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Singh N, Sarna R, Tripathi M, Chauhan R, Kumar S. Anesthetic Challenges in a Patient of Morquio Syndrome Associated with Acromegaly. Ann Neurosci 2023; 29:245-248. [PMID: 37064287 PMCID: PMC10101157 DOI: 10.1177/09727531221137403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 02/03/2023] Open
Abstract
Background Morquio syndrome is one of the rare storage disorders associated with excessive deposition of keratin sulfate and chondroitin-6-sulfate in bones, cartilages, heart valves, and cornea. Although most individuals with this syndrome appear normal at birth; skeletal abnormalities often develop within the first year of life. Restricted breathing, joint stiffness, and cardiac abnormalities are also common. The multisystem involvement in these patients poses unique anesthestic challenges and there is a paucity of literature regarding the anesthetic management of patients with this condition. Case Report We report a successful management of a rare case of 34 years old male with Morquio syndrome who presented an association of acromegaly and was planned for surgical resection of the tumor under general anesthesia. Conclusion Such rare disorders primarily require thorough knowledge about the disease, its presentation and management strategies for a better outcome. Keeping in mind the multisystem involvement a proper teamwork and coordination of various specialities becomes an utmost importance.
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Affiliation(s)
- Nidhi Singh
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashi Sarna
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Kumar
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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Bindra A, Bharadwaj S, Mishra N, Masapu D, Bhargava S, Luthra A, Marda M, Hrishi AP, Bhagat H, Bidkar PU, Vanamoorthy P, Ali Z, Khan MA. Preanesthetic Evaluation and Preparation for Neurosurgical Procedures: An Indian Perspective. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1749649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Background A questionnaire-based survey was conducted to determine the preanesthetic evaluation (PAE) practices among the members of the Indian Society of Neuroanesthesiology and Critical Care (ISNACC). The survey aimed to assess the current clinical practice of PAE and optimization of neurosurgical patients in India.
Methods An online questionnaire was designed by the working group of ISNACC and circulated among its active members. Response to individual questions was considered significant if 50% or more respondents concurred. The survey questions to which less than 50% of respondents concurred were identified as inconclusive results.
Results Out of 438 active ISNACC members, 218 responded. Responses were obtained from various parts of the country. The majority of participants were practicing neuroanesthesiology. Questions asked were regarding clinical assessment, preoperative optimization, prognostication, and airway management in neurosurgery. More than 50% of practitioners acceded to most of the questions; however, the percentage of responses varied across different questions (50–100%). The questions related to preoperative duplex scanning in chronically immobilized patients, preoperative cognitive testing, and risk stratification during neurosurgical procedures received an inconclusive response (< 50%).
Conclusion The survey highlights the variable PAE practices perused by ISNACC members across the country. A guideline for uniform PAE practices may help to enhance research and improve perioperative care.
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Affiliation(s)
- Ashish Bindra
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Suparna Bharadwaj
- Department of Neuroanesthesiology and Neurocritical Care, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India
| | - Nitasha Mishra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Dheeraj Masapu
- Department of Neuroanesthesia, Sakra World Hospital, Bangalore, Karnataka, India
| | - Saurabh Bhargava
- Department of Emergency Medicine, National Institute of Medical Sciences Medical College, Jaipur, Rajasthan, India
| | - Ankur Luthra
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Marda
- Department of Neuroanaesthesia and Critical Care, Max Super-Specialty Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
| | - Ajay P. Hrishi
- Department of Neuroanaesthesia, Sree Chitra Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prasanna U. Bidkar
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ponniah Vanamoorthy
- Department of Neurocritical Care and Neuroanaesthesiology, MGM Healthcare PVT. LTD., Chennai, Tamil Nadu, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology and Critical Care, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Maroof A. Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Flukes S, Laufer I, Cracchiolo J, Geer E, Lin AL, Brallier J, Tsui V, Afonso A, Tabar V, Cohen MA. Integration of an enhanced recovery after surgery program for patients undergoing pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2022; 8:330-338. [PMID: 36474665 PMCID: PMC9714042 DOI: 10.1016/j.wjorl.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/01/2021] [Indexed: 02/09/2023] Open
Abstract
Evidence-based enhanced recovery after surgery (ERAS) programs aim to improve patient outcomes and shorten hospital stays. The objective of this study is to describe the development, implementation, and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors. A systematic review of the literature was performed, best practices were discussed with stakeholders, and institutional guidelines were established and implemented. Key performance indicators (KPI) were measured and patient-reported outcome surveys were collected. The ERAS protocol was introduced successfully at our institution. We describe the process of initiation of the program and the perioperative management of our patients. We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement, with a particular emphasis on the use of data informatics and metrics to monitor outcomes. We expect that this approach will translate to improved quality of care for these often-complex patients.
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Affiliation(s)
- Stephanie Flukes
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Ilya Laufer
- Department of NeurosurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jennifer Cracchiolo
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Andrew L. Lin
- Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jess Brallier
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Van Tsui
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Anoushka Afonso
- Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Viviane Tabar
- Department of NeurosurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Marc A. Cohen
- Head and Neck Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNYUSA,Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31-81. [PMID: 34762729 DOI: 10.1097/aln.0000000000004002] [Citation(s) in RCA: 314] [Impact Index Per Article: 157.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
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Kapoor I, Mahajan C, Prabhakar H. Assessment of Airway in Patients with Acromegaly Undergoing Surgery: Predicting Successful Tracheal Intubation. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0039-1692550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
AbstractBackground In the field of anesthesia, acromegaly is considered a cause of difficult tracheal intubation and airway management. There is a high probability of unanticipated difficult intubation in acromegalic patients despite a lower percentage of patients being identified preoperatively as having a difficult airway. In this study, we carried out various airway assessment tests preoperatively and during induction of anesthesia to find out the predictors of easy tracheal intubation in patients with acromegaly.Methods All patients of either sex, diagnosed as a case of acromegaly and scheduled to undergo pituitary surgery were enrolled over a period of 3 years. Various airway assessment tests were performed prior to surgery, which included modified Mallampati (MP) classification (sitting and supine), mouth opening (MO), upper lip bite test (ULBT), neck movement (NM), thyromental (TM) distance, thyrohyoid (TH) distance, sternomental (SM) distance, hyomental (HM) distance, length of upper incisors (IL), receding mandible (RM), any history of obstructive sleep apnea (OSA), mask ventilation (MV), Cormack-Lehane (CL) III and IV, and external laryngeal manipulation (ELM). Results were reported as odds ratios (95% confidence interval [CI]). The p-value < 0.05 was considered statistically significant.Results A total of 42 patients were enrolled over a period of 3 years. The male-to-female ratio was 19:23 with a mean age of 37.95 years and mean weight of 72.7 kg. Out of 15 airway assessment parameters, only ULBT and CL grade showed significant results.Conclusion We conclude that ULBT and CL grading are reliable predictors of easy intubation in patients with acromegaly undergoing surgery.
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Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Mallampati test with phonation, tongue protrusion and supine position is most correlated with Cormack-Lehane test. Odontology 2020; 108:617-625. [PMID: 32040653 DOI: 10.1007/s10266-020-00490-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
Many modified Mallampati tests have been developed to date. Samsoon's modified Mallampati test (standard Mallampati test) is currently widely used. We newly designed seven types of assessment protocol of Mallampati test, in addition to standard Mallampati test. In this study, we studied the correlation between eight types of protocol (standard and seven alternative protocols) of Mallampati test and Cormack-Lehane test. We newly designed assessment protocols as new Mallampati test. These are different protocols depending on the presence or absence of phonation, those of protrusion of tongue, and sitting position or supine position. The oropharyngeal structures visualized by these eight types of Mallampati test for total of 145 patients undergoing dental oral surgery were evaluated. The scores derived via eight types of Mallampati test were recorded. The influence of phonation, tongue protrusion and body position on Mallampati test score was analyzed, respectively. The relationships between eight types of Mallampati test and Cormack-Lehane test were analyzed. Tongue protrusion, phonation and sitting position tended to lower the score of Mallampati test (p < 0.001, respectively). The standard Mallampati test was not correlated with Cormack-Lehane test. In the new Mallampati tests, assessment protocol with tongue protrusion, phonation and sitting position, that with tongue protrusion and supine position, or that with tongue protrusion, phonation and supine position were significantly correlated with Cormack-Lehane test, respectively. (p = 0.020, p = 0.007 and p = 0.004, respectively). The standard Mallampati test did not correlate with Cormack-Lehane test. Mallampati test with phonation, tongue protrusion and supine position were most correlated with Cormack-Lehane test.
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Lee HC, Kim MK, Kim YH, Park HP. Radiographic Predictors of Difficult Laryngoscopy in Acromegaly Patients. J Neurosurg Anesthesiol 2019; 31:50-56. [DOI: 10.1097/ana.0000000000000471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Mukaihara K, Hasegawa-Moriyama M, Iwasaki T, Yamasaki Y, Kanmura Y. Evaluation of the pharyngeal airway using computational fluid dynamics in patients with acromegaly. Laryngoscope Investig Otolaryngol 2018; 3:133-138. [PMID: 29721547 PMCID: PMC5915828 DOI: 10.1002/lio2.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/06/2018] [Accepted: 03/01/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives Perioperative airway management may be particularly challenging in patients with acromegaly undergoing trans‐sphenoidal pituitary surgery (TSS). Management for airway obstruction is required prior to pituitary surgery to minimize perioperative hypoxia. The purpose of this retrospective study was to evaluate airway obstruction by simulation of computational fluid dynamics (CFD) using computed tomography (CT) images in patients who had undergone TSS. Methods CT images of the nasopharyngeal airways of patients with acromegaly (n = 5) or nonfunctional pituitary adenoma (n = 6) undergoing TSS from April 2012 to January 2017 were used to construct these airways in three dimensions. Estimated airflow pressure and velocity in the retropalatal airway (RA), oropharyngeal airway (OA), and hypopharyngeal airway (HA) were simulated using CFD. Results Estimated pharyngeal airflow pressure in the HA, OA, and RA was significantly greater in patients with acromegaly than in those with nonfunctional pituitary adenomas whereas the estimated pharyngeal airflow velocity was significantly impaired only in the RA of patients with acromegaly. Minimum postoperative SpO2 both within 3 hours and from 3 to 12 hours after the end of anesthesia was significantly lower in the patients with acromegaly. Additionally, estimated volume of tongue and pharyngeal airflow pressure in the HA, OA, and RA correlated with minimum postoperative SpO2. Conclusion Pharyngeal airflow pressure estimated from CT images is high in patients with acromegaly, and these values correlate with postoperative minimum values for SpO2. Preoperative evaluation of CT images by CFD can predict difficulty in airway management and perioperative hypoxia. Level of Evidence 4.
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Affiliation(s)
- Keika Mukaihara
- Department of Anesthesiology and Critical Care Medicine Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Maiko Hasegawa-Moriyama
- Department of Anesthesiology and Critical Care Medicine Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Tomonori Iwasaki
- Department of Pediatric Dentistry Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Youichi Yamasaki
- Department of Pediatric Dentistry Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Yuichi Kanmura
- Department of Anesthesiology and Critical Care Medicine Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
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Abstract
PURPOSE To investigate the characteristics of difficult intubation and identify novel efficient predictors in patients with acromegaly. METHODS Patients with either untreated acromegaly or non-functional pituitary adenomas were enrolled. Patients with acromegaly underwent hormone assays, upper airway computed tomography and magnetic resonance imaging examinations and preoperative overnight polysomnography. The modified Mallampati classification, mouth opening, neck circumference, and neck extension were assessed, and the Cormack-Lehane grades and the time of tracheal intubation were recorded. RESULTS Patients with acromegaly had a higher incidence of difficult intubation (62.5%). The time of tracheal intubation was prolonged, the neck circumference was enlarged, and the neck extension was confined. In patients with acromegaly and difficult intubation, the insulin-like growth factor 1 levels and apnea/hypoxia index were significantly higher compared to patients without difficult intubation (1115.40 ± 253.73 vs. 791.67 ± 206.62 ng/ml, P = 0.020; 22.17 ± 23.25 vs. 2.47 ± 2.84, P = 0.026, respectively). The bilateral regression analysis revealed that high levels of insulin-like growth factor 1 were an independent risk factor for developing difficult intubation (p = 0.042, Exp B = 1.006). The modified Mallampati classification was positively correlated with apnea/hypoxia index and could be calculated using the following logarithmic equation: MMC = 0.2982 * ln (AHI) + 2.1836. CONCLUSIONS In patients with acromegaly, neck movement is confined, the time of tracheal intubation is prolonged, and the neck circumference is enlarged, and these patients suffer from an increased incidence of difficult intubation (62.5%) during anesthesia induction. The apnea/hypoxia index and insulin-like growth factor 1 levels are both increased in acromegalic patients with difficult intubation, and elevated insulin-like growth factor 1 levels are an independent risk factor of difficult intubation in acromegalic patients.
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Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zhuhua Zhang
- Department of Radiography, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
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