Competing mortality in patients diagnosed with bladder cancer: evidence of undertreatment in the elderly and female patients

Background: Bladder cancer (BC) predominantly affects the elderly and is often the cause of death among patients with muscleinvasive disease. Clinicians lack quantitative estimates of competing mortality risks when considering treatments for BC. Our aim was to determine the bladder cancer-specific mortality (CSM) rate and other-cause mortality (OCM) rate for patients with newly diagnosed BC. Methods: Patients (n ¼ 3281) identified from a population-based cancer registry diagnosed between 1994 and 2009. Median follow-up was 48.15 months (IQ range 18.1–98.7). Competing risk analysis was performed within patient groups and outcomes compared using Gray’s test. Results: At 5 years after diagnosis, 1246 (40%) patients were dead: 617 (19%) from BC and 629 (19%) from other causes. The 5-year BC mortality rate varied between 1 and 59%, and OCM rate between 6 and 90%, depending primarily on the tumour type and patient age. Cancer-specific mortality was highest in the oldest patient groups. Few elderly patients received radical treatment for invasive cancer (52% vs 12% for patients o60 vs 480 years, respectively). Female patients with high-risk non-muscle-invasive BC had worse CSM than equivalent males (Gray’s Po0.01). Conclusion: Bladder CSM is highest among the elderly. Female patients with high-risk tumours are more likely to die of their disease compared with male patients. Clinicians should consider offering more aggressive treatment interventions among older patients

Nothing Lasts Forever: Environmental Discourses on the Collapse of Past Societies

The study of the collapse of past societies raises many questions for the theory and practice of archaeology. Interest in collapse extends as well into the natural sciences and environmental and sustainability policy. Despite a range of approaches to collapse, the predominant paradigm is environmental collapse, which I argue obscures recognition of the dynamic role of social processes that lie at the heart of human communities. These environmental discourses, together with confusion over terminology and the concepts of collapse, have created widespread aporia about collapse and resulted in the creation of mixed messages about complex historical and social processes

Avascular necrosis of the femoral head: inter- and intraobserver variations of Ficat and ARCO classifications

Diagnosis of avascular necrosis (AVN) of the femoral head depends on the combination of clinical symptoms and evaluation of radiographs and/or magnetic resonance imaging (MRI). To evaluate the evolution of AVN, the Ficat and the Association Research Circulation Osseous (ARCO) classification are commonly used to assess both imaging modalities. For comparison reasons, these classifications need to be reliable and reproducible to provide sufficient therapy options for the patient. Therefore, the aim of our study was to evaluate the interobserver reliability and the intraobserver reproducibility of these classifications. Patients with suspected AVN were examined using either radiographs or radiographs and MRI. The radiographs and/or MR images were reviewed initially and at 3 months by two general orthopaedic surgeons, two orthopaedic residents, and two general radiologists using the Ficat classification for radiographs and MR images as well as the ARCO classification for MR images only. In all, 38 patients (54 hips) were enrolled. There were 10 patients who presented with radiographs and 28 patients with radiographs and MR scans. Paired comparisons revealed a mean interobserver kappa reliability coefficient of 0.39 for the first and of 0.32 for the second review using the Ficat classification for radiographs, whereas for the MR images a mean of 0.39 in the first and of 0.34 in the second reading resulted. The MRI evaluation using the ARCO classification resulted in a mean interobserver reliability coefficient of 0.37 in the first and of 0.31 in the second reading. The mean kappa value for intraobserver reproducibility using the Ficat classification was 0.52 for radiographs and 0.50 for MR images, whereas a reproducibility of 0.43 resulted for the ARCO classification. This study showed poor interobserver reliability and fair intraobserver variability, diminishing any meaningful comparison of studies using the Ficat as well as the ARCO classification. Thus, the Ficat and ARCO staging systems are still not sufficient to reliably assess the status of AVN alone

Critical analysis of quality of life and cost-effectiveness of enhanced recovery after surgery (ERAS) for patient's undergoing urologic oncology surgery: a systematic review

Purpose: Enhanced recovery after surgery (ERAS) protocols have been implemented across a variety of disciplines to improve outcomes. Herein we describe the impact of ERAS on quality of life (QOL) and cost for patients undergoing urologic oncology surgery. Methods: A systematic literature search using the MEDLINE, Scopus, Clinictrials.gov, and Cochrane Review databases for studies published between 1946 and 2020 was conducted. Articles were reviewed and assigned a risk of bias by two authors and were included if they addressed ERAS and either QOL or cost-effectiveness for patients undergoing urologic oncology surgery. Results: The literature search yielded a total of 682 studies after removing duplicates, of which 10 (1.5%) were included in the review. Nine articles addressed radical cystectomy, while one addressed ERAS and QOL for laparoscopic nephrectomy. Six publications assessed the impact of ERAS on QOL domains. Questionnaires used for assessment of QOL varied across studies, and timing of administration was heterogeneous. Overall, ERAS improved patient QOL during early phases of recovery within the realms of bowel function, physical/social/cognitive functioning, sleep and pain control. Costs were assessed in 4 retrospective studies including 3 conducted in the United States and one from China all addressing radical cystectomy. Studies demonstrated either decreased costs associated with ERAS as a result of decreased length of stay or no change in cost based on ERAS implementation. Conclusion: While limited studies are published on the subject, ERAS implementation for radical cystectomy and laparoscopic nephrectomy improved patient-reported QOL during early phases of recovery. For radical cystectomy, there was a decreased or neutral overall financial cost associated with ERAS. Further studies assessing QOL and cost-effectiveness over the entire global period of care in a variety of urologic oncology surgeries are warranted.This article is freely available to RD&E staff via NHS OpenAthens (subject to any publisher embargo). Click on the Publisher URL, and log in with NHS OpenAthens if prompted.This study was conducted with the support of a Department of Defense Peer Reviewed Cancer Research Program (PRCRP) Career Development Award (W81XWH1710576) (SBW).published version, accepted version (12 month embargo