The State of Machine Learning in Outcomes Prediction of Transsphenoidal Surgery: A Systematic Review.

The purpose of this analysis is to assess the use of machine learning (ML) algorithms in the prediction of postoperative outcomes, including complications, recurrence, and death in transsphenoidal surgery. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed all papers that used at least one ML algorithm to predict outcomes after transsphenoidal surgery. We searched Scopus, PubMed, and Web of Science databases for studies published prior to May 12, 2021. We identified 13 studies enrolling 5,048 patients. We extracted the general characteristics of each study; the sensitivity, specificity, area under the curve (AUC) of the ML models developed as well as the features identified as important by the ML models. We identified 12 studies with 5,048 patients that included ML algorithms for adenomas, three with 1807 patients specifically for acromegaly, and five with 2105 patients specifically for Cushing's disease. Nearly all were single-institution studies. The studies used a heterogeneous mix of ML algorithms and features to build predictive models. All papers reported an AUC greater than 0.7, which indicates clinical utility. ML algorithms have the potential to predict postoperative outcomes of transsphenoidal surgery and can improve patient care. Ensemble algorithms and neural networks were often top performers when compared with other ML algorithms. Biochemical and preoperative features were most likely to be selected as important by ML models. Inexplicability remains a challenge, but algorithms such as local interpretable model-agnostic explanation or Shapley value can increase explainability of ML algorithms. Our analysis shows that ML algorithms have the potential to greatly assist surgeons in clinical decision making.

Synovial cysts at the cervicothoracic junction: Illustrative series of three cases.

Background: Spinal synovial cysts are an uncommon pathology, estimated to affect 0.65-2.6% of the population. Cervical spinal synovial cysts are even rarer, accounting for only 2.6% of spinal synovial cysts. They are more commonly found in the lumbar spine. When they occur, they can compress the spinal cord or surrounding nerve roots resulting in neurological symptoms, particularly when they increase in size. Decompression and cyst resection are the most common treatment and typically result in resolution of symptoms. Methods: The authors present three cases of spinal synovial cysts occurring at the C7-T1 junction. They occurred in patients aged 47, 56, and 74, respectively, and presented with symptoms of pain and radiculopathy. Diagnosis was made with computed tomography (CT) scan and magnetic resonance imaging (MRI). The cysts were managed with laminectomy, resection, and fusion. Results: All patients reported full resolution of symptoms. There were no intra or postoperative complications. Conclusion: Cervical spinal synovial cysts are an uncommon cause of radiculopathy and pain in the upper extremities. They can be diagnosed through CT scans and MRI, and treatment with laminectomy, resection, and fusion results in excellent outcomes.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair.

Introduction There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique. Methods Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran's I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001.  Results  There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively). Conclusions Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.

Chronic allergic fungal sinusitis invading the skull base in an immunocompetent male: illustrative case.

BACKGROUND: Allergic fungal sinusitis (AFS) is an immunoglobulin E-mediated reaction to fungal organisms in the sinonasal region and can be categorized as acute or chronic. Acute infection is typical in immunocompromised patients, while chronic infection is classically seen in immunocompetent patients. Spread of infection to the skull base is a rare and potentially lethal complication of prolonged infection. Surgical management is frequently augmented with steroid therapy to prevent recurrence. OBSERVATIONS: The authors present a case of a 20-year-old African American male with prolonged headaches and blurred vision who was diagnosed with chronic invasive fungal sinusitis resulting in invasion of fungal burden into the anterior skull base and the posterior aspect of the clivus, in addition to complete obliteration of the maxillary sinus. The patient was managed surgically without complication and with gradual improvement in vision. LESSONS: Early management and detection of AFS should be a focus to prevent erosion of the fungal burden into the skull base. Neurosurgery and ear, nose, and throat surgery have a multidisciplinary role in the management of advanced AFS cases.

Cholic acid-based novel micellar nanoplatform for delivering FDA-approved taxanes.

AIM: To structurally modify our existing cholic acid (CA)-based telodendrimer (TD; PEG5K-CA8) for effective micellar nanoencapsulation and delivery of the US FDA-approved members of taxane family. MATERIALS & METHODS: Generation of hybrid TDs was achieved by replacing four of the eight CAs with biocompatible organic moieties using solution-phase peptide synthesis. Drug loading was done using the standard evaporation method. RESULTS: Hybrid TDs can generate micelles with narrow size distributions, low critical micelle concentration values (1-6 µM), better hematocompatibility and lack of in vitro cytotoxicity. CONCLUSION: Along with PEG5K-CA8, CA-based hybrid nanoplatform is the first of its kind that can stably encapsulate all three FDA-approved taxanes with nearly 100% efficiency up to 20% (w/w) loading.