Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort

Background:

The present study documents the natural history and outcomes of high-risk bladder cancer after radical cystectomy (RC) in patients who did not receive neoadjuvant chemotherapy during a contemporary time period.

Methods:

We analyzed 1180 patients from 1993 to 2008 with >pT3N0 or pT0-4N+ bladder cancer who underwent RC ± standard (sLND) or extended (eLND) lymph node dissection from 8 Canadian centres.

Results:

Of the 1180 patients, 55% (n = 643) underwent sLND, 34% (n = 402) underwent ePLND and 11% did not undergo a formal LND. Of the total number of patients, 321 (27%) received adjuvant chemotherapy. The median follow-up was 2.1 years (range: 0.6 to 12.9). Overall 30-day mortality was 3.2%. Clinical and pathological stages T3-4 were present in 6.1% and 86.7% of the patients, respectively; this demonstrates a dramatic understaging. Overall survival (OS) at 2 and 5 years was 60% and 43%, respectively. Patients who received adjuvant chemotherapy had a 2- and 5-year disease-specific survival (DSS) of 72% and 57% versus 64% and 51% for those who did not (log-rank p = 0.0039). The 2- and 5-year OS for high-risk node-negative disease was 67% and 52%, respectively, whereas for node-positive patients, the OS was 52% and 32%, respectively (p < 0.001). The OS, DSS and RFS for patients with pN0 were significantly improved compared to those who did not undergo a LND (log-rank p = 0.0035, 0.0241 and 0.0383, respectively).

Interpretation:

This series suggests that bladder cancer outcomes in advanced disease have improved in the modern era. The need for improved staging investigations, use of neoadjuvant chemotherapy and performance of complete LND is emphasized.     

Contemporary management of infrarenal aortic graft infection: early and late results in 82 patients

Management of aortic graft infection (AGI) remains contentious. The purpose of this study was to evaluate factors of clinical significance which influence the outcome of different treatment modalities for AGI. From 2000 to 2008, 82 consecutive patients were treated for AGI. In situ reconstruction (ISR) was performed in 63 patients with various conduits, extra-anatomic reconstruction (EAR) in 11, conservative treatment in five and resection without reconstruction in three. The perioperative mortality rate for the series (33%) was similar for EAR and ISR and was higher in patients with secondary aortoenteric fistula (P < 0.001) in those undergoing emergency aortic reconstruction (P < 0.001) and in AGI caused by virulent organisms (P < 0.05). Fifteen (27%) of the surviving patients developed a recurrence of infection (RI). EAR patients were more exposed to RI (P < 0.04). In conclusion, ISR may be more appropriate for AGI, but this study cannot draw a conclusion relating to the optimal conduit for ISR.     

Stercoral ulcer as a cause of lower gastrointestinal (LGI) bleeding in chronic hemodialysis patients

Gastrointestinal (GI) bleeding is more common in patients with chronic kidney disease and is associated with higher mortality than in the general population. Stercoral ulceration of the colon is rarely reported in the nephrology literature. We observed 2 cases of stercoral ulcer presenting as lower gastrointestinal (LGI) bleeding in patients on chronic hemodialysis. Both patients were elderly (81 and 75 years, respectively) with a history of constipation. Diagnosis of stercoral ulcer as the cause of lower GI bleeding was made using endoscopic procedures. Stercoral ulcer should be considered in cases of lower GI bleeding in chronic dialysis patients.     

Blast-induced tinnitus and hearing loss in rats: behavioral and imaging assays

Abstract The current study used a rat model to investigate the underlying mechanisms of blast-induced tinnitus, hearing loss, and associated traumatic brain injury (TBI). Seven rats were used to evaluate behavioral evidence of tinnitus and hearing loss, and TBI using magnetic resonance imaging following a single 10-msec blast at 14?psi or 194 dB sound pressure level (SPL). The results demonstrated that the blast exposure induced early onset of tinnitus and central hearing impairment at a broad frequency range. The induced tinnitus and central hearing impairment tended to shift towards high frequencies over time. Hearing threshold measured with auditory brainstem responses also showed an immediate elevation followed by recovery on day 14, coinciding with behaviorally-measured results. Diffusion tensor magnetic resonance imaging results demonstrated significant damage and compensatory plastic changes to certain auditory brain regions, with the majority of changes occurring in the inferior colliculus and medial geniculate body. No significant microstructural changes found in the corpus callosum indicates that the currently adopted blast exposure mainly exerts effects through the auditory pathways rather than through direct impact onto the brain parenchyma. The results showed that this animal model is appropriate for investigation of the mechanisms underlying blast-induced tinnitus, hearing loss, and related TBI. Continued investigation along these lines will help identify pathology with injury/recovery patterns, aiding development of effective treatment strategies.     

Evidence-based Review: Management of Open Pediatric Fractures

Open fractures in the pediatric population are rare. As such, recommendations for care based on high-level studies are scarce. Furthermore, most level I and II recommendations come from studies involving open fractures in adults. Although it is generally accepted that open pediatric fractures have better outcomes than open fractures in adults, the lack of quality studies provide ample opportunities to answer questions regarding care of these injuries. This review explores the available literature and gives corresponding recommendations based on the level of evidence.