The relative value of postoperative versus preoperative Karnofsky Performance Scale scores as a predictor of survival after surgical resection of glioblastoma multiforme.

The Karnofsky Performance Scale (KPS) score is a widespread metric to stratify patient prognosis and determine appropriate management in glioblastoma multiforme(GBM). Low preoperative KPS values have been associated with shorter overall survival (OS). However, surgical resection can have a dramatic effect on a patient's functional status which subsequently alters their KPS score. To determine the predictive value of preoperative verses postoperative KPS scores in terms of OS in patients with GBM. We conducted a retrospective review of 163 patients who underwent initial surgical intervention for pathologically proven GBM at our institution between 2003 and 2013. Pre and postoperative performance status, demographic, operative, and treatment variables were recorded for each patient. Multivariate regression analysis identified predictors of prolonged OS. The adequacy index was calculated to compare the predictive value of preoperative and postoperative KPS score. Median preoperative and postoperative KPS scores were 70 and 80, respectively. Overall, 92 (57 %) patients experienced an improvement in their KPS score, 40 (25 %) remained stable, and 29 (18 %) declined. Higher postoperative KPS (P = 0.0001), radiation therapy (P < 0.0001), younger age (P = 0.0443) and the absence of diabetes (P = 0.0006) were each independently associated with increased OS in a multivariate regression model. Postoperative KPS score has superior predictive value compared to pre-operative KPS score (A = 0.758 vs. 1.002). Postoperative KPS scores have superior predictive capabilities in terms of OS in GBM and should replace preoperative KPS scores when estimating prognosis in this population.

Publication misrepresentation among neurosurgery residency applicants: an increasing problem.

OBJECT Misrepresentation of scholarly achievements is a recognized phenomenon, well documented in numerous fields, yet the accuracy of reporting remains dependent on the honor principle. Therefore, honest self-reporting is of paramount importance to maintain scientific integrity in neurosurgery. The authors had observed a trend toward increasing numbers of publications among applicants for neurosurgery residency at Vanderbilt University and undertook this study to determine whether this change was a result of increased academic productivity, inflated reporting, or both. They also aimed to identify application variables associated with inaccurate citations. METHODS The authors retrospectively reviewed the residency applications submitted to their neurosurgery department in 2006 (n = 148) and 2012 (n = 194). The applications from 2006 were made via SF Match and those from 2012 were made using the Electronic Residency Application Service. Publications reported as "accepted" or "in press" were verified via online search of Google Scholar, PubMed, journal websites, and direct journal contact. Works were considered misrepresented if they did not exist, incorrectly listed the applicant as first author, or were incorrectly listed as peer reviewed or published in a printed journal rather than an online only or non-peer-reviewed publication. Demographic data were collected, including applicant sex, medical school ranking and country, advanced degrees, Alpha Omega Alpha membership, and USMLE Step 1 score. Zero-inflated negative binomial regression was used to identify predictors of misrepresentation. RESULTS Using univariate analysis, between 2006 and 2012 the percentage of applicants reporting published works increased significantly (47% vs 97%, p < 0.001). However, the percentage of applicants with misrepresentations (33% vs 45%) also increased. In 2012, applicants with a greater total of reported works (p < 0.001) and applicants from unranked US medical schools (those not ranked by US News & World Report) were more likely to have erroneous citations (p = 0.038). CONCLUSIONS The incidence of legitimate and misrepresented scholarly works reported by applicants to the authors' neurosurgery residency program increased during the past 6 years. Misrepresentation is more common in applicants from unranked US medical schools and those with a greater number of reported works on their application. This trend is concerning in a profession where trustworthiness is vital. To preserve integrity in the field, programs should consider verifying citations prior to submitting their rank lists.

Pituitary Apoplexy After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitor: A Novel Complication.

Pituitary adenomas are common in the general population. They can be complicated by intratumoral hemorrhage, otherwise known as apoplexy, which frequently presents with neurologic deficits that may necessitate urgent surgical decompression. Many risk factors for pituitary apoplexy have been suggested in the literature. We present a case of symptomatic apoplexy in a woman following the intravitreal administration of the vascular endothelial growth factor (VEGF) inhibitor ranibizumab. Ophthalmoplegia resolved and visual acuity significantly improved following gross total resection of the tumor via an endoscopic endonasal surgical approach. The association between intravitreal injection of a VEGF inhibitor and pituitary apoplexy has not been previously described, but physicians performing these procedures should be aware of this potential complication.

Imaging of Resected Nonfunctioning Pituitary Adenomas: The Cost of Surveillance.

Objectives To determine the cost of annual magnetic resonance imaging (MRI) surveillance after resection of nonfunctioning pituitary adenomas (NFPAs) and its effectiveness in reducing visual compromise due to tumor recurrence. Design Retrospective case series. Setting Vanderbilt University Medical Center (2003-2011). Participants A total of 120 patients underwent primary transsphenoidal resection and surveillance of NFPAs between 2003 and 2011. Main Outcome Measures Time from initial surgery to most recent imaging or progression. Surveillance MRI costs according to Centers for Medicare and Medicaid database and visual field deficits. Results Patients received 382 surveillance scans at a total cost of $218,477.30. The median follow-up was 47 months (interquartile range [IQR]: 26-76), and the median interval between scans was 357 days (IQR: 225-434). Overall, 50 scans (13%) revealed tumor growth. The cost per scan revealing growth was $4,369.55. The cost to identify 19 patients (16%) with clinically significant growth was $11,498.80 per patient. A total of 5 of 19 patients (26%) experienced new visual deficits prior to intervention. Patients with visual decline tended to have longer scan intervals than those with preserved vision (mean: 239 versus 794 days; p = 0.0584). No patient with annual surveillance imaging experienced visual decline. Conclusions Annual MRI scans are a sensitive and cost-conscious method to identify NFPA recurrence prior to visual decline.