Clinical application of the "sellar barrier's concept" for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning analysis.

Background: Recently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach. Methods: We conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli "Federico II," were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets. Results: According to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10-6), MRI barrier: weak (p = 4.487 × 10-8), intraoperative barrier: strong (p = 2.788 × 10-7), and intraoperative barrier: weak (p = 2.191 × 10-10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10-8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively. Conclusions: There is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.

[Pituitary carcinoma: is it too late?] / Carcinoma pituitario: es demasiado tarde?

TITLE: Carcinoma pituitario: es demasiado tarde?

[Tumor-to-tumor: a wolf in sheep's clothing]. / Tumor-to-tumor: un lobo disfrazado de cordero.

TITLE: Tumor-to-tumor: un lobo disfrazado de cordero.

Surgical treatment of cerebellar hemangioblastomas.

BACKGROUND: Hemangioblastomas (HBL) are uncommon tumors of the central nervous system (CNS), corresponding to 1-2.5% of all intracranial tumors. They can present sporadically or in patients with von Hippel-Lindau (VHL) disease and are most often located in the cerebellum, brainstem, and spinal cord. VHL disease is a multiple neoplasia syndrome inherited in an autosomal dominant fashion and caused by a VHL suppressor gene deletion. We present our experience in the management of patients with cerebellar HBL. METHODS: Thirty consecutive patients with cerebellar HBL were included in this study. Hospital charts, radiological images, and operative records were reviewed. Modified Rankin scores were used to evaluate the clinical course. RESULTS: Thirty patients diagnosed with cerebellar HBL were operated. Complete total resection was achieved in 93% of the cases. Postoperatively, 83% of the patients showed good functional recovery. CONCLUSIONS: HBL of the cerebellum should be resected when symptomatic or when the tumor (or a tumor-associated cyst) shows signs of enlargement. Surgical intent should seek en bloc resection to minimize intraoperative bleeding. Patients with HBLs must be tested for VHL gene mutations, and in confirmed cases, relatives should be offered genetic counseling.

Congenital transmission of Trypanosoma cruzi: an operational outline for detecting and treating infected infants in north-western Argentina.

We designed a set of procedures for first-line local health services to detect and treat the congenital transmission of Trypanosoma cruzi at a province-wide scale, and field-tested the programme in the province of Tucumán, northwestern Argentina, from 1992 to 1994. The programme consists of routine screening of pregnant women for seroreactivity to T. cruzi, serological and parasitological follow-up of the newborn at least twice during the first year of age, treatment of the infected infants, and evaluation of the outcome. 927 (5.5%) of 16 842 pregnant women were seroreactive to T. cruzi by indirect haemagglutination assay and ELISA. Twenty-one (6.7%) of 315 newborns to seroreactive mothers were diagnosed as infected with T. cruzi parasites microhaematocrit concentration before 30 days of age. Five newborns who initially tested negative had a T. cruzi infection detected by microhaematocrit and/or serological techniques at 3 or 6 months of age. Thus, congenital infection was diagnosed in 26 (7.1%) infants born to seroreactive women and residing in houses free of triatomine bugs. Four of 6 infants born to seroreactive mothers died during the first year of age and had some evidence of T. cruzi infection; one of the deaths was attributed to T. cruzi based on clinical evidence. After specific treatment with nifurtimox or benznidazole, 30 of 32 infants remained parasitologically and serologically negative. This study shows the feasibility of controlling the incidence of congenitally acquired T. cruzi infections at a province-wide scale by means of a specific screening programme at first-line health services level.

[Shigellosis in Tucumán]. / Shigellosis en Tucumán

In 731 diarrhea cases studied from January 1971 to June 1973 in Tucumán a significant increase of shigellosis in eutrophic children was observed. The frequency of Shigella isolations, considering all the enteropathogens found, were: 15,5 %; 13 % and 21,3 % in 1971, 1972 and 1973, respectively (Table 1). All the strains of Shigella isolated belonged to the Shigella flexneri B or Shigella sonnei D groups, being the percentage for the former 78 % in 1971; 93 % in 1972 and 77 % in 1973 (Table 2). The age distribution of patients with shigellosis is shown in Table 3, the 87,7 % occurring within the first 3 years of life. S. flexneri B and S. sonnei D strains showed similar sensitivity to nalidixic acid, cephalosporines, chloramphenicol and trimethoprim plus sulfametoxazol; S. flexneri B was more susceptible to rifampicin, although this antibiotic was not used for therapeutics. A different sensitivity to kanamicin was observed being S. flexneri B, less susceptible than S. sonnei D, (Table 4). Fifty five percent of the cases showed clinical improvement after 48 h. of starting antibiotic treatment; 80 % after 72 h. and only 20 % required 96 or more for significant recovery. Although the number of patients with some degree of malnutrition was small, 7 out of the 8 cases studied required 72 h. or more for recovery.

Shigellosis en Tucumán / [Shigellosis in Tucumán]

In 731 diarrhea cases studied from January 1971 to June 1973 in Tucumán a significant increase of shigellosis in eutrophic children was observed. The frequency of Shigella isolations, considering all the enteropathogens found, were: 15,5

; 13

and 21,3

in 1971, 1972 and 1973, respectively (Table 1). All the strains of Shigella isolated belonged to the Shigella flexneri B or Shigella sonnei D groups, being the percentage for the former 78

in 1971; 93

in 1972 and 77

in 1973 (Table 2). The age distribution of patients with shigellosis is shown in Table 3, the 87,7

occurring within the first 3 years of life. S. flexneri B and S. sonnei D strains showed similar sensitivity to nalidixic acid, cephalosporines, chloramphenicol and trimethoprim plus sulfametoxazol; S. flexneri B was more susceptible to rifampicin, although this antibiotic was not used for therapeutics. A different sensitivity to kanamicin was observed being S. flexneri B, less susceptible than S. sonnei D, (Table 4). Fifty five percent of the cases showed clinical improvement after 48 h. of starting antibiotic treatment; 80

after 72 h. and only 20

required 96 or more for significant recovery. Although the number of patients with some degree of malnutrition was small, 7 out of the 8 cases studied required 72 h. or more for recovery.

Shigellosis en Tucumán / [Shigellosis in Tucumán]

In 731 diarrhea cases studied from January 1971 to June 1973 in Tucumán a significant increase of shigellosis in eutrophic children was observed. The frequency of Shigella isolations, considering all the enteropathogens found, were: 15,5

in 1971, 1972 and 1973, respectively (Table 1). All the strains of Shigella isolated belonged to the Shigella flexneri B or Shigella sonnei D groups, being the percentage for the former 78

in 1972 and 77

in 1973 (Table 2). The age distribution of patients with shigellosis is shown in Table 3, the 87,7

occurring within the first 3 years of life. S. flexneri B and S. sonnei D strains showed similar sensitivity to nalidixic acid, cephalosporines, chloramphenicol and trimethoprim plus sulfametoxazol; S. flexneri B was more susceptible to rifampicin, although this antibiotic was not used for therapeutics. A different sensitivity to kanamicin was observed being S. flexneri B, less susceptible than S. sonnei D, (Table 4). Fifty five percent of the cases showed clinical improvement after 48 h. of starting antibiotic treatment; 80

after 72 h. and only 20

required 96 or more for significant recovery. Although the number of patients with some degree of malnutrition was small, 7 out of the 8 cases studied required 72 h. or more for recovery.