Exile Vol. XXXV No. 1

ARTWORK Untitled by Eric Whitney (cover) Untitled by Rory Herbster 7 Little Boy by Eric Whitney 45 FICTION Through the Window Pane by Jennifer Read 4 to whom i may concern by Chris Campi 19 For Lack of Sleep by Amy Judge 26 Jonathan by Jim Cox 39 Skin Deep by Eric Whitney 51 NON-FICTION A Theopoetic by Robert Marshall 11 POETRY Clay Pot by Christopher Collette 1 Ars Poetica by Mans Agantyr 2 Bible Thumber by Chris Rynd 6 Play by Amy Judge 9 Satellites by Andrew C. Carinston 10 Music - Love? by Shammon J. Salser 15 Allusion by Rosemary Walsh 17 Self Portrait by Margaret Dawson 18 On Our Way by Lynn Pendleton 21 They called her Mitzi... by Jen Miller 22 Storms of Illusion by Kevin Merriman 23 Beauty by Andrew C. Carington 24 Thoughts of a Husband by Kent Lambert 25 The Music of the Sum by Zach Smith 31 Don\u27t Think by Mary Forsythe 32 Aspiration by Tim Emrick 33 Where We Go Together by Man Angantyr 35 Sunset by Chris Byrd 36 The Child of my Fatalism by Jennifer Peterson 37 Untitled by Kent Lambert 38 Terribly close to being... by Michael Payne 44 Anne Frank\u27s House by Mary Forsythe 47 Invitation by Kevin Merriman 48 Height Protest by Jen Miller 49 Dancer by Bradford Cover 50 Ars Poetica by Amy Judge 55 Editorial decision is shared equally among the Editorial Board members -title page NOTE: The author of the poem Satellites is listed as Andrew C. Carinston in the published table of contents. This is likely a misspelling as there are four instances of an Andrew C. Carington elsewhere in this edition, including the attribution on the page where Satellites is published. NOTE: The author of the poem Where We Go Together is listed as Man Angantyr in the published table of contents. This is likely a misspelling as there are four instances of an Mans Angantyr elsewhere in this edition, including the attribution on the pages where Where We Go Together is published. NOTE: Chris Byrd is listed as the author of the poem Sunset in the published version. However a note in the received version indicates that the author is actually Chris Rynd, whose poem Bible Thumper is also published in this issue. No Chris Byrd is listed among the contributors to this issue. NOTE: The author of the poem Music = Love? is listed as Shammon J. Salser in the published table of contents. This is likely a misspelling. Where Music = Love? appears the author is listed as Shannon J. Salser. The same is true of the contributors section. NOTE: Though the published table of contents is followed here, the poem by Zach Smith that is published on page 31 is listed as The Music of the Sun on page 31

Systematic Review and Meta-analysis of Minimally Invasive Procedures for Surgical Inguinal Nodal Staging in Penile Carcinoma

CONTEXT: There are several procedures for surgical nodal staging in clinically node-negative (cN0) penile carcinoma.OBJECTIVE: To evaluate the diagnostic accuracy, perioperative outcomes, and complications of minimally invasive surgical procedures for nodal staging in penile carcinoma.EVIDENCE ACQUISITION: A systematic review of the Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov was conducted. Published and ongoing studies reporting on the management of cN0 penile cancer were included without any design restriction. Outcomes included the false negative (FN) rate, the number of nodes removed, surgical time, and postoperative complications.EVIDENCE SYNTHESIS: Forty-one studies were eligible for inclusion. Four studies comparing robot-assisted (RA-VEIL) and video-endoscopic inguinal lymphadenectomy (VEIL) to open inguinal lymph node dissection (ILND) were suitable for meta-analysis. A descriptive synthesis was performed for single-arm studies on modified open ILND, dynamic sentinel node biopsy (DSNB) with and without preoperative inguinal ultrasound (US), and fine-needle aspiration cytology (FNAC). DSNB with US + FNAC had lower FN rates (3.5-22% vs 0-42.9%) and complication rates (Clavien Dindo grade I-II: 1.1-20% vs 2.9-11.9%; grade III-V: 0-6.8% vs 0-9.4%) in comparison to DSNB alone. Favourable results were observed for VEIL/RA-VEIL over open ILND in terms of major complications (2-10.6% vs 6.9-40.6%; odds ratio [OR] 0.18; p &lt; 0.01). Overall, VEIL/RA-VEIL had lower wound-related complication rates (OR 0.14; p &lt; 0.01), including wound infections (OR 0.229; p &lt; 0.01) and skin necrosis (OR 0.16; p &lt; 0.01). The incidence of lymphatic complications varied between 20.6% and 49%.CONCLUSIONS: Of all the surgical staging options, DSNB with inguinal US + FNAC had the lowest complication rates and high diagnostic accuracy, especially when performed in high-volume centres. If DSNB is not available, favourable results were also found for VEIL/RA-VEIL over open ILND. Lymphatic-related complications were comparable across open and video-endoscopic ILND.PATIENT SUMMARY: We reviewed studies on different surgical approaches for assessing lymph node involvement in cases with penile cancer. The results show that a technique called dynamic sentinel node biopsy with ultrasound guidance and fine-needle sampling has high diagnostic accuracy and low complication rates. For lymph node dissection in penile cancer cases, a minimally invasive approach may offer favourable postoperative outcomes.</p

Mycophenolate plus methylprednisolone versus methylprednisolone alone in active, moderate-to-severe Graves' orbitopathy (MINGO): a randomised, observer-masked, multicentre trial.

European guidelines recommend intravenous methylprednisolone as first-line treatment for active and severe Graves' orbitopathy; however, it is common for patients to have no response or have relapse after discontinuation of treatment. We aimed to compare the efficacy and safety of add-on mycophenolate to methylprednisolone in comparison with methylprednisolone alone in patients with moderate-to-severe Graves' orbitopathy. MINGO was an observer-masked, multicentre, block-randomised, centre-stratified trial done in two centres in Germany and two in Italy. Patients with active moderate-to-severe Graves' orbitopathy were randomly assigned to receive intravenous methylprednisolone (500 mg once per week for 6 weeks followed by 250 mg per week for 6 weeks) either alone or with mycophenolate (one 360 mg tablet twice per day for 24 weeks). The prespecified primary endpoints were rate of response (reduction of at least two parameters of a composite ophthalmic index [eyelid swelling, clinical activity score, proptosis, lid width, diplopia, and eye muscle motility] without deterioration in any other parameter) at 12 weeks and rate of relapse (a worsening of symptoms that occurred after a response) at 24 and 36 weeks. Rates of response at week 24 and sustained response at week 36 were added as post-hoc outcomes. Prespecified primary outcomes and post-hoc outcomes were assessed in the modified intention-to-treat population (defined as all patients assigned to treatment who received at least one infusion of methylprednisolone, when outcome data were available), and safety was assessed in all patients who received at least one dose of study drug. This trial is registered with the EU Clinical Trials Register, EUDRACT number 2008-002123-93. 164 patients were enrolled and randomised between Nov 29, 2009, and July 31, 2015. 81 were randomly assigned to receive methylprednisolone alone and 83 to receive methylprednisolone with mycophenolate. In the intention-to-treat population at 12 weeks, responses were observed in 36 (49%) of 73 patients in the monotherapy group and 48 (63%) of 76 patients in the combination group, giving an odds ratio (OR) of 1·76 (95% CI 0·92-3·39, p=0·089). At week 24, 38 (53%) of 72 patients remaining in the monotherapy group and 53 (71%) of 75 patients remaining in the combination therapy group had responded to treatment (2·16, 1·09-4·25, p=0·026). At week 24, relapse occurred in four (11%) of 38 patients in the monotherapy group and four (8%) of 53 patients in the combination group (OR 0·71, 0·17-3·03, p=0·72). At week 36, relapse occurred in an additional three (8%) patients in the monotherapy group and two (4%) patients in the combination group (0·65, 0·12-3·44, p=0·61). At week 36, 31 (46%) of 68 patients in the monotherapy group and 49 (67%) of 73 patients in the combination group had a sustained response (OR 2·44, 1·23-4·82, p=0·011). 23 patients had 24 serious adverse events, with 11 events in ten patients in the combination group and 13 events in 13 patients in the monotherapy group. Mild and moderate (grade 1-2) drug-related adverse events occurred in 16 (20%) of 81 patients receiving monotherapy and 21 (25%) of 83 patients receiving combination therapy (p=0·48). Although no significant difference was seen in the rate of response at 12 weeks or rate of relapse at 24 and 36 weeks, post-hoc analysis suggested that addition of mycophenolate to treatment with methylprednisolone improved rate of response to therapy by 24 weeks in patients with active and moderate-to-severe Graves' orbitopathy. Novartis, Germany

Unanswered questions in prostate cancer — findings of an international multi-stakeholder consensus by the PIONEER consortium

PIONEER is a European network of excellence for big data in prostate cancer consisting of 37 private and public stakeholders from 9 countries across Europe. Many progresses have been done in prostate cancer management, but unanswered questions in the field still exist, and big data could help to answer these questions. The PIONEER consortium conducted a two-round modified Delphi survey aiming at building consensus between two stakeholder groups — health-care professionals and patients with prostate cancer — about the most important questions in the field of prostate cancer to be answered using big data. Respondents were asked to consider what would be the effect of answering the proposed questions on improving diagnosis and treatment outcomes for patients with prostate cancer and to score these questions on a scale of 1 (not important) to 9 (critically important). The mean percentage of participants who scored each of the proposed questions as critically important was calculated across the two stakeholder groups and used to rank the questions and identify the highest scoring questions in the critically important category. The identification of questions in prostate cancer that are important to various stakeholders will help the PIONEER consortium to provide answers to these questions to improve the clinical care of patients with prostate cancer.</p

External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study

Objective: To externally validate Yonsei nomogram. Methods: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12&nbsp;months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. Results and limitation: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47&nbsp;months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. Conclusions: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up

Warm ischemia time length during on-clamp partial nephrectomy: dose it really matter?

52siBackground: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT >30 min. on the long-term renal function following on-clamp partial nephrectomy (PN). Methods: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year followup, and preoperative eGFR ≥60 ml/min/1.73m2. Patients were divided into two groups according to WIT length: group Ⅰ "WIT ≤30 min." and group Ⅱ "WIT >30 min.". A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. Results: The primary cohort consisted of 3526 patients: group Ⅰ (n=2868) and group Ⅱ (n=658). After matching the final cohort consisted of 344 patients in each group. At last followup, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group Ⅰ vs. 87% in group Ⅱ, p=0.638) and (-10 in group Ⅰ vs. -11 in group Ⅱ, p=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group Ⅰ vs. 81% in group Ⅱ, log-rank, p=0.763) and the matched groups (78.8% in group Ⅰ vs. 76.3% in group Ⅱ, log-rank, p=0.905). Univariable Cox regression analysis showed that WIT >30 min. was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, p=0.764) nor upgrading into CKD stage ≥Ⅲ (HR:0.972, 95%CI 0.805-1.173, p=0.764). Retrospective design is a limitation of our study. Conclusions: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR ≥60 ml/min/1.73m2.reservedopenAbdel Raheem, Ali; Alowidah, Ibrahim; Capitanio, Umberto; Montorsi, Francesco; Larcher, Alessandro; Derweesh, Ithaar; Ghali, Fady; Mottrie, Alexader; Mazzone, Elio; DE Naeyer, Geert; Campi, Riccardo; Sessa, Francesco; Carini, Marco; Minervini, Andrea; Raman, Jay D; Rjepaj, Chris J; Kriegmair, Maximilian C; Autorino, Riccardo; Veccia, Alessandro; Mir, Maria Carmen; Claps, Francesco; Choi, Young Deuk; Ham, Won S; Tadifa, John P; Santok, Glen D; Furlan, Maria; Simeone, Claudio; Bada, Maida; Celia, Antonio; Carrion, Diego M; Aguilera Bazan, Alfredo; Ruiz, Cristina B; Malki, Manar; Barber, Neil; Hussain, Muddassar; Micali, Salvatore; Puliatti, Stefano; Alwahabi, Abdelaziz; Alqahtani, Abdulrahman; Rumaih, Abdullah; Ghaith, Ahmed; Ghoneem, Ayman M; Hagras, Ayman; Eissa, Ahmed; Alenzi, Mohammed J; Pavan, Nicola; Traunero, Fabio; Antonelli, Alessandro; Porcaro, Antonio B; Illiano, Ester; Costantini, Elisabetta; Rha, Koon HAbdel Raheem, Ali; Alowidah, Ibrahim; Capitanio, Umberto; Montorsi, Francesco; Larcher, Alessandro; Derweesh, Ithaar; Ghali, Fady; Mottrie, Alexader; Mazzone, Elio; DE Naeyer, Geert; Campi, Riccardo; Sessa, Francesco; Carini, Marco; Minervini, Andrea; Raman, Jay D; Rjepaj, Chris J; Kriegmair, Maximilian C; Autorino, Riccardo; Veccia, Alessandro; Mir, Maria Carmen; Claps, Francesco; Choi, Young Deuk; Ham, Won S; Tadifa, John P; Santok, Glen D; Furlan, Maria; Simeone, Claudio; Bada, Maida; Celia, Antonio; Carrion, Diego M; Aguilera Bazan, Alfredo; Ruiz, Cristina B; Malki, Manar; Barber, Neil; Hussain, Muddassar; Micali, Salvatore; Puliatti, Stefano; Alwahabi, Abdelaziz; Alqahtani, Abdulrahman; Rumaih, Abdullah; Ghaith, Ahmed; Ghoneem, Ayman M; Hagras, Ayman; Eissa, Ahmed; Alenzi, Mohammed J; Pavan, Nicola; Traunero, Fabio; Antonelli, Alessandro; Porcaro, Antonio B; Illiano, Ester; Costantini, Elisabetta; Rha, Koon