Management and treatment of brain tumors during pregnancy: an Italian survey.

PURPOSE: The management of brain tumors during pregnancy is challenging. The clinical rarity and prognostic heterogeneity of such condition makes it difficult to develop standardized guidelines of treatment. The aim of this study was to assess the treatment options used in pregnant women with brain tumors that are currently used in Italy, considering the management of these patients reported in current literature in this field. METHODS: A survey addressing the treatments options and management of brain tumors during pregnancy was designed on behalf of an ad-hoc task-force Neuro-Oncology committee of the Società Italiana di Neurochirurgia (SINch) to analyze the management of pregnant patients with brain tumors. We conducted a search of the literature published between January 2011 and September 2021, using MEDLINE (PubMed) in accordance to PRISMA guidelines. Data were discussed to obtain recommendations after evaluation of the selected articles and discussion among the experts. RESULTS: A total of 18 Neurosurgical centers participated in the survey. A total of 31 pregnant women were included in this retrospective study. Meningiomas and gliomas were the two most common types of brain tumors diagnosed during pregnancy. An emergency surgical procedure was required in 12.9% of cases. CONCLUSION: A multidisciplinary and tailored approach is fundamental. In women showing clinical stability, neurosurgical options should preferably be delayed if possible, and considered during the second trimester or after delivery. In patients with acute neurological symptoms or tumor progression, medical abortion in the first trimester or a C-section in the second and third trimester need to be considered.

Home management of COVID-19 symptomatic patients: a safety study on COVID committed home medical teams.

To reduce the overburden in the hospital, during the COVID-19 pandemic, some "COVID Committed Home Medical Teams" (CCHTs) were created in Italy. These units consist of a small pool of general practitioners who aim to evaluate all patients with COVID-19 who require a medical examination directly at home. After the first visit (which can end with patient hospitalisation or home management), CCHTs periodically monitor the patients' clinical conditions and vital signs (usually a revaluation every 24-48 hours, except for a sudden worsening). However, this strategy - which reduces the pressure on hospitals - has never been evaluated for patient safety. Our study aims to determine whether a home-based monitoring and treatment strategy for non-severe COVID-19 patients was safe as direct hospital admission by the emergency department. We conducted a retrospective observational study about 1,182 patients admitted to the hospital for COVID-19 between September 2020 and April 2021, confronting in-hospital and 30-day mortality in both CCHT-referred (n=275) and directly admitted by emergency department (n=907). Patients assessed by the CCHT had lower in-hospital and 30-day mortality (18% vs 28%, p=0.001; and 20% vs 30%, p=0.002); but, in the propensity score matching comparison, there was no characteristic between the two groups turned out significantly different. CCHT did not correlate with in-hospital or 30-day mortality. CCHT is a safe strategy to reduce hospital overburden for COVID-19 during pandemic surges.

Development and Validation of the Acute PNeumonia Early Assessment Score for Safely Discharging Low-Risk SARS-CoV-2-Infected Patients from the Emergency Department.

A continuous demand for assistance and an overcrowded emergency department (ED) require early and safe discharge of low-risk severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients. We developed (n = 128) and validated (n = 330) the acute PNeumonia early assessment (aPNea) score in a tertiary hospital and preliminarily tested the score on an external secondary hospital (n = 97). The score's performance was compared to that of the National Early Warning Score 2 (NEWS2). The composite outcome of either death or oral intubation within 30 days from admission occurred in 101 and 28 patients in the two hospitals, respectively. The area under the receiver operating characteristic (AUROC) curve of the aPNea model was 0.86 (95% confidence interval (CI), 0.78-0.93) and 0.79 (95% CI, 0.73-0.89) for the development and validation cohorts, respectively. The aPNea score discriminated low-risk patients better than NEWS2 at a 10% outcome probability, corresponding to five cut-off points and one cut-off point, respectively. aPNea's cut-off reduced the number of unnecessary hospitalizations without missing outcomes by 27% (95% CI, 9-41) in the validation cohort. NEWS2 was not significant. In the external cohort, aPNea's cut-off had 93% sensitivity (95% CI, 83-102) and a 94% negative predictive value (95% CI, 87-102). In conclusion, the aPNea score appears to be appropriate for discharging low-risk SARS-CoV-2-infected patients from the ED.

Acute kidney injury and single-dose administration of aminoglycoside in the Emergency Department: a comparison through propensity score matching.

Purpose: According to the Surviving Sepsis Campaign, aminoglycosides (AG) can be administered together with a ß-lactam in patients with septic shock. Some authors propose administering a single dose of an AG combined with a ß-lactam antibiotic in septic patients to extend the spectrum of antibiotic therapy. The aim of this study has been to investigate whether a single shot of AG when septic patients present at the Emergency Department (ED) is associated with acute kidney injury (AKI). Methods: We retrospectively enrolled patients based on a 3-year internal registry of septic patients visited in the Emergency Department (ED) of Pordenone Hospital. We compared the patients treated with a single dose of gentamicin (in addition to the ß-lactam) and those who had not been treated to verify AKI incidence. Results: 355 patients were enrolled. The median age was 71 years (IQR 60-78). Less than 1% of the patients had a chronic renal disease. The most frequent infection source was the urinary tract (31%), followed by intra-abdominal and lower respiratory tract infections (15% for both). 131 patients received gentamicin. Unmatched data showed a significant difference between the two groups in AKI (79/131, 60.3% versus 102/224, 45.5%; p=0.010) and in infectious disease specialist's consultation (77/131, 59% versus 93/224, 41.5%; p=0.002). However, after propensity score matching, no significant difference was found. Conclusion: Our experience shows that a single-shot administration of gentamicin upon admission to the ED does not determine an increased incidence of AKI in septic patients.

The gender impact in the era of COVID-19: an Italian neurosurgical perspective.

BACKGROUND: The aim of this study was to understand the impact of SARS-COVID-19 disease on neurosurgeons and our profession; specifically, to trace the role of women, in particular young neurosurgeons, in addressing this health emergency. METHODS: This cross-sectional study evaluated the impact of SARS-COVID-19 disease on Italian neurosurgeons stratified by gender [44 (49.9%) males and 49 (52,1%) females] enrolled through a questionnaire-based online survey. RESULTS: Ninety-three Italian neurosurgeons were included in this study. The percentage of female participants was 52,1%(49) and 53%(50) were younger than 40 years. Men were significantly more affected than women by complications (14 versus 3), while there was no gender difference in the Covid infection rate. Furthermore the social impact of the Pandemia was the same between men and women. CONCLUSIONS: Our analysis did not show significant differences between the two genders in the susceptibility, and mortality from COVID-19. The possible and immediate implementation of anti-COVID-19 measures and devices, associated with a lower risk of transmission in the treatment of neurosurgical pathologies, has likely, moderated and disregarded the socio-psychological "gender gap" of the Covid-19 pandemic.

Diffuse low grade glioma and pregnancy: Practical considerations and clinical tips.

OBJECTIVE: The interaction between pregnancy and diffuse low-grade glioma (DLGG) is poorly investigated. The goal of this study was to provide further insights into the relationship between pregnancy and DLGG. METHODS: A total of 12 patients were selected from a shared database of DLGGs, according to the following inclusion criteria: DLGG diagnosis in post-partum, DLGG recurrence after pregnancy in patients previously operated for DLGG. The extent of surgical resection (EOR) at first surgery were evaluated. All cases were assessed based on the 2016 WHO classification. The tumor growing patter, expresses by preoperative ΔT2T1 MRI index was evaluated. RESULTS: In four cases newly diagnosed DLGG were detected patients in post-partum. Seven women, previously operated for DLGG, experienced pregnancy during the natural history of glioma, and were affected by tumor recurrence after pregnancy. One singular had an incidental LGG not surgically treated, who presented an important tumor growth after pregnancy. Radiological and surgical data were discussed according to literature. CONCLUSIONS: Pregnancy does not seem to have an impact on the survival of women with DLGG. The potential role of pregnancy as risk factor in tumor recurrence is described, however, not proven. In this regard, the association between pregnancy and Tumor recurrence is extremely doubtful, and currently attributable to the simple coincidence. Further multicenter molecular investigations are required to better understand the mechanisms by which the pregnancy, in patients with a pervious surgery for DLGG, may influence tumor regrowth in comparison with the natural history of the disease.

From the Champion to the Team: New Treatment Paradigms in Contemporary Neurosurgery.

In our discipline, neurosurgery, the role of the leader has evolved and has been complemented by the collaboration of specific professionals of different disciplines, aiming at the overall result of curing people and defeating the disease. Indeed, the multidisciplinary cooperation and the innovative strength of a team composed of different specialists such as radiologists, anesthesiologists, pathologists, molecular biologists, geneticists, oncologists, psychologists, physiatrists, physiotherapists, neurologists, engineers, mathematics, statisticians, and economists, greatly has changed the way we see the patient and treat pathology: from a single to multiperspective vision, thus generating a synergy that improves the surgeon's and the overall work. An old African adage goes like this: "If you want to go fast, go alone. if you want to go far, go together," which in our opinion fully summarizes the sense of our contribution on the state of the art in neurosurgical contemporary practice.

Spheno-Orbital Meningiomas: When the Endoscopic Approach Is Better.

Spheno-orbital meningiomas were historically treated by traditional craniotomies. However, in the past few years new endoscopic treatments have been successfully performed. In this study, we analyzed different indications for craniotomy and endoscopy, and the advantages and disadvantages of these procedures.Thirty patients with spheno-orbital meningiomas were operated on over 2 years, between 2013 and 2014. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed in all patients preoperatively. Navigated surgical removal and histological confirmation, as well as follow-up examinations, including CT scan at 24 h and MRI at 3, 6, and 12 months after surgery, were performed. Twenty-three patients were treated by traditional fronto-temporal, fronto-temporo-orbital, and supraorbital craniotomies; in six cases the tumor was removed via endoscopic endonasal and lateral transorbital resection. Only one case required a combined supraorbital and endoscopic endonasal approach.We analyzed the results of the different surgical techniques, in particular those of the endoscopic approaches.In selected cases, the endoscopic approach to spheno-orbital meningiomas, compared with traditional approaches, may be more effective in removing tumors completely. The surgical technique is easy and the rate of complications is low.

Transorbital endoscopic approaches to the skull base: current concepts and future perspectives.

INTRODUCTION: Transorbital endoscopic surgery is one of the most recent fields of skull base surgery. This paper presents the emerging applications of transorbital endoscopic approaches to the skull base and their current results on the treatment of selected extradural and intradural lesions, based on a review of meta-analysis and recent clinical series. EVIDENCE ACQUISITION: A PubMed, Cochrane and Ovid search for articles published from 2000 to 2015 was performed using the search terms "endoscopic skull base surgery", "transorbital endoscopic approach", and "transorbital neuroendoscopic surgery". No anatomical or preclinical studies were included in the present review. Among the clinical case series available, only those describing transorbital approaches to the skull base have been considered, excluding from the analysis the studies addressing the orbit and orbital pathologies. EVIDENCE SYNTHESIS: Although performed in extremely selected cases, there is a growing body of evidence suggesting that this technique may be effective for the treatment of cerebrospinal fluid leaks, for the drainage of epidural abscess or hematoma, and for the removal of several skull base tumors such as spheno-orbital meningioma. For the treatment of intradural pathologies there is only anecdotal evidence suggesting effectiveness and safety. Factors that may contribute to the enhanced efficacy compared to traditional external approaches were the acceptable complication rates, the reduced hospitalization time and limited morbidity for the patients, avoiding the need for large external craniotomies and brain retraction. CONCLUSIONS: Minimally-invasive endoscopic skull base surgery has substantially evolved in the last decades through the collaboration of different teams around the world. The transorbital endoscopic approaches directed to the anterior and middle cranial base may represent safe and feasible techniques with great potential for new applications in the nearby future.