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Many of the considerable number of young people who identify as transgender or gender diverse do not conform to traditional binary notions of gender (male vs female), and instead have a non-binary gender identity. This narrative Review summarises literature related to the sociodemographic and clinical profiles of young people with a non-binary gender identity. Young people identifying as non-binary form a substantial minority of the general population. They experience lower levels of support and are at increased risk of experiencing abuse and victimisation than young people who are cisgender. Furthermore, compared with young people who are transgender and binary, people who identify as non-binary experience less access to trans-specific health care. Young people identifying as non-binary have poor mental health outcomes, with high rates of depression, anxiety, and suicidal ideation that were found to be similar if not higher than in those who are transgender and binary. This Review highlights that young people who identify as non-binary are highly vulnerable and likely to have important health-care needs.

Background Meningiomas are heterogeneous, with differences in anatomical, histopathological, and clinical characteristics. Such spatial variability in meningioma biology is thought to result from differences in the expression of critical developmental regulators. We hypothesized that the variability in meningioma biology would follow gradients such as in embryology and tested a cohort of 366 meningiomas for histopathological and immunohistochemical gradients. Methods The medical records from 366 patients treated for meningiomas from 2003 to 2016 were retrospectively analyzed for age, gender, anatomical localization, recurrence-free survival, overall survival, histopathological diagnosis, and immunohistochemistry findings for 6 markers: epithelial membrane antigen (EMA), progesterone receptor (PR), CD34, S100, p53, and Ki-67 labeling index. Results EMA, PR, S100, p53, and CD34 were expressed in 94%, 73%, 49%, 26%, and 23% of the tumors, respectively. p53 expression correlated positively with Ki-67 and World Health Organization (WHO) grade (rτ = 0.31 and rτ = 0.4, respectively). PR positivity correlated inversely with S100, p53, Ki-67, and WHO grade (rτ = −0.19, rτ = −0.14, rτ = −0.15, and rτ = −0.16, respectively). All secretory meningiomas were positive for EMA and PR and negative for S100, and this pattern exhibited a rostrocaudal gradient. The overall proportion of EMA+PR+S100− cases was significantly lower in the cranial vault (30.3%) than in the skull base (45.89%; P = 0.021). The proportion of WHO grade II-III tumors was greater in cranial vault than in skull base meningiomas. Conclusions Unsupervised methods detected an association between the anatomical location and tumor biology in meningiomas. Unlike the categorical associations that former studies had indicated, the present study revealed a rostrocaudal gradient in both the cranial vault and the skull base, correlating with human developmental biology.

Background Dural thickening is observed in lymphoma, dural carcinomatosis, meningioma, tuberculosis, and autoimmune diseases. We encountered a patient with dural thickening and complaints of neck and back pain, numbness and loss of strength in the hands. The patient also suffered from polychondritis and had previously received steroid and methotrexate treatment for this indication. The patients’ serum was also positive for ANA, yet she did not have any other findings suggesting lupus. Our radiological and pathological analysis revealed IHSP (IgG4-related hypertrophic sclerosing pachymeningitis). In this review study, we provided a detailed literature survey to increase the awareness about IHSP in the neurosurgical community. Methods MRI (magnetic resonance imaging)-based radiological analyses revealed a posterior extramedullary spinal mass extending from C2 to T2-T3 level. The dural mass was surgically excised and a broad panel of immunohistochemical markers including S100, EMA, CD246/ALK-1, CD45, CD20, CD79a, CD138, CD68, CD1a and CD34 was studied. Immunoglobulin heavy chain/kappa chain gene rearrangement analysis was performed which ruled out a lymphoproliferative disorder. Results MRI and pathological findings suggested IHSP. As the disease relapsed with a new anterior extramedullary multilobulated lesion extending from C5 to T1 level, the patient is now closely monitored for further medical and surgical treatment. Conclusions IHSP is a relatively novel entity of hypertrophic pachymeningitis and should be included in the differential diagnosis of dural thickening. The fibrosis accompanying IHSP may not respond to medical treatment, which includes steroids and immunosuppressive agents. Additionally, neurological deficits, seizures, spinal decompression, hydrocephalus, or brainstem compression necessitate early surgical intervention. A continued vigilance is also necessary as the disease may relapse long-term following surgical treatment.

Highlights • Arachnoid cysts should be included in the differential diagnosis of sellar cystic lesions. • Other sellar cystic lesions may present with similar clinical and radiological findings. • The definitive diagnosis is made on histopathologic examination and immunohistochemical staining. • Surgery is still the treatment of choice in lesions which are symptomatic, causing decompression and pituitary hypofunction., Introduction Arachnoid cysts (ACs) are frequently found on intracranial imaging studies but intrasellar arachnoid cysts are rarely encountered. Presentation of case We present a 49-year old patient who had headaches for 6 months and cystic sellar mass was found in his cranial imaging. We operated him by transnasal transsphenoidal route. Our intraoperative diagnosis was an arachnoid cyst and pathologic studies verified our observation. He did well postoperatively and after a 1 year follow-up he was left free from future follow-ups. Discussion As common cystic lesions occupying the sellar region can simulate ACs both clinically and radiologically, neurosurgeon can fail to include ACs in making the initial diagnosis preoperatively. Conclusion Although a rare entity, arachnoid cysts should be considered in the differential diagnosis of sellar region.

Background: To optimize positive outcomes, the design of new pharmacy services should consider the preferences of consumers with chronic condition(s) and their carers. Objectives: (i) To evaluate the relative importance of community pharmacy service characteristics, from the perspective of consumers with chronic condition(s) and carers; (ii) To compare consumer and carer preferences to health professional beliefs about ideal service characteristics for consumers. Method: A discrete choice experiment was completed by consumers with chronic condition(s) and/or carers (n = 602) and health professionals (n = 297), recruited from four regions in Australia. Participants were each randomized to one survey version containing four (from a total 72) different choices between two new pharmacy services. Consumer and carer participants were also given an ‘opt out’ alternative of current service. Each service was described using six attributes related to pharmacy service characteristics: continued medicines supply, continuity and coordinated care, location, medication management, education and information, and cost. Results: Consumers and carers placed highest priority on continued medicines supply by a pharmacist for regular and symptom flare up medicines (100 priority points), a pharmacy located within a ‘one-stop’ health center (61 points) and home delivery of medicines (52 points). Although continued medicines supply was most important for consumers and carers, pharmacy location was perceived by health professionals to be the most important characteristic for consumers. Participants were less inclined to choose new services if their current pharmacy offered high quality services that were person-centered, easy to access and responsive to their needs. Younger, more highly educated and employed participants, and those with established condition(s) were more likely to choose new services. Conclusions: Person-centered care is a fundamental tenet for pharmacy services. The provision of continued medicines supply (e.g. through pharmacist prescribing), convenient and coordinated care delivered through a one stop health centre, and home delivery of medicines, should be prioritized when planning pharmacy services to best assist consumers to manage chronic conditions.

Aggressive pituitary adenomas have a high risk of recurrence, a lack of therapeutic response, and resistance to conventional treatment. So far, no satisfactory biomarkers are available for predicting their behavior. Some specific pituitary adenoma histotypes are more prone to follow an aggressive behavior. Pituitary carcinomas are rare and show cerebrospinal and/or systemic metastasis. They have worse prognosis than aggressive adenomas, and radiation is of limited use in their treatment.

In the present study, performance of a group of adults with Asperger Syndrome (AS) on two series of object reversal and extinction was compared with that of a group of adults with typical development. Participants were requested to learn a stimulus-reward association rule and monitor changes in reward value of stimuli in order to gain as many points as possible. In order to assess whether difficulties with stimulus-reward association learning and with reversal and/or extinction might be related to social and behavioural impairments, we performed correlation analyses between test measures and scores measuring the severity of clinical symptoms in the areas of repetitive behaviours and social interaction as assessed by the Autism Diagnostic Interview-Revised (ADI-R) [Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview-revised: A recise version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24, 659–685]. Individuals with AS showed difficulties in establishing rapid stimulus-reward associations, whereas no severe impairment was observed in reversal and extinction learning. In addition, the present findings show that these difficulties correlate with scores in social reciprocal interaction, suggesting that the diminished ability in the assignment of reinforcement value to incoming stimuli might be related to disturbances in social behaviour often reported in autism spectrum disorders.

Summary Background Determining the most advantageous size of liposuction cannula and injection needles in terms of adipocyte viability could help to increase fat graft survival. When recurrent injections are necessary, storing fat tissue which is harvested during the first operation could be a practical solution if it is stored at an appropriate temperature providing the highest amount of viable fat cells. Methods Fat tissue was removed from the abdomen of 10 consecutive female patients by 6-, 4- and 2-mm-diameter liposuction cannulas. Fat tissue harvested with the 6mm cannula was injected through 14, 16 and 20g needles and collected in separate tubes. An additional three tubes of fat samples were prepared from fat tissue obtained with the 6mm cannula to be stored at +4, −20 and −80°C for 2 weeks. Viability of the fat grafts was evaluated by fat cell isolation with collagenase digestion and staining with supravital dye and counting adipocytes with a haemocytometer. Results The viability of fat grafts harvested with the 6mm cannula was higher than grafts obtained with smaller cannulas. The viability of fat grafts injected through 14, 16 and 20g needles were similar to each other. The viability of fat grafts stored at +4°C was similar to fresh tissue whereas freezing fat grafts caused significant loss of viable adipocytes compared to fresh tissue. Conclusions The use of larger liposuction cannulas for fat tissue harvesting provides more viable fat grafts. A temperature of +4°C could be proposed as an effective and easily available way of storing fat grafts for at least 2 weeks.

We present imaging findings of a 45-year-old-male patient referred for increasing left hemiparesis during the last few days. CT and CT perfusion (CTP) revealed a mass lesion with reduced regional cerebral blood flow (rCBF) and regional cerebral blood volume (rCBV) with prolonged mean transit time (MTT), suggesting either irreversible infarction or a low grade tumor. MRI revealed a well defined cortically based homogenous nonenhancing tumoral mass. Surgical excision was performed and histology showed extraventricular neurocytoma (EVN), a low grade tumor composed of synaptophysin positive and glial fibrillary acidic protein (GFAP) negative neuron cells.

Purpose Posttransplant anemia (PTA) is associated with a higher risk of cardiac mortality, which is the most frequent cause of death among renal transplant recipients. In this study, we sought to determine the prevalence and causes of PTA among Turkish patients. Patients and methods The study included 75 (52 male, 23 female) adults. Anemia was defined as an hemoglobin (Hb) level ≤ 13 g/dL for men and ≤ 12 g/dL for women. Results The prevalence of PTA was 49.3% at a mean duration of 60.45 months after renal transplantation. The most frequent causes of PTA were erythropoietin (EPO) and iron deficiency. The mean Hb level of 12.76 ± 2.31 g/dL was significantly higher in male compared to female patients (13.26 ± 2.31 g/dL vs 11.64 ± 1.93 g/dL, P = .005). The Hb value was positively correlated with creatinine clearance and serum albumin level, and negatively correlated with serum creatinine level, the amount of proteinuria, and cyclosporine level. Creatinine clearance and serum albumin level were found to be an independent risk factors for PTA upon multivariate analysis. Only 12 of 37 anemic patients received treatment for anemia: 5 (13.5%) with EPO and 7 (18.9%) with iron preparations. Conclusion PTA a common complication was unfortunately neglected in this setting. Impaired renal allograft function and decreased serum albumin were major risk factors for PTA. Increased cyclosporine levels were also correlated with decreased Hb concentrations.

Fourth ventricular low-grade tumoral or dysplastic neuronal lesions have been reported as an epileptic focus for recently described cerebellar epilepsy in the form of repetitive and stereotyped attacks of hemifascial spasm, eye blinking, fascial movements, head deviation and dysautonomic manifestations. The case of a 3-month old infant having fourth ventricular mass with similar symptoms such as paroxysmal facial movements, eye blinking, eyelid contractions and abnormal head posture is reported in this article. After a few days of her admission, her attacks displayed a new form with altered consciousness and left limb jerks which were unresponsive to medical therapy. Following the surgical excision of the lesion 10 months ago, attacks disappeared and she is still seizure free. Histopathological diagnosis was ganglioneurocytoma. The seizures (which may be intractable in cerebellar epilepsy) are thought to have arisen from subcortical structures such as cerebellum, brain stem nuclei or the lesion itself. In the case of intractable episodes, surgical excision may prevent further seizures and help patients have a normal cognitive and motor development.

Background Symptomatic cysts of epithelial origin occurring in the fourth ventricle are very rare. When such a cyst is encountered, the treatment strategy includes surgical removal or fenestration of the cyst into subarachnoid space. Case 1 A 23-year-old male was diagnosed as having a cyst located in the fourth ventricle causing hydrocephalus; the patient underwent cyst removal via craniotomy. The histopathologic diagnosis was neuroepithelial cyst. Because clinical and neuroradiological findings persisted, he underwent VP shunting. The cyst disappeared and did not recur. Case 2 A 54-year-old woman was diagnosed as having a cystic mass in the fourth ventricle and dilatation of the ventricles. Magnetic resonance imaging showed the same findings as those of the first case. The patient refused craniotomy for total mass excision. Therefore, a VP shunt was applied. Postoperatively, the clinical findings and hydrocephalus improved, and complete disappearance of the cystic mass was observed unexpectedly. Both cases had 2 years of follow-up. Conclusion There is no proven mechanism to explain resolution of fourth ventricle cysts after a supratentorial VP shunting. We hypothesize that disappearance of the cyst could result from rupture of its wall because of pressure gradient, which might be facilitated by a VP shunt. The current report should not be taken as an argument against cyst removal, which is the established way of treatment. However, considering that the pathogenesis and pathophysiology of these cysts are unclear, VP shunting should be considered especially for recurrent cases accompanied by hydrocephalus.

Background Allopurinol is a xanthine oxidase inhibitor that prevents the generation of free radicals and may play a role in the protection of the cells during cerebral ischemia. Methods We evaluated the protective and therapeutic effect of allopurinol on reversible focal cerebral ischemia-reperfusion model in rats. Cerebral blood flow to the left hemisphere of adult Sprague-Dawley rats (n = 40) was temporarily interrupted by middle cerebral artery (MCA) and bilateral common carotid artery (CCA) occlusion for 3 hours in 5 groups of 8 rats each. Allopurinol (50 mg/kg) was given intraperitoneally 2 hours and immediately before ischemia and immediately and 2 hours after reperfusion in 4 different groups of rats, respectively. Animals were kept alive 24 hours after reperfusion. After sacrifice, infarction volumes and ratios of the brain slices were calculated, and the results were compared with those of the control group. Results The difference between the allopurinol-administered group and the control group 2 hours before for both infarction volumes and infarction ratios achieved statistical significance. Regarding the allopurinol-administered group immediately before ischemia, infarction volumes and infarction ratios were diminished, but there was no statistically significant difference. The difference between allopurinol-administered and control group immediately after and 2 hours after reperfusion for both infarction volumes and infarction ratios achieved no statistical significance. Conclusion This study showed that allopurinol has a protective effect, but not a therapeutic effect, on cerebral ischemia.

We report 2 patients with suprasellar haemangioblastoma (HBL). The first, a 54-year-old man, presented with headache and gradually worsening bilateral visual field defects that had progressed to complete blindness on the right side. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain demonstrated a suprasellar mass. The mass was removed through a pterional craniotomy. The postoperative course was uneventful. He had no stigmata of von Hippel-Lindau (VHL) disease. After 5 years follow-up, vision in the left eye is normal but the right eye remains blind and MRI reveals no recurrence. The second, a 38-year-old man presented with a 2-month history of severe headaches and complete visual loss in the left eye. He had had surgery for excision of a cerebellar HBL, 5 years prior to this presentation. CT and MRI revealed a residual mass in the posterior fossa and a new suprasellar mass. He underwent craniotomy and subtotal excision of the suprasellar tumour. The histological diagnosis was HBL in both patients. HBL in the sellar and suprasellar region are rare and may be sporadic or occur in association with VHL disease. The literature is reviewed and diagnosis and treatment options discussed.

Subependymal giant cell astrocytomas are benign tumors that constitute one of the primary features of tuberous sclerosis. Two infants with tuberous sclerosis had very unusual subependymal giant cell astrocytomas, confirmed on biopsy in one of the infants. In both cases, contrast-enhanced cranial magnetic resonance imaging suggested a calcified intra-axial mass with diffuse basal ganglia involvement extending into the lateral ventricle. Computed tomography confirmed calcification in both cases. The first patient had right temporal lobectomy for intractable epilepsy. Biopsy of the basal ganglia lesion in that case suggested subependymal giant cell astrocytoma. In infants, subependymal giant cell astrocytomas can present with unusual morphology and may feature diffuse basal ganglia involvement and severe calcification.

Prefabrication of fat tissue using a fascial flap based on the superficial inferior epigastric artery was studied in rats. First, the superficial inferior epigastric fascia was transposed over the inguinal fat pad. Two weeks later fascia and fat were elevated together as a prefabricated composite flap. At this stage, a pilot study was done in ten rats and perfusion of the flaps was tested with fluorescein. After confirming fluorescein staining of the prefabricated flaps, the study continued with experimental and control groups of rats. In the experimental group, prefabricated flaps were transposed to the subcostal area. In the control group, the pedicles of the flaps were severed, creating composite grafts. These grafts were transferred to the subcostal area in the same manner as in the experimental group. One week later the flaps were re-elevated and grafts were exposed. Fluorescein tests and Indian ink microangiography were carried out. In the experimental group, the flaps were stained, while grafts in the control group were not stained. Fat and fascia were found to be viable in the experimental group, while they were necrotic in the control group on histopathological examination. Based on these findings, we can conclude that the prefabrication of fat by vascular fascia is successful and may have application in plastic surgery.

A 2-year-old boy with hemimegalencephaly and Hirschsprung's disease is reported. The unique association of these two entities is considered to be the presence of a common insult or insults that affect the innervation of the bowel and the formation of the cerebral cortex. Short-segment subtype of Hirschsprung's disease may suggest that this effect occurred between the eighth and twelfth weeks of gestation. Although there is a well-known coexistence of Hirschsprung's disease with the malformations that share a common neurocristopathic origin (abnormalities of neural crest cell growth, migration, or differentiation), a few extremely rare cases, as in this case, might reflect the coexistence of Hirschsprung's disease with a cerebral malformation (i.e., hemimegalencephaly) that is a nonneurocristopathic entity by itself.

In this study various techniques with different periods of ischaemia have been used in order to describe a standardisable and reproducible model of reversible focal cerebral ischaemia in normotensive rats. Cerebral blood flow to the left hemisphere of the rats was temporarily interrupted by middle cerebral artery occlusion only in four rats of each group, by simultaneous middle cerebral artery and ipsilateral common carotid artery occlusion in six rats of each group, and by middle cerebral artery and bilateral common carotid artery occlusion in six rats of each group. Within each group temporary ischaemia lasted for 1, 2 or 3 h and animals survived for 24 h following reperfusion. An infarct of significant size with low standard deviation was observed after 3 h of distal middle cerebral artery and bilateral common carotid artery occlusion followed by 24 h of reperfusion. We have found that the ratio of the infarct volume to the supratentorial brain volume is a more reliable criterion (with less standard deviation) than infarct volume alone and could be used for comparison of results obtained in experimental studies