Historical and future trends in emergency pituitary referrals: a machine learning analysis.

PURPOSE: Acute pituitary referrals to neurosurgical services frequently necessitate emergency care. Yet, a detailed characterisation of pituitary emergency referral patterns, including how they may change prospectively is lacking. This study aims to evaluate historical and current pituitary referral patterns and utilise state-of-the-art machine learning tools to predict future service use. METHODS: A data-driven analysis was performed using all available electronic neurosurgical referrals (2014-2021) to the busiest U.K. pituitary centre. Pituitary referrals were characterised and volumes were predicted using an auto-regressive moving average model with a preceding seasonal and trend decomposition using Loess step (STL-ARIMA), compared against a Convolutional Neural Network-Long Short-Term Memory (CNN-LSTM) algorithm, Prophet and two standard baseline forecasting models. Median absolute, and median percentage error scoring metrics with cross-validation were employed to evaluate algorithm performance. RESULTS: 462 of 36,224 emergency referrals were included (referring centres = 48; mean patient age = 56.7 years, female:male = 0.49:0.51). Emergency medicine and endocrinology accounted for the majority of referrals (67%). The most common presentations were headache (47%) and visual field deficits (32%). Lesions mainly comprised tumours or haemorrhage (85%) and involved the pituitary gland or fossa (70%). The STL-ARIMA pipeline outperformed CNN-LSTM, Prophet and baseline algorithms across scoring metrics, with standard accuracy being achieved for yearly predictions. Referral volumes significantly increased from the start of data collection with future projected increases (p < 0.001) and did not significantly reduce during the COVID-19 pandemic. CONCLUSION: This work is the first to employ large-scale data and machine learning to describe and predict acute pituitary referral volumes, estimate future service demands, explore the impact of system stressors (e.g. COVID pandemic), and highlight areas for service improvement.

FEL performance achieved at PAL-XFEL using a three-chicane bunch compression scheme.

PAL-XFEL utilizes a three-chicane bunch compression (3-BC) scheme (the very first of its kind in operation) for free-electron laser (FEL) operation. The addition of a third bunch compressor allows for more effective mitigation of coherent synchrotron radiation during bunch compression and an increased flexibility of system configuration. Start-to-end simulations of the effects of radiofrequency jitter on the electron beam performance show that using the 3-BC scheme leads to better performance compared with the two-chicane bunch compression scheme. Together with the high performance of the linac radiofrequency system, it enables reliable operation of PAL-XFEL with unprecedented stability in terms of arrival timing, pointing and intensity; an arrival timing jitter of better than 15 fs, a transverse position jitter of smaller than 10% of the photon beam size, and an FEL intensity jitter of smaller than 5% are consistently achieved.

A national evaluation of the management practices of acute diverticulitis.

INTRODUCTION: Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases. METHODS: A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated. RESULTS: Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required. CONCLUSION: This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.

Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions.

Introduction: Microsurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons. Materials and Methods: Consultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis. Results: The most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning. Conclusions: While some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.