Exploring the Relationship Between Objective Pupillometry Metrics and Midline Shift.

ABSTRACT: BACKGROUND: Pupillary examinations provide early subtle signs of worsening intracranial pathology. Objective pupillomtery assessment, although not yet the standard of care, is considered best practice. However, inconsistent findings from objective pupillometry studies have caused a lack of consensus among clinicians; as such, no clinical guidelines are available to guide clinical use of objective pupillometer devices. To add to the body of evidence, the purpose of this project was to explore the relationship between objective pupillometry metrics and midline shift (MLS). METHODS: A retrospective chart review of pupillometer data was conducted. Midline shift was correlated with objective pupillometry metrics including Neurological Pupil Index (NPi), pupil size, and anisocoria. Midline shift was measured for the patient's initial neuroimaging and with any defined neurological change. Spearman ρ was used for statistical analysis of correlations between pupillometer metrics and MLS measured at both the septum pellucidum and pineal gland. RESULTS: A total of 41 patients were included in the analysis; most were White (58.5%) and male (58.5%), with a mean (SD) age of 58.49 (16.92) years. Spearman ρ revealed statistically significant positive correlations between right pupil NPi and anisocoria with MLS, and significant negative correlations between left pupil NPi and pupil size with MLS. CONCLUSIONS: Results from this project are consistent with previous studies. Objective pupillometry continues to be a valuable component of a comprehensive neurological examination, because it has the ability to discern early and subtle changes in a patient's neurological status, leading to lifesaving interventions.

Charlson co-morbidity index as a predictor of outcome after surgery for renal cell carcinoma with renal vein, vena cava or right atrium extension.

PURPOSE: Surgery is the most effective treatment for renal cell carcinoma with tumor thrombus but predictors of outcome and patient survival are variable. Co-morbidity may affect therapeutic decision making and survival, although to our knowledge this factor has not been studied in patients with tumor thrombus. We analyzed the Charlson co-morbidity index as a predictor of outcome after surgery. MATERIAL AND METHODS: From 1970 to 1998, 303 patients underwent surgical resection. The Charlson index, surgical era, completeness of resection, patient age, sex, tumor level, TNM stage, grade and perinephric fat invasion were studied retrospectively as univariate and multivariate predictors of outcome. RESULTS: The level of tumor thrombus was 0 (renal vein only) in 127 patients, and I to IV in 66, 58, 36 and 16, respectively. At 5 years overall, cause specific and metastasis-free survival were 32%, 42% and 41%, while at 10 years they were 21%, 32% and 30%, respectively. For the whole cohort significant multivariate predictors of cause specific survival were metastasis (p = 0.0001), grade (p = 0.0001), perinephric fat involvement (p = 0.02) and tumor levels 0 versus I to IV (p = 0.048). The Charlson index did not predict outcome (univariate model p = 0.65). CONCLUSIONS: Characteristics of the primary tumor remained the most important predictors of cause specific survival in this cohort. The Charlson index did not predict cause specific survival in this cohort of surgically treated patients. Prospective assessment of co-morbidity in patients treated with surgery versus conservative therapy is warranted.

Metastatic prostate carcinoma to bone: clinical and pathologic features associated with cancer-specific survival.

BACKGROUND: The objective of this study was to examine the clinical and pathologic features of metastatic prostate carcinoma to bone in a large cohort of men, and the associations of these features with outcome. METHODS: Sixty-eight men who underwent surgery for metastatic prostate carcinoma to bone for stabilization of a pathologic fracture or impending fracture were studied. Clinical characteristics included the type of treatment for the primary and metastatic prostate carcinoma, age and serum prostate specific antigen (PSA) at the diagnosis of the metastatic prostate carcinoma, radiographic findings of the metastasis (osteoblastic, osteolytic, or mixed), and the number of metastatic sites at the time of the surgery for the metastasis. Pathologic features examined included Gleason score of the metastatic prostate carcinoma. Immunohistochemical stains for MIB-1, cytokeratin, PSA, synaptophysin, chromogranin A, serotonin, estrogen receptor, progesterone receptor, and androgen receptor were performed for all cases. The Kaplan-Meier method was used to estimate cancer-specific survival. The duration of follow-up was defined as the interval from the date of surgery for the metastasis to the date of death or last follow-up. Univariate and multivariate Cox proportional hazards models were fit to assess the features that were associated with death from prostate carcinoma. RESULTS: The average (standard deviation) time from the surgery for the metastasis to death from prostate carcinoma was 1.5 (1.9) years, ranging from 0 days to 10 years, with a median of 1 year. The estimated cancer-specific survival rates at 1 year, 2 years, and 3 years were 54.3%, 28.8%, and 22.9%, respectively. Median cancer-specific survival occurred at 1.1 years. After 4 years of follow-up, there were only seven patients left at risk for death from prostate carcinoma. Features that were found to be significantly associated with death from prostate carcinoma univariately included the interval between the diagnosis of metastasis and the surgery for metastasis (P < 0.001), androgen deprivation therapy before surgery for the metastasis (P = 0.002), presentation with metastasis (P = 0.003), the number of metastatic sites (P = 0.034), Gleason score of the metastasis (P = 0.002), and tumor positivity for chromogranin A (P = 0.041). On multivariate analysis, the interval between the diagnosis of metastasis and the surgery for metastasis (P < 0.001), Gleason score of the metastasis (P < 0.001), and tumor positivity for chromogranin A (P = 0.009) were associated significantly with death from prostate carcinoma. CONCLUSIONS: Although cancer-specific survival for patients after surgery for prostate carcinoma metastatic to bone is poor, assessments of tumor differentiation of the metastasis and chromogranin A positivity provide prognostic information.