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Strapazzon G.,EURAC Institute of Mountain Emergency Medicine | Nardin M.,General Hospital of Bolzano | Zanon P.,General Hospital of Bolzano | Kaufmann M.,Innsbruck Medical University | And 2 more authors.
Annals of Emergency Medicine | Year: 2012

Clinical reports on management and rewarming complications after prolonged avalanche burial are not common. We present a case of an unreported combination of respiratory failure and unexpected spontaneous hypoglycemia during noninvasive rewarming from severe hypothermia. We collected anecdotal observations in a 42-year-old, previously healthy, male backcountry skier admitted to the ICU at a tertiary care center after 2 hours 7 minutes of complete avalanche burial, who presented with a patent airway and a core body temperature of 25.0°C (77.0°F) on extrication. There was no decrease in core body temperature during transport (from 25.0°C [77.0°F] to 24.7°C [76.5°F]). Atrial fibrillation occurred during active noninvasive external rewarming (to 37.0°C [98.6°F] during 5 hours), followed by pulmonary edema and respiratory failure (SaO 2 73% and PaO 2/FIO 2 161 mm Hg), which resolved with endotracheal intubation and continuous positive end-respiratory pressure. Moreover, a marked spontaneous glycemic imbalance (from 22.2 to 1.4 mmol/L) was observed. Despite a possible favorable outcome, clinicians should be prepared to identify and treat severe respiratory problems and spontaneous hypoglycemia during noninvasive rewarming of severely hypothermic avalanche victims. © 2011 American College of Emergency Physicians.


Xylinas E.,New York Medical College | Xylinas E.,University of Paris Descartes | Rink M.,New York Medical College | Rink M.,University of Hamburg | And 25 more authors.
European Urology | Year: 2014

Background: There is a lack of consensus regarding the optimal approach to the bladder cuff during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Objectives: To compare the oncologic outcomes following RNU using three different methods of bladder cuff management. Design, setting, and participants: Retrospective analysis of 2681 patients treated with RNU for UTUC at 24 international institutions from 1987 to 2007. Intervention: Three methods of bladder cuff excision were performed: transvesical, extravesical, and endoscopic. Outcome measurements and statistical analysis: Univariable and multivariable models tested the effect of distal ureter management on intravesical recurrence, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Results and limitations: Of the 2681 patients, 1811 (67.5%) underwent the transvesical approach; 785 (29.3%), the extravesical approach; and 85 (3.2%), the endoscopic approach. There was no difference in terms of RFS, CSS, and OS among the three distal ureteral management approaches. Patients who underwent the endoscopic approach were at significantly higher risk of intravesical recurrence compared with those who underwent the transvesical (p = 0.02) or extravesical approaches (p = 0.02); the latter two groups did not differ from each other (p = 0.40). Actuarial intravesical RFS estimates at 2 and 5 yr after RNU were 69% and 58%, 69% and 51%, and 61% and 42% for the transvesical, extravesical, and endoscopic approaches, respectively. In multivariate analyses, distal ureteral management (p = 0.01), surgical technique (open vs laparoscopic; p = 0.02), previous bladder cancer (p < 0.001), higher tumor stage (trend; p = 0.01), concomitant carcinoma in situ (CIS) (p < 0.001), and lymph node involvement (trend; p < 0.001) were all associated with intravesical recurrence. Excluding patients with history of previous bladder cancer, all variables remained independent predictors of intravesical recurrence. Conclusions: The endoscopic approach was associated with higher intravesical recurrence rates. Interestingly, concomitant CIS in the upper tract is a strong predictor of intravesical recurrence after RNU. The association of laparoscopic RNU with intravesical recurrence needs to be further investigated. © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.


Cha E.K.,New York Medical College | Tirsar L.-A.,EuromedClinic | Tirsar L.-A.,University of Tübingen | Schwentner C.,University of Tübingen | And 8 more authors.
European Urology | Year: 2012

Background: Although the performance of immunocytology has been established in the surveillance of patients with urothelial carcinoma of the bladder (UCB), its value in the initial detection of UCB in patients with painless hematuria remains unclear. Objective: To determine whether immunocytology improves our ability to predict the likelihood of UCB in patients with painless hematuria. Further, to test the clinical benefit of immunocytology in this setting using decision curve analysis. Design, setting, and participants: The subjects were 1182 consecutive patients without a history of UCB presenting with painless hematuria and were enrolled at three centres. Intervention: All patients underwent upper-tract imaging, cystourethroscopy, voided urine cytology, and immunocytology analysis. Bladder tumors were biopsied and histologically confirmed as UCB. Measurements: Multivariable regression models were developed. Area under the curve was measured and compared using the DeLong test. A nomogram was constructed from the full multivariable model. Decision curve analysis was performed to evaluate the clinical benefit associated with use of the multivariable models including immunocytology. Results and limitations: Immunocytology had the largest contribution to a multivariable model for the prediction of UCB (odds ratio: 18.3; p < 0.0001), which achieved a 90.8% predictive accuracy. Decision curve analysis revealed that models incorporating immunocytology achieved the highest net benefit at all threshold probabilities. Conclusions: Immunocytology is a strong predictor of the presence of UCB in patients who present with painless hematuria. Incorporation of immunocytology into predictive models improves diagnostic accuracy by a statistically and clinically significant margin. The use of immunocytology in the diagnostic workup of patients with hematuria appears promising and should be further evaluated. © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.


Rink M.,Cornell University | Rink M.,University of Hamburg | Xylinas E.,Cornell University | Xylinas E.,University of Paris Descartes | And 16 more authors.
European Urology | Year: 2013

Background: Cigarette smoking is a common risk factor for developing upper tract urothelial carcinoma (UTUC). Objective: To assess the impact of cigarette smoking status, cumulative smoking exposure, and time from cessation on oncologic UTUC outcomes in patients treated with radical nephroureterectomy (RNU). Design, setting, and participants: A total of 864 patients underwent RNU at five institutions. The median follow-up in this retrospective study was 50 mo. Smoking history included smoking status, quantity of cigarettes per day (CPD), duration in years, and years from smoking cessation. The cumulative smoking exposure was categorized as light-short-term (≤19 CPD and ≤19.9 yr), moderate (all combinations except light-short-term and heavy-long-term), and heavy-long-term (≥20 CPD and ≥20 yr). Interventions: RNU with or without lymph node dissection. No patient received neoadjuvant chemotherapy. Outcome measurements and statistical analysis: Univariable and multivariable logistic regression and competing risk regression analyses assessed the effects of smoking on oncologic outcomes. Results and limitations: A total of 244 patients (28.2%) never smoked; 297 (34.4%) and 323 (37.4%) were former and current smokers, respectively. Among smokers, 87 (10.1%), 331 (38.3%), and 202 (23.4%) were light-short-term, moderate, and heavy-long-term smokers, respectively. Current smoking status, smoking ≥20 CPD, ≥20 yr, and heavy-long-term smoking were associated with advanced disease (p values ≤0.004), greater likelihood of disease recurrence (p values ≤0.01), and cancer-specific mortality (p values ≤0.05) on multivariable analyses that adjusted for standard features. Patients who quit smoking ≥10 yr prior to RNU did not differ from never smokers regarding advanced tumor stages, disease recurrence, and cancer-specific mortality, but they had better oncologic outcomes then current smokers and those patients who quit smoking <10 yr prior to RNU. The study is limited by its retrospective nature. Conclusions: Cigarette smoking is significantly associated with advanced disease stages, disease recurrence, and cancer-specific mortality in patients treated with RNU for UTUC. Current smokers and those with a heavy and long-term smoking exposure have the highest risk for poor oncologic outcomes. Smoking cessation >10 yr prior to RNU seems to mitigate some detrimental effects. These results underscore the need for smoking cessation and prevention programs. © 2012 European Association of Urology.


Xylinas E.,New York Medical College | Xylinas E.,University of Paris Descartes | Kent M.,Sloan Kettering Cancer Center | Kluth L.,New York Medical College | And 13 more authors.
British Journal of Cancer | Year: 2013

Background:The European Organization for Research and Treatment of Cancer (EORTC) risk tables and the Spanish Urological Club for Oncological Treatment (CUETO) scoring model are the two best-established predictive tools to help decision making for patients with non-muscle-invasive bladder cancer (NMIBC). The aim of the current study was to assess the performance of these predictive tools in a large multicentre cohort of NMIBC patients.Methods:We performed a retrospective analysis of 4689 patients with NMIBC. To evaluate the discrimination of the models, we created Cox proportional hazard regression models for time to disease recurrence and progression. We incorporated the patients calculated risk score as a predictor into both of these models and then calculated their discrimination (concordance indexes). We compared the concordance index of our models with the concordance index reported for the models.Results:With a median follow-up of 57 months, 2110 patients experienced disease recurrence and 591 patients experienced disease progression. Both tools exhibited a poor discrimination for disease recurrence and progression (0.597 and 0.662, and 0.523 and 0.616, respectively, for the EORTC and CUETO models). The EORTC tables overestimated the risk of disease recurrence and progression in high-risk patients. The discrimination of the EORTC tables was even lower in the subgroup of patients treated with BCG (0.554 and 0.576 for disease recurrence and progression, respectively). Conversely, the discrimination of the CUETO model increased in BCG-treated patients (0.597 and 0.645 for disease recurrence and progression, respectively). However, both models overestimated the risk of disease progression in high-risk patients.Conclusion:The EORTC risk tables and the CUETO scoring system exhibit a poor discrimination for both disease recurrence and progression in NMIBC patients. These models overestimated the risk of disease recurrence and progression in high-risk patients. These overestimations remained in BCG-treated patients, especially for the EORTC tables. These results underline the need for improving our current predictive tools. However, our study is limited by its retrospective and multi-institutional design. © 2013 Cancer Research UK.


Rink M.,Cornell University | Rink M.,University of Hamburg | Zabor E.C.,Sloan Kettering Cancer Center | Furberg H.,Sloan Kettering Cancer Center | And 17 more authors.
European Urology | Year: 2013

Background: Cigarette smoking is the best-established risk factor for urothelial carcinoma development. Objective: To elucidate the association of pretreatment smoking status, cumulative exposure, and time since smoking cessation on outcomes of patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). Design, setting, and participants: We retrospectively collected clinicopathologic and smoking variables, including smoking status, number of cigarettes per day (CPD), duration in years, and time since smoking cessation, for 1506 patients treated with RC for UCB. Lifetime cumulative smoking exposure was categorized as light short-term (≤20 CPD for ≤20 yr), light long-term (≤20 CPD for >20 yr), heavy short-term (>20 CPD for ≤20 yr), and heavy long-term (>20 CPD for >20 yr). Intervention: RC and bilateral lymph node (LN) dissection without neoadjuvant chemotherapy. Outcome measurements and statistical analysis: Logistic regression and competing risk analyses assessed the association of smoking with disease recurrence, cancer-specific mortality, and overall mortality. Results and limitations: There was no difference in clinicopathologic factors between patients who had never smoked (20%), former smokers (46%), and current smokers (34%). Smoking status was associated with the cumulative incidence of disease recurrence (p = 0.004) and cancer-specific mortality (p = 0.016) in univariable analyses and with disease recurrence in multivariable analysis (p = 0.02); current smokers had the highest cumulative incidences. Among ever smokers, cumulative smoking exposure was associated with advanced tumor stages (p < 0.001), LN metastasis (p = 0.002), disease recurrence (p < 0.001), cancer-specific mortality (p = 0.001), and overall mortality (p = 0.037) in multivariable analyses that adjusted for standard characteristics; heavy long-term smokers had the worst outcomes, followed by light long-term, heavy short-term, and light short-term smokers. Smoking cessation ≥10 yr mitigated the risk of disease recurrence (hazard ratio [HR]: 0.44; p < 0.001), cancer-specific mortality (HR: 0.42; p < 0.001), and overall mortality (HR: 0.69; p = 0.012) in multivariable analyses. The study is limited by its retrospective nature. Conclusions: Smoking is associated with worse prognosis after RC for UCB. This association seems to be dose-dependent, and its effects are mitigated by >10 yr smoking cessation. Health care practitioners should counsel smokers regarding the detrimental effects of smoking and the benefits of smoking cessation on UCB etiology and prognosis. © 2012 European Association of Urology.


Rink M.,Cornell University | Rink M.,University of Hamburg | Furberg H.,Sloan Kettering Cancer Center | Zabor E.C.,Sloan Kettering Cancer Center | And 14 more authors.
European Urology | Year: 2013

Background: Cigarette smoking is the best-established risk factor for urothelial carcinoma (UC) development, but the impact on oncologic outcomes remains poorly understood. Objective: To analyse the effects of smoking status, cumulative exposure, and time from smoking cessation on the prognosis of patients with primary non-muscle-invasive bladder cancer (NMIBC). Design, setting, and participants: We collected smoking data from 2043 patients with primary NMIBC. Smoking variables included smoking status, average number of cigarettes smoked per day (CPD), duration in years, and time since smoking cessation. Lifetime cumulative smoking exposure was categorised as light short term (≤19 CPD, ≤19.9 yr), light long term (≤19 CPD, ≥20 yr), heavy short term (≥20 CPD, ≤19.9 yr) and heavy long term (≥20 CPD, ≥20 yr). The median follow-up in this retrospective study was 49 mo. Interventions: Transurethral resection of the bladder with or without intravesical instillation therapy. Outcome measurements and statistical analysis: Univariable and multivariable logistic regression and competing risk regression analyses assessed the effects of smoking on outcomes. Results and limitations: There was no difference in clinicopathologic factors among never (24%), former (47%), and current smokers (29%). Smoking status was associated with the cumulative incidence of disease progression in multivariable analysis (p = 0.003); current smokers had the highest cumulative incidences. Among current and former smokers, cumulative smoking exposure was associated with disease recurrence (p < 0.001), progression (p < 0.001), and overall survival (p < 0.001) in multivariable analyses that adjusted for the effects of standard clinicopathologic factors and smoking status; heavy long-term smokers had the worst outcomes, followed by light long-term, heavy short-term, and light short-term smokers. Smoking cessation >10 yr reduced the risk of disease recurrence (hazard ratio [HR]: 0.66; 95% confidence interval [CI], 0.52-0.84; p < 0.001) and progression (HR: 0.42; 95% CI, 0.22-0.83; p = 0.036) in multivariable analyses. The study is limited by its retrospective nature. Conclusions: Smoking status and a higher cumulative smoking exposure are associated with worse prognosis in patients with NMIBC. Smoking cessation >10 yr abrogates this detrimental effect. These findings underscore the need for integrated smoking cessation and prevention programmes in the management of NMIBC patients. © 2012 European Association of Urology.


Mayr R.,General Hospital of Bolzano | Fritsche H.-M.,University of Regensburg | Pycha A.,General Hospital of Bolzano | Pycha A.,Riga Stradins University
Expert Review of Anticancer Therapy | Year: 2014

Radical cystectomy (RC) with pelvic lymph node dissection constitutes the gold standard treatment for muscle-invasive urothelial carcinoma of the bladder and high-risk nonmuscle-invasive disease refractory to instillation therapy. Although RC is performed with curative intent, the overall 5-year survival has been reported to be as low as 62% in the current literature. Various clinicopathological parameters determine post-RC outcome, but besides these, the role of comorbidity has gained increasing attention. In the current clinical practice, comorbidity information is quantified using various evaluated comorbidity indices. In this paper, we discuss the most recent data on comorbidity and performance indices assessed in patients undergoing RC and highlight their clinical implications. © 2014 Informa UK Ltd.

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