypic variations , 19. ThiP < 0.05) as criteria, we identified 1094 radiation responsive genes that were upregulated or downregulated in U87-10gy vs U87 cells. Among these 1094 radiation responsive genes, 427 were upregulated and 667 were downregulated , between mRNA and protein expressions [A previous study of our recently described radioresistant GBM model revealed that radiation-induced accumulation of the adiation , 9. Howeressions , 58–62. ressions , 59, 60.Therapeutically, with the global alterations of multiple biological pathways observed in irradiated GBM cells, an effective GBM therapy may require a cocktail carrying multiple agents targeting multiple implicated pathways in order to have a chance at making a substantial impact on improving the overall GBM survival. These findings of aberrantly expressed mRNAs following irradiation provide a crucial comprehensive starting point to understand the complex mechanism of radioresistance in GBM, and should be combined with immunoblotting or other techniques of direct measurement of protein levels to supply a more accurate picture of how cells can be altered to be radioresistant. Many mRNAs, whose expressions were altered in our radioresistant GBM model, have never before been reported to be associated with the development of radioresistant GBM and should be further investigated to understand their roles in radioresistance.The absence of a major progress in the treatment of GBM is partly attributable to our poor understanding of both GBM tumor biology and the acquirement of treatment resistance in recurrent GBMs. Recurrent GBMs are characterized by their resistance to radiation. In this study, we used an established stable radioresistant GBM model to shed light on global mRNA expression changes after irradiation. Many mRNAs, the expressions of which were altered in our radioresistant U87 GBM model, have never before been reported to be associated with the development of radioresistant GBMs and should be concertedly further investigated to understand their roles in radioresistance.The U87 and U87-10gy glioblastoma cell lines were cultured in Eagle's minimum essential medium containing 10% (v/v) fetal bovine serum. Culture medium materials were obtained from Life Technologies, Inc. .RNA sequencing libraries were prepared using the TruSeq Stranded mRNA Library Prep Kit  according to the manufacturer`s protocol. The RNA concentration was measured with a NanoDrop 2000c spectrophotometer . Integrity was assessed using an Agilent 2200 TapeStation instrument . Briefly, polyA mRNA from an input of 500 ng high-quality total RNA (RINe>8) was purified and fragmented. First strand complementary deoxyribonucleic acid (cDNA) syntheses were performed at 25° C for 10 minutes, 42° C for 15 minutes, and 70° C for 15 minutes, using random hexameres and ProtoScript II Reverse Transcriptase . In a second strand cDNA synthesis, the RNA templates were removed and a second replacement strand was generated by incorporating deoxyuridine triphosphate  to generate ds cDNA. The blunt-ended cDNA was cleaned up from the second strand reaction mix with beads. Next, the 3′ ends of the cDNA were adenylated and then indexing adaptors were ligated. Polymerase chain reactions  were used to selectively enrich those DNA fragments that have adapter molecules on both ends and to amplify the amount of DNA in the library.The libraries were quantified using the Promega QuantiFluor dsDNA System on a Quantus Fluorometer . The size and purity of the libraries were analyzed using the High Sensitivity D1000 Screen Tape on an Agilent 2200 TapeStation instrument. The libraries were normalized, pooled, and subjected to cluster, and pair read sequencing was performed for 150 cycles on a HiSeq4000 instrument , according to the manufacturer's instructions.The method and detail to generate the stable radioresistant GBM model was previously described by us . U87 celhttp://david.abcc.ncifcrf.gov/). The heatmap was performed with a web-based program (http://www.heatmapper.ca/expression).The gene ontology enrichment analysis was performed using DAVID Bioinformatics Resources 6.7, NIAIS/NIH (


Stroke is a severe cerebrovascular disease and is the second greatest cause of death worldwide. Because diagnostic tools (CT and MRI) to detect acute stroke cannot be used until the patient reaches the hospital setting, a portable diagnostic tool is urgently needed. Because biological tissues have different impedance spectra under normal physiological conditions and different pathological states, multi-frequency electrical impedance tomography (MFEIT) can potentially detect stroke. Accurate impedance spectra of normal brain tissue (gray and white matter) and stroke lesions (ischemic and hemorrhagic tissue) are important elements when studying stroke detection with MFEIT. To our knowledge, no study has comprehensively measured the impedance spectra of normal brain tissue and stroke lesions for the whole frequency range of 1 MHz within as short as possible an ex vivo time and using the same animal model. In this study, we established intracerebral hemorrhage and ischemic models in rabbits, then measured and analyzed the impedance spectra of normal brain tissue and stroke lesions ex vivo within 15 min after animal death at 10 Hz to 1 MHz. The results showed that the impedance spectra of stroke lesions significantly differed from those of normal brain tissue; the ratio of change in impedance of ischemic and hemorrhagic tissue with regard to frequency was distinct; and tissue type could be discriminated according to its impedance spectra. These findings further confirm the feasibility of detecting stroke with MFEIT and provide data supporting further study of MFEIT to detect stroke. Acute stroke is a severe cerebrovascular disease. It can be broadly divided into ischemic stroke caused by cerebral venous thrombosis and hemorrhagic stroke caused by intracerebral hemorrhage or subarachnoid hemorrhage . Stroke According to the principle of impedance methods to detect stroke, these methods can be mainly divided into three categories. First, based on the fact that the impedance of the whole brain is different before and after stroke occurrence, it is expected to detect stroke by monitoring the dynamic impedance change of the whole brain during stroke ,13,14,15Accurate impedance spectra of normal brain tissue (gray and white matter) and stroke lesions (ischemic and hemorrhagic tissue), especially when obtained from the same animal , are important elements when studying stroke detection with MFEIT. Several studies have investigated the impedance of normal brain tissue and stroke lesions. Surowiec et al. measured the impedance of bovine gray and white matter in the frequency range from 20 kHz–100 MHz ; Stoy etAs for ischemic tissue, Wu et al. compared the impedance of normal brain tissue and ischemic tissue in rabbits within the 1 Hz–1 MHz range ,31; RancIn this study, we established intracerebral hemorrhage and ischemic models in rabbits. Then, we measured the impedance spectra of white matter, gray matter, ischemic and hemorrhagic tissue within 15 min after animal death at frequencies from 10 Hz–1 MHz. We analyzed the feasibility of using MFEIT to detect stroke with regard to the impedance spectra of tissues by comparing the difference in impedance spectra between normal tissue and stroke lesions and the difference in the ratio of change of impedance between hemorrhagic and ischemic tissue with regard to frequency. We also investigated the relationship between the specificity of the tissue impedance spectrum and the type of tissue using partial least squares discriminant analysis (PLS-DA).All experiments in this study were approved by the Institutional Animal Care and Use Committees of the Fourth Military Medical University, Xi’an, Shaanxi, China.2 was removed from each rabbit’s ear; using a scalpel, a vertical incision of about 3 cm in length was made 0.5 cm behind the line connecting the two otic edges. The periosteum within the visual field was also removed.Twenty-two New Zealand rabbits (2 ± 0.5 kg) obtained from the experimental animal center were divided into two groups, 11 in the intracerebral hemorrhage model and 11 in the ischemic model, respectively. Rabbits fasted for 4 h and were not allowed to drink water 2 h before the experimental procedures. They were initially anesthetized via intraperitoneal injection with 1.5% pentobarbital (2 mL/kg). After sedation, 3% pentobarbital (1 mL/kg) was injected into an ear vein to achieve a deep surgical level of anesthesia. Body temperature was measured using a rectal thermistor probe and maintained at 39.5 ± 0.5 °C using a warm-water blanket. Rabbits were placed in a stereotactic frame in the prone position employing raised eye and ear bars. An area of about 10 cmGiven that stroke mainly consists of local hemorrhage and ischemia, we established localized intracerebral hemorrhage and ischemic models, respectively.Autologous blood injection was adopted to produce the intracerebral hemorrhage model. To prepare to inject blood a,c, a ho2) from an LG150B-type cold light source  for 40 min and then the wound was sutured. After 40 min, the rabbit was sacrificed by administering a pentobarbital overdose, and the whole brain was removed to measure the tissues (10 rabbits) or immerse in formalin overnight for 24 h (1 rabbit). The measured tissues included ischemic tissue and gray matter on the contralateral side of the ischemic tissue (the ischemia obtained by photothrombotic method mainly occurs in gray matter).The photothrombotic stroke method was used to establish the ischemic model . Using aAfter the brain was removed, the gray matter, white matter and stroke lesions (hemorrhagic or ischemic tissue) were separated. To shorten the ex vivo time as much as possible, two experimenters simultaneously loaded the normal tissue or stroke lesions into two measuring boxes . Each meA 0.03 mol/L saline solution was injected into the measuring box, and its impedance was recorded as the control before each measurement. Peyman et al. obtained the theoretical conductivity of 0.03 mol/L saline solution , which iZ) with the Solartron 1260 system. If tissue impedance is equivalent to a parallel capacitance and conductance circuit [Z; Z; j is the unit imaginary number, C is the equivalent capacitance; G is the equivalent conductance; ω is the angular frequency, ε is the dielectric permittivity.We obtained the tissue impedance , In this study, we used To assess the histopathological change in stroke lesions, 1 cm in diameter sections of white and gray matter, and hemorrhagic and ischemic tissue were removed from the rabbit brain after animal death. Samples were fixed in 10% formalin for 24 h. Then, samples were cut into 3 mm-thick slices for hematoxylin and eosin staining and were reviewed by one pathologist (HMR) under an optical microscope.t-test.We used IBM SPSS Statistics for Windows, Version 20.0  to carry out the statistical analysis. The comparison of tissue impedance at different frequencies was performed with a paired samples SVI)—f, respectively, and f, respectively.To detect stroke with MFEIT, the first step is to discriminate stroke lesions from normal brain tissue. We used the impedance spectrum variation index ; the middle-frequency range ; and the high-frequency range . For each frequency range, the conductivity or permittivity at the reference frequency was compared with the other frequencies, as denoted by To study the relationship between tissue type and tissue impedance spectrum, we used PLS-DA to evaluate the statistical distribution of tissue impedance spectra, namely, discriminating each type of tissue by its impedance spectrum. PLS-DA has been widely used in the analysis of spectral data ,40 and w3) and ischemic (ischemic tissue was 4.5 ± 0.25-mm in diameter and 2.9 ± 0.1-mm in depth) models are shown in In all experiments, animals retained stable body temperature and respiration. While establishing the intracerebral hemorrhage model in two animals, blood broke into the ventricle; therefore, we added two more animals. Forty sets of data were obtained, 10 sets of data for gray matter, 10 for white matter, 10 for hemorrhagic and 10 for ischemic tissue, respectively. The hemorrhagic , while the conductivity of hemorrhagic tissue remained constant below 100 kHz and then increased within the 100 kHz–1 MHz range (p < 0.05 at 100 kHz and 1 MHz). The change in permittivity was similar to the change in conductivity. With regard to the magnitude of conductivity and permittivity, the conductivity of hemorrhagic tissue was smaller than that recorded for the other tissues. The difference in permittivity in ischemic tissue, and in white and gray matter, was small below 100 kHz, and the permittivity of hemorrhagic tissue was significantly different from the other three tissue types within the whole frequency range.Over the whole frequency range b, the diIn the PLS-DA model, the independent variable, X, consisted of the conductivity or permittivity of all tissues at each frequency , while the dependent variable, Y, consisted of the 40-set sample of gray matter (10), white matter (10), hemorrhagic (10) and ischemic (10) tissue, which were assigned to 1–1.1 (0.01 increments), 2–2.1 (0.01 increments), 3–3.1 (0.01 increments) and 4–4.1 (0.01 increments), respectively.The PLS-DA results for conductivity are shown in The significant difference between our study and previous ones is that we comprehensively measured the impedance spectra of normal brain tissue and hemorrhagic and ischemic tissue, from 10 Hz–1 MHz, and analyzed them within 15 min after animal death.In the case of normal brain tissue, white matter impedance was greater than gray matter impedance over the whole frequency range , which lThe change in impedance in ischemic tissue was about 40% from 10 Hz–1 MHz. Ranck et al. reported that the change within the 5 Hz–50 kHz could be as great as 200% , but theIn the case of hemorrhagic tissue (clotted blood), the impedance of clotted blood was greater than that of fresh blood, which is in accordance with previous reports ,45. ThisIn our study, in order to control measurement conditions to ensure the accuracy of measurement, we used an infant incubator to maintain the temperature at 37 °C, with 60% humidity. Because we measured the tissue impedance within 15 min after animal death, there may be a difference between our measured results and the actual values of in vivo impedance before the sacrifice of the animal. However, the hematoxylin and eosin-stained images of normal brain tissues clearly show that the cells of normal white matter, as well as gray matter were arranged neatly and tightly. Furthermore, there are no morphological changes in normal tissue cells as in ischemic tissue cells . TherefoWhen detecting stroke, the first step is to differentiate stroke lesions from normal brain tissue. In The second step is to discriminate ischemic from hemorrhagic stroke. In this study, we established a PLS-DA model using conductivity and permittivity spectra to discriminate between different types of brain tissue. As shown by the PCA score plot, all measurements fell within their own unique tissue-specific area. Our regression analysis also showed that each tissue could be clearly separated. This is a good indication that the impedance spectrum of each tissue  is unique and specific. In practice, stroke detection with MFEIT is very complicated. The boundary voltages always result from both normal head tissues and stroke lesions other than the latter alone, so PLS-DA would hardly be an appropriate method for stroke detection. However, based on this analysis, the specific impedance spectrum of each tissue over the whole frequency range may provide helpful information for stroke detection.In this study, we established hemorrhagic and ischemic models and comprehensively measured and compared the impedance spectra of gray matter, white matter, ischemic and hemorrhagic tissue within 15 min after animal death using frequencies from 10 Hz–1 MHz. The results showed that the impedance spectra of stroke lesions obviously differed from normal brain tissue ; the ratio of change in impedance in ischemic and hemorrhagic tissue with regard to frequency was distinct ; and the results of the PLS-DA showed that the tissue impedance spectra could be used to discriminate the different types of tissue. These findings further validate the feasibility of detecting stroke with MFEIT by means of tissue impedance spectra in animal experiments and provide support for further study of stroke detection with MFEIT.


A decline in air concentrations have coincided with consistent implementation of control measures. Such measures include on-line monitoring of leaks; benzene recovery; floating container roofs; improved valves and seals; hermetic pumps; recovery of loading gases and instalment of torches in terminals; cutback in coke combustion; a new production line spanning directly from the dock to aromatics production; and recovery of loading gases in the doc. Other tools in exposure management include personal leak monitors, on-line measurements, monitoring campaigns, risk assessment, and availability and user training of protective equipment. However, improvements are still needed. Hydrocarbon or benzene air concentrations have not declined in 8 of 17 units, in some of which concentrations exceed 10% of the relevant OEL8h value. In addition, for benzene even 10% of the current OEL, 0.1 ppm, might still possess a risk. With this in mind, methods to estimate exposure at the refineries need to be improved to enable measuring benzene concentrations <0.1 ppm. Shut downs of the refinery have been associated with peaks in exposure concentrations. Consequently, effort should be placed on safe working methods pertaining to shutdowns. Also, the connection and detachment of hoses continues to be problematic from the point of view of controlling exposure.Air concentrations of and inhalation exposure to total petroleum hydrocarbons (TPH) and benzene was monitored separately at two oil refineries from 1977 to 2014. Prevention policies and control measures that may explain changes were surveyed. The aim was to evaluate how the application of of Occupational Health and Safety Assessment Series OHSAS 18001.04 principles as well as Environmental protection Agency EPA and European Oil Company Organisation for Environment, Health and Safety CONCAWE practices have influenced air concentrations. Benzene air concentrations declined in 11 of 17 units, six of which were associated with declining exposures. Benzene air concentrations declined across all units on average by 46%. This amounts to an average yearly decline of 1.7%. TPH air concentrations declined in 10 of 17 units, seven of which were associated with declining exposures. The average decline in TPH air concentrations was 49%, corresponding to 1.3% per year. As a result, average working day exposure in 10 of 17 units have declined significantly and today, benzene and TPH exposure in most units are well below 10% of the current Occupational Exposure Limit (OEL During continuous operation, many of the unit operations as well as the transfer of streams between units is associated with stray leaks or sampling and maintenance operations, leading to exposure of personnel to petrochemicals ,2. In adBenzene has been classified by the International Agency for Research on Cancer (IARC) as carcinogenic to humans (Group 1 classification), based on the etiology of leukemia. In addition, benzo(a)pyrene is categorized to Group 1, based on lung tumourigenesis and other genotoxic effects. Some other TPH compounds or petroleum products, such as gasoline, are considered to be probably or possibly carcinogenic to humans . Most of the other TPH compounds and products are considered not classifiable (Group 3) by IARC. In addition to cancers, inhalation exposure to TPH compounds may be associated with symptoms of the central nervous system, in addition to headaches, dizziness and irritation of eyes and the respiratory tract . 8h) of “Category two” solvent petrols, 200 mg/m3. Based on, for instance, neurotoxic, irritatory, liver toxic, reproductive and developmental effects [8h of these solvent petrols in Finland has been lowered stepwise from 1150 mg/m3 to 200 mg/m3 between 1977 and 2014 , National Institut Occupational and Security Health (NIOSH) or American Conference of Governmental Industrial Hygienists (ACGIH) [During regular operation conditions, exposure in modern refineries to benzene and other hydrocarbons is mostly below Finnish OEL (ACGIH) ,8. Expos (ACGIH) ,9,10. Du (ACGIH) ,8. Durin (ACGIH) ,8.Benzene concentration of crude oil can be up to 4 g/L . Within Absorption of benzene through the lungs is rapid. The proportions absorbed are inversely related to the exposure concentration ,7. At exThe present study was initiated by the finding that workers employed at the refineries during 1967–1982, had a 2–3 fold risk of attaining kidney cancer, when compared to the general (reference) population ,18, and In short, the aim was to evaluate how the application of Occupational Health and Safety Assessment Series (OHSAS) 18001 and 18004 principles as well as Environmental protection Agency (EPA) and European Oil Company Organisation for Environment, Health and Safety (CONCAWE) exposure management practices have influenced air concentrations of and inhalation exposure to the examined agents.The Neste Ltd.  refineries in Porvoo and Naantali produce fuels, solvents, bitumen and lubricants, including the most important oil products. The refinery in Naantali was put into use in 1957, while the Porvoo refinery has operated since 1966. The Naantali refinery was originally designed to refine fuels, lubricants and bitumen products from crude oil, with an annual capacity of 800,000 tons. In 2014, the total capacity of oil products and renewable products of the two refineries were 15 million and 2 million tons per year, respectively. In 2014, the main product groups were motor gasoline and gasoline components (26%), diesel fuel (37%), renewable fuels (12%) and heavy fuel oil (8%).The company has a certified Occupational Health and Safety management system based on OHSAS 18001 (2007) . In addiExposure monitoring in the refineries is based on annual monitoring programmes planned by HSE Services in cooperation with the manufacturing units and the occupational health care unit. HSE Services gathers all occupational hygiene samples in the refineries. The timetable of exposure monitoring following initial measurements at a new unit, are dependent on the concentrations in the initial measurements as well as the implementation schedule of exposure management measures. In each case, measurements are followed up within five years.In addition to the units and working tasks included in the basic monitoring programs, exposure monitoring is performed in conjunction with accidents or production disturbances or changes with a potential to increase exposure.To prevent excessive exposure and detect leaks, hydrocarbons and various flammable gases, carbon monoxide, hydrogen sulfide and oxygen are continually measured on-line using personal Leak Detection And Repair monitors (LDAR monitors) carried by all workers in the refinery area ,21. In aBenzene concentrations in the production area are currently monitored by an on-line gas chromatograph connected to 11 stationary sampling points. The measuring range of the chromatograph is 0.5 ppm. The data is visible to the unit operators. The alarm limit pertaining to these measurements is 0.3 ppm. Altogether 4588 samples were taken and analysed by Neste Ltd. HSE Services during the relevant time span (1977–2014) . Out of The results that include breathing zone samples outside of respirators as well as stationary point samples not necessarily descriptive of average 8 or 12 h working day exposure are referred to as “air concentrations” throughout. Samples collected from stationary points were collected at a height of 1.5 m above the floor or ground.tert-butyl ether (MTBE), tert-amyl methyl ether (TAME), in addition to aliphatic hydrocarbons. Samples were analysed using a gas chromatograh equipped with Flame Ionization Detectors (FID) and one or two columns. If two columns were used, they were of dissimilar polarity characteristics: for instance, HP-InnoWax  and HP 5 .Samples were withdrawn to SKC-226-01 charcoal adsorbent tubes at a sampling rate of ca. 0.1 L/min using SKC 222  or Gilian LFS-113 DC  sample pumps, or other SKC or Gillian (Sensidyne LP) pumps with a similar sampling range (0.05–0.2 L/min). Aliphatic and aromatic hydrocarbons with a boiling point of ca. 35–220 °C, were extracted from the adsorbent in 4 mL glass tubes with 1.5 mL of carbon disulfide. Main components in the samples were dependent on the production unit and work-task examined and included for example benzene, toluene, ethylbenzene, xylenes, methyl Compounds were identified and quantitated using pure calibrators at a minimum of three different concentrations, spanning the concentration range of 0.01–10 µL/sample. The Limit Of Quantitation (LOQ) of the analysis corresponded to the smallest calibrator and was generally ca. 8 µg/sample. For benzene, the detection limit was 13 µg/sample, corresponding to ca. 0.1 ppm for a sample withdrawn during a workday (7 h) with a sampling rate of 100 mL/min. Blanks and control standards (one in each run) were spiked onto sorbent tubes and prepared analogically to the samples.Samples were kept refrigerated (−20 °C) until analysis. The samples were analysed with an HP or Agilent 6890 gas chromatograph operated using MS Chemstation software , and equipped with two FID detectors, one for each column. The operating conditions were set and the results calculated as described in the reference methods NIOSH 1500–1501. p-value  as described by Warner (2013) [x,y = √(t2/(t2 + n − 2)) at the t-test critical value (t) corresponding to the relevant degree of freedom. The test was performed to distinguish units where the concentration of benzene and/or total volatile hydrocarbons significantly increased or decreased as a function of the date of sampling during the time-interval of the measurements, from those where a statistically significant change could not be verified.A linear regression analysis was performed on the sampling date (x) and concentration (y) data. The Pearson correlation coefficient was tested against its sample-size dependent r (2013) : ρx,y = 1,y1) to the concentration at the end point :%Ch = (y1 − y2)/y1 × 100.If a linear relationship (sampling date vs. concentration) was established, the proportional (%) change in concentrations was estimated by comparing the value at the starting point of the regression interval (xThe production lines (1–5) differ in their output and also in the raw materials used and, consequently, in their benzene emissions as well as the amount and profile of volatile hydrocarbons emitted to their immediate environment. Production lines 1–3 produce mainly gasoline and production line 4 mainly diesel fuel. Production line 5 yields bitumen, small engine gasoline and solvents, in addition to diesel fuel. Production lines 1–4 are situated in Porvoo, while line 5 is in Naantali.3 and 1 mg/m3, respectively. The medians of the air concentrations amount to 5% (benzene) and 0.5% (TPH) of the current OEL8h values, 1 ppm for benzene and 200 mg/m3 for TPH.Characteristic for the production lines in Porvoo (lines 1–4) is that while accidents, shut downs and operating disturbances have on occasion led to high benzene and TPH concentrations, the air concentrations during normal working shifts have been fairly low during all of the years studied , with th3, median 15 mg/m3 . In production lines 1–5, benzene concentrations have very rarely reached concentrations that necessitate the use of respiratory protective equipment. In fact, in production lines 2 and 4, no such incidents have been monitored , the average and median benzene air concentrations have been of the same magnitude as in the Porvoo production lines, namely 0.35 and 0.05 ppm, respectively. The average and median TPH concentrations have, however, been notably higher in production line 5 than in other production lines: average 56 mg/monitored . 8h value  benzene exposures could be established only in line 5, where the initial exposures were higher than in the more recently built production lines in Porvoo , benzene as well as TPH air concentrations have occasionally reached values closed to prevailing OELmparison . During 8h were recorded relatively frequently up until 2008 but during recent years, benzene air concentrations have usually remained below 10% of the OEL8h  have been measured only in conjunction with two isolated incidents not descriptive of average working day exposure: a temporary operational break in an exhaust ventilator in a cool storage room and the uncontrolled purification of equipment using hexane  have been measured in association with the application of corrosion inhibitors. In other words, TPH exposures in the maintenance functions were fairly low to begin with and have remained so during the measured time interval.In the maintenance unit, benzene air concentrations—as well as exposure—has been low throughout the years, while TPH air concentrations and exposure show an increase based on the calculations . However8h has been measured only once in the unloading terminal, from the breathing zone of an operator wearing a half mask.Harbour functions as well as the distribution and unloading of petrochemicals include tasks that yield high air concentrations and are repeated several times during a normal working day. As high immediate benzene concentrations may be relevant to the manifestation of health implications, it is important that all units where benzene emissions is of concern, show a declining trend with time. This has been the case with the benzene air concentrations in the harbour functions (relative decline of measured concentrations 49%), as well as the distribution terminal  to 593 (2007–2009) . On aver to 593 . In these units, no statistically significant decline in exposure could be recorded, regardless of whether the air concentrations declined or not  estimate on cancer risk this represents a cancer risk in the range of 0.05–0.66 per 1000 in 40 years occupational exposure . It shoud or not .8h values (−). In addition, measuring techniques and analysis methods of organic emissions have improved, and new techniques and equipment have become available enabling online measurement of air concentrations and in some cases even exposure. Consequently, it is likely that in 2014 we get a more reliable picture of air concentrations and work related exposure at the refineries, than we did in 1977.As the present investigation spans nearly four decades, numerous outside factors have affected work related exposure to hydrocarbons in the refineries. Such factors include : lowering the maximum benzene concentration allowed in petrol gradually: 3.5% in 1980, 2.5% in 1985, 2% 1991, 1% in 1994 (−); increase of benzene-rich effluents from polymer production units to wastewater treatment plant in Porvoo (+); changes in production capacity and product portfolio (±); technological progress and better process engineering techniques (−); new legislation concerning safety and risk management as well as cancer registry (−); stricter OELIn managing exposure, particular effort should be placed on control of emissions at the source . In the 8h and TPH air concentrations below 50% of the current TPH OEL8h. This would help to focus the need for protective equipment mainly to infrequent tasks short in duration.Providing other control measures are inadequate to prevent excessive exposure, the use of protective equipment is necessary. Neste Ltd. has a corporate policy for the use of protective equipment. Enforcing and supporting the use of protective equipment is often problematic. In fact, it has been suggested that “personal protective equipment should be used only sparingly and under appropriate circumstances, and never as a substitute for more reliable and effective engineering or administrative controls” . In othe8h to begin with. In conclusion, air concentrations of TPH and benzene have generally declined with time (1977–2014). In more than half of the units where a decrease in air concentrations were established, this decrease was accompanied by a decrease in exposure. When a decrease in exposure could not be established, the exposure was without exception less than 10% of the current OEL8h value  short term (≤15 min) peak exposures may play a role in benzene carcinogenesis . Therefo8h value . ConsideRegardless of the unit or exposure agent, the maintenance shut downs of the refineries  have generally been associated with clear peaks in the air concentrations. Consequently, particular effort should be placed on safe working methods pertaining to shutdowns as well as the use and condition of respiratory protective equipment of subcontractors and in-house workers alike. Also, while recovery of loading gases in the distribution terminals and docks will most likely lower air concentrations in these units, the connection and detachment of hoses continue to be challenging from the point of view of controlling excessive exposure.Benzene and hydrocarbon air concentrations in some of the units investigated will most likely continue to have room for improvement for years to come. In the Neste refineries, personal LDAR-monitors and on-line measurements, monitoring campaigns and risk assessment procedures, availability of protective equipment as well as training programs are effective tools in the monitoring and management of exposure. However, ensuring safe working conditions and working methods will continue to require persistent work. Many problematic work tasks and situations will still have to be addressed in order to improve high air concentrations and further lessen the need for protective equipment. Also, as an instrument in lowering exposure with recent risk estimates in mind, methods to estimate exposure at the refineries need to be improved to enable measuring benzene concentrations <0.1 ppm.


The purpose of this prospective analysis was to evaluate the patient and surgeon satisfaction levels after using a fully preloaded acrylic, hydrophobic, monofocal “premium” IOL in pseudoexfoliation syndrome.  42 eyes of twenty-eight patients with progressed cataract formation and pseudoexfoliation syndrome (PXF) or pseudoexfoliation glaucoma and best corrected distance visual acuity (BCDVA) between 0.30–1.00 logMAR were enrolled. After a detailed preexamination, they underwent phacoemulsification and implantation of the acrylic, hydrophobic, heparin-coated, single-piece, monofocal intraocular lens  with 360° square edge and ultraclear purity aspheric ZO optic. We evaluated the visual performance of the IOL and the patient satisfaction. We also evaluated the intraoperative handling of the injector and the behavior of the IOL in these complicated cases (PXF). n=39) and by 100% (n=42) within 1.0 D of all cases, respectively. Patient satisfaction was very high, and no halos or glare were reported in any case. The fully preloaded injector system enabled an easy IOL preparation and safe implantation.  The BCDVA increased from mean 0.48 logMAR (range 0.30–1.00 logMAR) preoperatively to −0.05 ± 0.13 logMAR postoperatively. The mean IOL power was 23.5 D (range 16.5–27.5 D). The target refraction using the Haigis formula within ±0.5 D was reached by 92.9%  is safe and enhances OR workflow in complicated cases as pseudoexfoliation. In these cases, an adapted approach  with considering possible complications is necessary to achieve best outcomes. The pseudoexfoliation syndrome (PXF) was first described in 1917 by the Finnish ophthalmology resident Lindberg. Lindberg modified a Zeiss microscope and constructed a slit lamp on his own because slit lamps were not commercially available at that time. He conducted a study of more than 200 patients and recorded his findings with skilful hand drawings  and a best corrected distance visual acuity (BCDVA) between 0.30 and 1.00 logMAR were enrolled. The main inclusion criteria was an existing and detectable pseudoexfoliation syndrome with its characteristic findings in the anterior segment which includes the typical PXF disc with its fluffy deposits on the anterior lens capsule, the transillumination defect on the pupillary borders, and the poor pupillary dilation . The intraoperative application of the 6.25 mm Malyugin ring to enlarge the pupil was mandatory, which is another inclusion criterion. 27 eyes were diagnosed with pseudoexfoliation glaucoma, high intraocular pressure (IOP) regulated with topical glaucoma medication, and pathognomonic glaucoma-associated defects in optic nerve disc with visual field loss. The cloudy lenses were graded with the “LOCS III” (Lens Opacities Classification System) in nuclear, cortical, and subcapsular opacities. Exclusion criteria included other severe eye pathologies such as corneal dystrophy, posttraumatic corneal wound scar, diabetic proliferative retinopathy, age-related macular degeneration, or retinal dystrophy. In all cases, phacoemulsification and removing of the cloudy lens were performed with the same phacomachine (Abbott Signature Whitestar) by the same surgeon in the same facility. Repeated measurements were performed preoperatively to avoid or minimize complications of cataract extraction and get the best outcomes in these PXF eyes. An increased awareness was required because of the problem this disorder may induce. Biometry was performed with the IOLMaster 500  twice to increase accuracy even in hard nuclear or dense subcapsular cataracts. In 4 cases, ultrasound measurement of the axial length (Axis) was necessary. In all cases, Scheimpflug measurement with the Pentacam AXL  for exact evaluation of the corneal topography, keratometry, and pachymetry was performed. Objective measurements of the refractive error including autorefraction and IOP measurements with Goldmann tonometry were performed at least 3 times (1–12 weeks) before surgery. Perimetry results  were meaningful and utilizable in just 8 cases, and in all the other cases, the dense cataract had already blocked too much light and the visual acuity was worse. A special preoperative procedure of eye drops was applied: 3 days prior to surgery, patients received bromfenac (NSAID) eye drops (2 times daily) and cyclopentolate eye drops 3 hours prior to surgery. Tetracaine eye drops (4x) as topical anesthesia were instilled 30 minutes before surgery, and disinfecting eye drops were used several times. In all cases, the fully preloaded, acrylic, hydrophobic, heparin-coated, single-piece, monofocal, “premium IOL”-CT LUCIA 601P  was implanted without any complications . The lenn=39) and within 1.0 D by 100% (n=42) of all cases, respectively. Patient satisfaction was very high, and no halos or glare were reported in any of the cases. The fully preloaded injector system  enabled an easy and safe IOL preparation and good OR workflow (n=0) in terms of posterior capsule defects or (sub)luxation of the lens were experienced. Intraocular pressure (IOP) was independent from medications in pseudoexfoliation syndrome patients, and pseudoexfoliation glaucoma patients showed lower values after lens extraction with a mean decrease of 4 mmHg 3 months postoperatively. These findings showed a significant correlation to the anterior chamber depth measured with the Pentacam . The lens position image analysis of retroillumination photos of 40 eyes showed well-centered IOLs, and the effective lens position (ELP) did not change significantly over the postoperative course of 3 months. In two cases, an intense capsular phimosis (8 weeks after surgery) with “myopic shift effect” led to a slight displacement of the IOL in the direction of the anterior chamber with resulting myopia (−1.0 D). The slit lamp exam and retroillumination photo showed a clear acrylic optic with high purity without any glistenings.42 eyes of twenty-eight patients  with dense cataracts and pseudoexfoliation syndrome were included. The mean age of the participants was 77.9 years ± 7.5 years. The cloudy lenses (cataracta senilis) were graded with the “LOCS III” (Lens Opacities Classification System) in 16 nuclear (8x NC5 and 8x NC6), 14 cortical , and 12 subcapsular posterior (5x P4 and 7x P5) lens opacities. The best corrected distance visual acuity (BCDVA) increased from mean 0.48 logMAR (range 0.30–1.00 logMAR) preoperatively to −0.05 ± 0.13 logMAR postoperatively. The mean IOL power was 23.5 D (range 16.5–27.5 D). The target refraction with Haigis formula was reached within ± 0.5 D by 92.9%  is a very elegant and time-saving method to achieve a round, large pupil without damaging the iris sphincter and without the need of making extra paracentesis. Especially in the PXF eyes, the surgical procedure should be as gentle as possible. To enlarge the pupil and to separate the synechiae, cohesive viscoelastic devices (OVDs) can be used. The use of trypan blue for staining the anterior capsule can be very wise in cases of poor red-reflex in dense subcapsular cataracts.Zonular weakness and phacodonesis can make the capsulorhexis, phacoemulsification,irrigation/aspiration, and implantation of the IOL challenging. Depending on the severity of the zonular dialysis, a capsular tension ring (CTR) should be used in the intraoperative course as soon as possible to facilitate the situation.Less anterior capsule tension makes the capsulorhexis in the PXF eyes more difficult. The filling of the anterior chamber with OVD should be repeated, and the rhexis should be done with a sharp needle or forceps very slowly and carefully to generate as less pressure to the zonules as possible. The size and design of the rhexis is most important for good IOL centration because of potential postoperative shrinkage and phimosis in the PXF eyes.Phacoemulsification has to be performed with special respect for the weak zonules and the thinner posterior lens capsule. A chopping technique with low ultrasound energy and low irrigation/aspiration adjustments is recommended. The cortical removal is a crucial step in the PXF eyes. The “Hurricane I/A technique” allows a tangential vector resultant voltage on the zonules smaller than the conventional radial suction. In some cases, the “dry” removal of cortex with a cannula (stripping technique) is the best way to preserve zonular fibers.Several studies have confirmed that the acrylic, hydrophobic IOLs are the best choice in pseudoexfoliation syndrome. Considerations should include the diameter of the lens, the haptic design and IOL stability, the edges regarding the PCO rate, and the surface of the lens. There are studies with controversial results regarding the effect of a heparin coat, and its benefit has not been confirmed till now . FurtherThe implantation of the IOL should be as harmless as possible with a minimum of stress to the zonules, less manipulation in the anterior chamber, and fast orientation/centration of the IOL in the capsular bag . TherefoIt is well known that, in pseudoexfoliation, the intraocular pressure may rise up rapidly 2 hours after surgery. Persistent intraocular pressure elevations and persistent inflammation in the first postoperative period are very common . TherefoWith the rising life expectancy, the zonules are finally lost from the epithelium and the bag with the IOL may loose into the vitreous. It was found that 6-7 years following cataract surgery, posterior chamber intraocular lenses were positioned lower in pseudoexfoliation syndrome than in control eyes . Due to Pseudoexfoliation syndrome is a systemic, age-related disease and occurs worldwide, but the prevalence varies between different regions. PXF is a risk factor for both glaucoma (≈30%) and cataract formation. Moreover, several studies have verified that PXF is correlated with an increased risk of intraoperative and/or postoperative complications . The depPseudoexfoliation syndrome is a common disorder, and every cataract surgeon has to face the special challenges associated with it. Careful preoperative considerations and special intraoperative care to ensure safe surgery are necessary to get the best postoperative outcomes.Our prospective analysis in cataract patients with pseudoexfoliation syndrome and dense cataracts showed that the implantation of the fully preloaded CT LUCIA 601P  is safe and enhances OR workflow in complicated cases. Postoperatively, no halos or glare were reported by the patients. We have not observed a single case of glistenings till now, and therefore, we fully recommend the CT LUCIA 601P in complicated cases, and we believe that the label of “premium” is appropriate.