In this paper a Computer Aided Detection (CAD) system is presented to automatically detect Cerebral Microbleeds (CMBs) in patients with Traumatic Brain Injury (TBI). It is believed that the presence of CMBs has clinical prognostic value in TBI patients. To study the contribution of CMBs in patient outcome, accurate detection of CMBs is required. Manual detection of CMBs in TBI patients is a time consuming task that is prone to errors, because CMBs are easily overlooked and are difficult to distinguish from blood vessels.This study included 33 TBI patients. Because of the laborious nature of manually annotating CMBs, only one trained expert manually annotated the CMBs in all 33 patients. A subset of ten TBI patients was annotated by six experts. Our CAD system makes use of both Susceptibility Weighted Imaging (SWI) and T1 weighted magnetic resonance images to detect CMBs. After pre-processing these images, a two-step approach was used for automated detection of CMBs. In the first step, each voxel was characterized by twelve features based on the dark and spherical nature of CMBs and a random forest classifier was used to identify CMB candidate locations. In the second step, segmentations were made from each identified candidate location. Subsequently an object-based classifier was used to remove false positive detections of the voxel classifier, by considering seven object-based features that discriminate between spherical objects (CMBs) and elongated objects (blood vessels). A guided user interface was designed for fast evaluation of the CAD system result. During this process, an expert checked each CMB detected by the CAD system.A Fleiss' kappa value of only 0.24 showed that the inter-observer variability for the TBI patients in this study was very large. An expert using the guided user interface reached an average sensitivity of 93%, which was significantly higher (p = 0.03) than the average sensitivity of 77% (sd 12.4%) that the six experts manually detected. Furthermore, with the use of this CAD system the reading time was substantially reduced from one hour to 13 minutes per patient, because the CAD system only detects on average 25.9 false positives per TBI patient, resulting in 0.29 false positives per definite CMB finding.

Objective and design: The endoscopic technique has been recently introduced in the field of transsphenoidal pituitary surgery. This technique allows inspection of sellar, supra-and parasellar structures and removal of the tumor under direct visualization, is minimally traumatic and permits easier reoperations. This is the first report on the results of endoscopic surgery for patients with Cushing's disease. Our aim was to retrospectively analyze the results of pituitary surgery in 35 consecutive patients with Cushing's disease operated in our hospital after the introduction of the endoscopic technique (1998 -2004). Methods: Remission was defined as suppression of plasma cortisol (# 50 nmol/L) after 1 mg dexamethasone overnight determined in the first 3 months after surgery and disappearance of clinical signs and symptoms of hypercortisolism. The patients were followed for an average of 27 months (range 4 to 81 months, median 20 months). Results: Pituitary MRI showed a macroadenoma in 6 patients, a microadenoma in 17 patients and no adenoma in 12 patients. After the initial surgery 27 patients (77%) were in remission. None of the patients had a relapse during follow-up. In the remaining 8 patients hypercortisolemia persisted after surgery. Three of them had a second endoscopic pituitary surgery resulting in remission in two patients. In one patient a second endoscopic pituitary surgery will soon follow. The remaining four patients were treated with radiotherapy postoperatively. Two of them were at the time of data collection in remission. One patient from the remission group had a serious epistaxis and three patients had cerebrospinal fluid leakage, one requiring an external lumbar drain, shortly after surgery. No complications were recorded in the failure group. Postoperatively 34% of all patients required substitution with levothyroxine, 40% required substitution with glucocorticoids, 17% received estrogens or testosterone and 6% still required desmopressin. Conclusions: Endoscopic transsphenoidal pituitary surgery resulted in our series of patients with Cushings disease in an excellent postoperative remission rate. A randomized clinical trial, comparing endoscopic and conventional pituitary surgery in patients with Cushings disease, is needed to determine the pros and cons of both techniques.European Journal of Endocrinology 154 675-684

Contrary to the findings in mice, circulating sclerostin is decreased in patients with chronic endogenous hypercortisolism and increases after treatment. These findings suggest that in humans, chronic exposure to glucocorticoids affects the number or function of osteocytes rather than the production of sclerostin.

Context: A wide range (15-56%) of prevalences of anterior pituitary insufficiency are reported in patients after traumatic brain injury (TBI). However, different study populations, study designs, and diagnostic procedures were used. No data are available on emergency-department-based cohorts of TBI patients. Objective: To assess the prevalence of pituitary dysfunction in an emergency-department-based cohort of TBI patients using strict endocrinological diagnostic criteria. Methods: Of all the patients presenting in the emergency department with TBI over a 2-year period, 516 matched the inclusion criteria. One hundred and seven patients (77 with mild TBI and 30 with moderate/severe TBI) agreed to participate. They were screened for anterior pituitary insufficiency by GHRH-arginine testing, evaluation of fasting morning hormone levels (cortisol, TSH, free thyroxine, FSH, LH, and 17b-estradiol or testosterone), and menstrual history 3-30 months after TBI. Abnormal screening results were defined as low peak GH to GHRH-arginine, or low levels of any of the end-organ hormones with low or normal pituitary hormone levels. Patients with abnormal screening results were extensively evaluated, including additional hormone provocation tests (insulin tolerance test, ACTH stimulation test, and repeated GHRH-arginine test) and assessment of free testosterone levels. Results: Screening results were abnormal in 15 of 107 patients. In a subsequent extensive endocrine evaluation, anterior pituitary dysfunction was diagnosed in only one patient (partial hypocortisolism). Conclusion: By applying strict diagnostic criteria to an emergency-department-based cohort of TBI patients, it was shown that anterior pituitary dysfunction is rare (!1%). Routine pituitary screening in unselected patients after TBI is unlikely to be cost-effective.