Usefulness of atypical antipsychotics and choline esterase inhibitors in delirium: a review

Delirium is characterized by disturbances of consciousness, attention, cognition, perception, emotions, sleep, and psychomotor activity. Management of delirium involves ensuring safety, improving functioning, identifying and treating the illness underlying the delirium, and use of antipsychotics or benzodiazepines to control behavioural symptoms and prevent mortality. Haloperidol continues to be the most commonly used antipsychotic in delirium. However, in recent times data have emerged which suggest that atypical antipsychotics may be as efficacious as haloperidol in the treatment of delirium. This review intends to review the data with respect to usefulness of atypical antipsychotics in the treatment of delirium. Besides atypical antipsychotics, data with respect to another group of medications - cholinesterase inhibitors are also reviewed. Electronic and manual searches were conducted to identify all the relevant studies and case reports/case series. Evidence suggests that risperidone, olanzapine and quetiapine are as efficacious as haloperidol in the treatment of delirium but have lesser side effects. Data for other atypical antipsychotics are scarce. The data on cholinesterase inhibitors for treatment and prevention of delirium are beginning to accumulate, but do not seem to be convincing. Our review suggests that risperidone, olanzapine and quetiapine are good alternatives to haloperidol in the treatment of delirium.

Pathologic outcomes in patients with clinically low-risk prostate cancer deemed eligible for active surveillance

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Background: Active surveillance (AS) is becoming increasingly popular as a treatment option for men with clinically localized low-risk prostate cancer. Gleason score ≤ 6 and clinical stage ≤ T2a are selection criteria for AS. However, Gleason upgrading or upstaging from the diagnostic biopsy to the surgical specimen is not uncommon. We thus sought to identify risk factors that could more accurately predict Gleason upgrading and/or upstaging in AS-eligible men.

Methods: 786 patients from our prospective database of 2,412 men who underwent robotic-assisted radical prostatectomy by a single surgeon from January 2005 to August 2010 would have fulfilled standard AS criteria (Gleason sum ≤ 6, clinical stage ≤T2a disease, PSA <10ng/ml, <3 positive cores and ≤50% cancer present in a single core). This formed the basis of our study cohort. Clinicopathologic parameters, including number of cores at initial biopsy, biopsy cancer volume, preoperative PSA, number of cancer-positive cores, body mass index, and prostate volume were recorded prospectively. Data were evaluated using chi- square and multivariate logistic regression analyses. Receiver operator characteristic curves (ROC) were constructed to determine the optimal cutoff values.

Results: 320 of 786 AS-eligible patients (40.7%) had Gleason upgrading at final pathology following radical prostatectomy. Upstaging was present in 591 patients (75.1%). 626 patients (79.6%) had Gleason upgrading and/or upstaging. On univariate analysis, BMI, PSA density, preoperative PSA, lower prostate volume and maximum percentage of cancer in biopsy cores were predictors of Gleason upgrading and/or upstaging. On multivariate analysis, all variables, except for BMI and PSA density, lost statistical significance. PSA density > 0.1 ng/ml/cm3 and BMI >29 kg/m2 are the optimal cutoff values based on ROC analysis.

Conclusions: PSA density and BMI are significant predictors of Gleason upgrading and/or upstaging, and should be incorporated into contemporary selection criteria for AS protocols.

No significant financial relationships to disclose.

Nomograms to predict 3-year biochemical recurrence after robotic-assisted laparoscopic radical prostatectomy based on preoperative and perioperative variables of 774 patients

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Background: Predictors of biochemical recurrence after robotic-assisted laparoscopic radical prostatectomy (RALP) are not well reported in the literature. We wanted to investigate preoperative predictors as well as the influence of nerve sparing and positive surgical margin status on 3-year biochemical recurrence.

Methods: 774 patients with at least 3 year follow up had undergone RALP by a single surgeon at our institution. Biochemcial recurrence was defined as a postoperative PSA >0.2 ng/ml. Multivariable logistic regression models were used to develop the biochemical recurrence predictive nomograms: nomogram 1- age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, perineural invasion; nomogram 2- age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, perineural invasion, nerve sparing, positive surgical margins (none, unifocal, or multifocal). The predictive accuracy of the models was assessed in terms of discrimination and calibration.

Results: Both nomograms discriminated well between patients that recurred and those that did not (bootstrap corrected c-indices of 0.766 and 0.806 for nomograms 1 and 2 respectively). Nomogram 1 was well calibrated, but nomogram 2 over- predicted the probability of biochemical recurrence in patients at >30% risk.

Conclusions: Our nomogram based on age, BMI, PSA density, clinical stage, biopsy Gleason, percent positive cores, and perineural invasion on preoperative biopsy has a good predictive ability to differentiate between RALP-treated patients that biochemically recur by 3 years from those that do not. Adding nerve sparing and surgical margin status further improved discriminatory ability but at the expense of over-prediction for patients at high risk. These nomograms may be used to guide the use of nerve sparing and the management of positive margins in men undergoing RALP for clinically localized prostate cancer.

No significant financial relationships to disclose.

The relationship between prostate volume and histopathologic criteria of known prognostic importance in 2,207 men with prostate cancer

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Background: There is a paucity of data investigating the relationship between histopathologic variables of oncologic importance and prostate volume, and we aimed to investigate this.

Methods: 2,207 consecutive patients who underwent robotic-assisted radical prostatectomy (RARP) were studied. Preoperative demographic and both pre- and post-operative histopathologic parameters were compared among the small prostate (< 40cc), intermediate size (40-70cc), and large prostate (> 70cc) groups.

Results: Patients with smaller prostates were younger, had slightly lower BMIs, and lower PSAs than those with smaller prostates (p < 0.001). They also had worse histopathologic criteria (Gleason, core positivity, and maximum percent cancer) on preoperative biopsy and had worse radical specimen Gleason sums (p < 0.001), percent cancer (p < 0.001), and pathologic stage (p = 0.016). 11.5% of men in the small prostate group suffered a positive surgical margin (PSM) compared to 8.3% and 5.6% in the intermediate and large prostate groups, respectively (p = 0.008; Table). Basilar, posterolateral, and multifocal PSMs were commoner in the small prostate group.

Conclusions: Younger men have smaller prostates and worse preoperative histopathologic parameters despite lower PSAs. Men with small prostates undergoing RARP have worse final Gleason sums, tumor volume, extraprostatic extension (EPE), and PSM rates than those with larger prostates. We would thus caution against conservative management of men with clinically localized prostate cancer who have small prostates.

[Table: see text]

No significant financial relationships to disclose.

Multiphoton microscopy of human prostatic and periprostatic tissue architecture for improving identification of tissue structures: Implication in nerve-sparing radical prostatectomy

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Background: Introperative differentiation of various tissue types would aid the surgeon during dissection in radical prostatectomy. Specifically, it will enhance decision-making with regards wide excision or nerve-sparing. We investigated the value of a novel imaging technology (multiphoton microscopy-MPM) for providing “virtual” histology.

Methods: We imaged intraoperative surgical margins and biopsies, as well as radical prostatectomy sections. The imaging was carried out using intrinsic fluorescence and scattering properties of the tissues without any exogenous dye or contrast agent. The corresponding tissues were subjected to hematoxylin and eosin staining for histological confirmation of the structures.

Results: High-resolution images of the periprostatic tissue, nerves, prostate capsule, underlying acini, and individual acinar cells were obtained at varying magnifications. There was good correlation between MPM and histology in identification of all anatomic structures.

Conclusions: MPM provides microscopy level resolution in fresh human prostatic tissue, without the need for any extrinsic labeling agents or phototoxicity. It shows promise as a real-time intraoperative aid during radical prostatectomy.

No significant financial relationships to disclose.

Nerve-sparing radical prostatectomy: current concepts in a robotic era

Recovery of potency sufficient for penetrative intercourse at a year after surgery varies widely. Much of the progress achieved in the past two decades in improving potency outcomes after radical prostatectomy has resulted from an improved appreciation of the anatomic basis of the nerves responsible for erection. Recent studies suggest alternative and more complex course of nerves than previously described. Better appreciation of the variable and often invisible anatomical course of the cavernosal nerves continues to engender innovations in surgical technique to optimize their preservation. Exciting frontiers of research that include efforts in stem cell neural regeneration, development of specific fluorophores and biomarkers, and performing radical prostatectomy under hypothermic conditions may provide much-needed breakthroughs to improving potency outcomes following radical prostatectomy in this current age of improved life expectancy and heightened patient expectations.

Assessment of perineural infiltration and spread of oral squamous cell carcinoma: a clinicohistopathologic study

BACKGROUND

As the tumor spreads through the pathway of least resistance, the present study was carried out to evaluate the presence of perineural infiltration and spread of oral squamous cell carcinoma (OSCC) along the perineural spaces in gingivobuccal sulcus tumors infiltrating into the mandible.

AIMS AND OBJECTIVES

(1) To investigate the incidence of perineural invasion of OSCC along the inferior alveolar nerve and (2) to investigate the neurovascular bundle as a potential route of spread of OSCC.

MATERIALS AND METHODS

Twenty-six patients with histopathologically proven OSCC of the gingivobuccal sulcus with radiographic infiltration of the mandible were included. The surgical specimens were decalcified and serially sectioned. Each section was stained with hematoxylin and eosin and was screened for the presence of perineural invasion and spread. Results : Twenty-five specimens showed perineural infiltration but none of the cases showed perineural spread along the inferior alveolar canal. Also, not all cases showed any neurologic deficit. Follow-up of these cases showed early recurrence (6-8 months) in the study group.

CONCLUSION

Perineural infiltration is present in OSCC but perineural spread along the inferior alveolar canal is absent. It is a bad prognostic indicator.

Sequential spectral domain OCT documentation of retinal changes after branch retinal artery occlusion

Branch retinal artery occlusions (BRAO) are characterized histopathologically by inner retinal edema initially and atrophy in the presence of persistent ischemia. The duration of ischemia leading to irreversible atrophic retinal changes is not clear. Spectral-domain optical coherence tomography (SD-OCT) provides non-invasive detailed in-vivo histological changes in the retina. In this case report, we show sequential in vivo pathological changes seen in the inner retinal layers, in spite of clinical improvement, following the migration of an intraretinal embolus on the optic nerve head, which had previously resulted in symptomatic BRAO.

Intracameral Avastin dramatically resolves iris neovascularization and reverses neovascular glaucoma

PURPOSE

To report the biologic effect of intracameral bevacizumab in patients with iris neovascularization secondary to proliferative retinal vasculopathies.

METHODS

Sixteen eyes of 15 patients with iris neovascularization associated with or without neovascular glaucoma secondary to proliferative retinal vasculopathies received intracameral bevacizumab (1.25 mg). Ophthalmic evaluations included Snellen visual acuity (VA), complete ophthalmic iris angiography, and slit lamp photography. Main outcome measure was change in degree of iris neovascularization. Secondary outcomes included fluorescein iris angiographic leakage, control of intraocular pressure, and changes in VA.

RESULTS

All patients with neovascularization demonstrated by slit lamp photography and fluorescein angiography (16/16 eyes) had complete (or at least partial) reduction in leakage of the neovascularization within 3 weeks after the injection. Leakage from iris neovascularization resolved in 12 of 16 (75%) eyes. In two cases recurrent leakage was seen as early as 4 weeks necessitating repeat injection. Intraocular pressure was controlled with maximum medical therapy in eight of nine eyes reducing the need for glaucoma surgery. Visual acuity improved from a median of hand motions to 20/200.

CONCLUSIONS

In summary, intracameral bevacizumab was effective in reversing iris neovascularization in the majority of patients. It also facilitated intraocular pressure control in patients with associated glaucoma.