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It has become more and more apparent that some aspects of current medical practice can no longer be kept solely within the private preserve of the profession. Medical error is now treated in an open fashion because it is clear that frank debate over its incidence, causes and mechanisms are crucial to effective prevention. This has always been one of our worst kept secrets. Equally conflicts of interest [1] assume particular relevance in an occupation whose foundation values demand a robust ethical identity. This is the topic of this essay.

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Benign fibrous histiocytomas (BFHs) are tumors with fibroblastic and histiocytic components without histological anaplasia. Intracerebral lesions are exceptional and to our knowledge a spinal location was not yet described. We describe 2 cases of BFHs of the neural axis: the first, a 22-month-old boy with Down's syndrome, presented with a paraparesis and the magnetic resonance (MR) of the spine disclosed an intradural extramedullary, thoracic mass, totally resected; the second, a 13-year-old boy with left partial motor seizures, in whom the MR of the brain showed an intracerebral, right frontal tumor, also surgically removed. Both patients are free of recurrence, 6 years and 15 months after surgery, respectively. Histological examination and immunoreactivity for vimentin and histiocytic markers favored the diagnosis of BFH. It is likely that these tumors may originate from spinal dura mater mesenchymal stem cells and from the intracerebral perivascular pial sheath or the brain vessel walls themselves, respectively. Other benign, isolated, intracranial fibrohistiocytic neoplasms, namely the juvenile xanthogranuloma, can harbor a clinical, morphological and immunohistochemical profile overlapping the one of the BFH. Intracranial germ cell tumors may be associated with Down's syndrome, although harboring an unusual, non-pineal and non-chiasmatic location. One can speculate that a similar, still unknown genetic mechanism responsible for this association, could also induce the growth of other type of tumors in patients with this syndrome. BFHs should be added to the differential diagnosis of intracerebral or spinal dural attached tumors. Furthermore, we propose to name these intracranial tumors "benign isolated fibrohistiocytic tumors of the CNS".

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The author reviews briefly the sociocultural aspects of the quality control movements and how they relate to the medical profession. The "ethos" of the neurosurgical practice and the way to harmonize the new paradigms of modern medicine and the need to define parameters to evaluate quality are discussed.

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The few reports about clear cell meningiomas (CCM) point to an inordinate clinical aggressiveness despite their histological benignity. We studied 5 CCM aiming to assess their clinicopathological, cytometric, and ultrastructural features. Two patients were females and 3 males, with a mean age of 36 years. Two tumors were spinal, one of the cerebral convexity, one of the tentorium-clinoid region, and one of the base of the skull. The first 3 were totally removed and have not recurred for a mean follow-up time of 40 months. The tentorium-clinoid and the skull base tumors had radical subtotal and partial resections, and recurred after 16 and 1.5 months, respectively. All tumors but one, a non-recurrent one, presented no signs of histological anaplasia. The proliferative capacity, as assessed by MIB-1 staining index (SI), of recurrent tumors was slightly higher than that of those tumors that did not recur. All cases showed DNA diploid pattern. Amianthoid-type fibers were disclosed on ultrastructural study. CCM arose in patients younger than those with other variants of meningioma, the spinal canal and the posterior fossa were the common sites. Finally, intracranial tumors were linked to an aggressive behavior.

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A case of syringomyelia secondary to an extramedullary cervical spinal cord compression by a non-Hodgkin's lymphoma is described. After radiotherapy, the syrinx was no longer seen. The pathogenesis of this type of syrinx is discussed, and the potential benefit of radiotherapy in these cases is suggested.

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Three patients with normal pressure hydrocephalus and Parkinson's disease are reported. The recognition of this association is important because these two entities require specific therapeutic approaches. The presence of Parkinson's disease does not preclude an excellent response of the hydrocephalus to a shunting procedure. Although several reports of cases with the characteristic clinical manifestations of normal pressure hydrocephalus--progressive dementia, gait difficulty and urinary incontinence--have been published earlier, it was Adams and Hakim who emphasized the clinical triad and the effect of shunting the cerebrospinal fluid as a means of treatment. Messert and Baker stressed that the gait disturbance had a close resemblance to the freezing gait of parkinsonism. We are reporting three patients who had both conditions. Recognition of the existence of both disorders in the same patients is important since appropriate treatment of each of them led to marked improvement of their symptoms.

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Arteriovenous malformations have only rarely been implicated as a cause of basal ganglia dysfunction. In four instances where such a lesion was uncovered, abnormal involuntary movements were present. In two, tremor involving the contralateral limbs occurred, while in others the head and neck were involved in dystonic movements and posture. The clinical and angiographic characteristics of these four patients have been assessed and are presented in detail in this report. The possible mechanism by which arteriovenous malformations may disturb the internal circuitry of the basal ganglia and induce symptoms are discussed.

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Thirty patients with postencephalitic Parkinsonism were treated with levodopa. In seven patients, treatment was withdrawn because of adverse reactions or insufficient benefit. Improvements observed in 26 patients who remained on treatment for a sufficient period to permit adequate assessment were comparable with those previously reported in Parkinson's disease. Some sequelae of encephalitis lethargica-notably, oculogyria and drooling-were appreciably improved in most patients affected, whereas choreoathetoid dyskinesias were aggravated by levodopa. Adventitious choreiform involuntary movements and behaviour disorders were the major side-effects. Patients with postencephalitic Parkinsonism may respond as well as patients with Parkinson's disease to levodopa but they develop both favourable responses and side-effects at a lower dosage and require careful dosage adjustments and close surveillance.

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Psychiatric aspects of patients with Parkinsonism treated with L-dopa are described. These include acute psychosis in patients with or without previous psychiatric illness and worsening or improvement of pre-existing psychiatric conditions. Therapeutic management is discussed The relevance of these studies to the understanding of the psychiatric aspects of Parkinsonism in general is discussed.

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