A novel nomogram predicting lymph node invasion among patients with prostate cancer: The importance of extracapsular extension at multiparametric magnetic resonance imaging.

PURPOSE: To develop a novel risk tool that allows the prediction of lymph node invasion (LNI) among patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND). METHODS: We retrospectively identified 742 patients treated with RARP + ePLND at a single center between 2012 and 2018. All patients underwent multiparametric magnetic resonance imaging (mpMRI) and were diagnosed with targeted biopsies. First, the nomogram published by Briganti et al. was validated in our cohort. Second, three novel multivariable logistic regression models predicting LNI were developed: (1) a complete model fitted with PSA, ISUP grade groups, percentage of positive cores (PCP), extracapsular extension (ECE), and Prostate Imaging Reporting and Data System (PI-RADS) score; (2) a simplified model where ECE score was not included (model 1); and (3) a simplified model where PI-RADS score was not included (model 2). The predictive accuracy of the models was assessed with the receiver operating characteristic-derived area under the curve (AUC). Calibration plots and decision curve analyses were used. RESULTS: Overall, 149 patients (20%) had LNI. In multivariable logistic regression models, PSA (OR: 1.03; P= 0.001), ISUP grade groups (OR: 1.33; P= 0.001), PCP (OR: 1.01; P= 0.01), and ECE score (ECE 4 vs. 3 OR: 2.99; ECE 5 vs. 3 OR: 6.97; P< 0.001) were associated with higher rates of LNI. The AUC of the Briganti et al. model was 74%. Conversely, the AUC of model 1 vs. model 2 vs. complete model was, respectively, 78% vs. 81% vs. 81%. Simplified model 1 (ECE score only) was then chosen as the best performing model. A nomogram to calculate the individual probability of LNI, based on model 1 was created. Setting our cut-off at 5% we missed only 2.6% of LNI patients. CONCLUSIONS: We developed a novel nomogram that combines PSA, ISUP grade groups, PCP, and mpMRI-derived ECE score to predict the probability of LNI at final pathology in RARP candidates. The application of a nomogram derived cut-off of 5% allows to avoid a consistent number of ePLND procedures, missing only 2.6% of LNI patients. External validation of our model is needed.

Impact of terminating reimbursement of symptomatic slow-acting drugs in osteoarthritis in France on volume and cost of drug deliveries, assessed with administrative databases.

WITH OSTEOARTHRITIS (OA): As one of the leading causes of disability in adults worldwide, its toll on patients and its economic burden for payers are substantial. The issue of change in OA management with the evolution of reimbursement schemes needs to be addressed. OBJECTIVE: To assess the impact of terminating the reimbursement of symptomatic slow-acting drugs in OA (SYSADOAs) in France in terms of volume and cost, from a healthcare payer perspective. PRINCIPAL RESULTS: We obtained costs and volumes from French public national databases. We considered three exposure periods around cutoff dates according to decisions of decreased then terminated SYSADOA reimbursement. The periods included 19 345 (control), 20 066 (secondary), and 16 200 (primary) patients, respectively. Mean ages were 66.2 (±11.8), 65.3 (±11.6) and 64.6 (±11.5) years and about 70% were women. The volume of nonsteroidal anti-inflammatory drug (NSAID) deliveries estimated by defined daily doses (DDDs) decreased during the periods from 40.5 (±76.3) DDDs per patient in 2008 to 29.6 (±66.4) in 2015. The volume of analgesic deliveries increased slowly over the three periods, from 70.2 (±108.9) DDDs in 2008 to 76.9 (±123.1) in 2015 for all patients. MAJOR CONCLUSIONS: Our results did not show a measurable impact of terminating SYSADOA reimbursement on the delivery of NSAIDs and analgesics or on hospitalizations. However, neither do they allow for concluding that terminating SYSADOA reimbursement did not generate an increase in deliveries of non-reimbursed drugs, with their associated potential risks for public health.

Adherence to Guideline Recommendations for Perioperative Chemotherapy in Patients with pN2-3 M0 Squamous Cell Carcinoma of the Penis: Temporal Trends and Survival Outcomes.

AIMS: To analyse contemporary perioperative chemotherapy (CHT) guideline adherence rates for pN2-3 M0 squamous cell carcinoma of the penis, as well as CHT association with cancer-specific (CSM) and other-cause mortality (OCM). MATERIALS AND METHODS: Within the Surveillance, Epidemiology, and End Results databases, 311 pN2-3 M0 squamous cell carcinoma of the penis patients treated with inguinal lymph node dissection were identified. Univariable and multivariable logistic regression analyses focused on CHT rates, whereas cumulative incidence plots and multivariable competing risks regression analyses tested for CSM and OCM rates. RESULTS: CHT was administered to 140 (45%) patients and rates increased from 37.5 to 62.2% (2004-2015; P = 0.02). Specifically, annual CHT rates increased over time in patients younger or equal to 65 years and in patients older than 65 years (44.4-84.6% versus 28.6-50%, respectively), but this trend was not statistically significant (P = 0.1 and P = 0.2, respectively). The median follow-up was 13 months for both CHT (interquartile range 8.0-32.2) and no-CHT subgroups (interquartile range 5.0-40.0). In multivariable logistic regression analyses, more contemporary year of diagnosis interval (odds ratio 2.08, P < 0.01) and age older than 75 years (odds ratio 0.14, P < 0.001) were independent predictors of CHT use. In multivariable competing risks regression analyses, CHT use did not affect CSM (hazard ratio 1.02; P = 0.7) or OCM (hazard ratio 1.56; P = 0.8). CONCLUSIONS: CHT adherence rates sharply increased in the most recent years. Despite this increase over time, the lack of efficacy regarding CSM benefit is disappointing.

Cost utility modeling of early vs late total knee replacement in osteoarthritis patients.

Given the dramatic increase in the number of total knee replacement (TKR) surgeries in developed countries, the issue of the best time for surgery needs to be addressed from an economic perspective. OBJECTIVE: To assess, from the perspective of the healthcare payer, the cost-utility of two surgical strategies in which knee replacement is performed at the early or late stage of the disease in patients with knee osteoarthritis (OA). DESIGN: Patient data and evidence from published literature on economic costs and outcomes in OA, including utilities, non-pharmacological, pharmacological and surgical options, combined with population life tables were entered in a Markov model of OA. The model represented the lifetime experience of a cohort of patients following their therapeutic management, discounting costs (euros) and utilities (quality-adjusted life-years) at 4% annually. RESULTS: In the base-case scenario, early TKR cost €6,624 more than late TKR (€76,223 vs €69,599) with a 0.15 gain in QALYs (18.675 vs 18.524). This yielded an incremental cost-utility ratio (ICUR) of 43,631 €/QALY. Sensitivity analyses of the most influential uncertain parameters were performed and did not modify the direction of the conclusions: early TKR cost between €3,655 and €7,194 more than late TKR with a gain in QALYs between 0.15 and 0.39. The ICUR ranged from 17,131 €/QALY to 48,241 €/QALY. CONCLUSION: Our data do not support the early TKR strategy over the late TKR strategy in knee OA patients from a medico-economic perspective.

Robot-assisted radical prostatectomy: recent advances.

Robot assisted radical prostatectomy (RARP) represents the leading application of robotic surgery in the urologic field and it has become the main treatment option for localized prostate cancer (PCa) in the USA In the present review we summarized and critically analyzed the literature of the past five years about this widely used robotic procedure. RARP has continuously evolved in terms of technical modifications and procedural steps. Long-term data are now available, suggesting comparable oncological outcomes to those of open and laparoscopic radical prostatectomy. Good functional outcomes have also been demonstrated. Technological innovations and the introduction of more advanced robotic platforms featuring novel arm-integrated equipment, together with a mature clinical experience with the robotic approach, are likely to lead towards optimal outcomes. Despite the expanding clinical implementation of RARP in the management of prostate cancer, some issues related to this procedure remain matter of debate, such as costs, comparative outcomes versus other approaches, and its role in high risk disease.

[Survey on adherence to hygiene and dietary rules in patients with arterial occlusive disease]. / Enquête sur les conditions de suivi des règles hygiéno-diététiques chez l'artériopathe.

OBJECTIVE: Chronic arterial occlusive disease of the lower limbs, a common (800,000 patients in France) invalidating condition, can involve one or more arterial territories. In 90% of the cases, it is related to a more general disease, atherosclerosis. The risk factors are the same as for atherosclerosis and can be classed into three distinct groups: pathological conditions, constitutional characteristics, and lifestyle. Besides age and gender, smoking habits are by far the most predominant vascular risk factor for chronic arterial occlusive disease. Other factors include diabetes, known to play a particular role in diabetic arteriopathy, generally with more distal and quite severe lesions, high blood pressure, a less evident but certain risk factor, and hyperlipidemia, whole role in the pathogenesis of chronic arterial occlusive disease is well recognized though not predominant. These different data led us to analyze a cohort of patients with chronic arterial occlusive disease of the lower limbs to ascertain the cause of success or failure of hygiene and diet counseling. PATIENTS AND METHODS: The study protocol included three steps. We first established the profile of a typical arteriopathy patient based on demographic data, history of the arterial disease, personal and familial medical history and lifestyle: smoking habits, physical exercise, diet. The second step was to estimate the proportion of patients following hygiene and dietary rules. Finally, we looked for the reasons why the patients succeeded or failed in following these rules. This cross-sectional study involved 1,500 practitioners. Each physician selected 3 patients, men or women aged 40 to 80 years whose arteriopathy had reached the stage of intermittent claudication. Evaluation criteria were based on the demographic data and conditions of adherence to advice as well as conditions leading to success or failure: personal motivation, familial support, the patient's knowledge of the disease, its pathophysiological mechanisms, and the way the risk factors contribute to its genesis and aggravation. RESULTS: The sex ratio of the 3,294 recruited patients was 4.3 (2,672 men and 622 women). Disease duration and walking distance were 8.6 +/- 6 years and 418 +/- 297 meters respectively. Thirty-eight percent of the patients had undergone surgery of the lower limbs. One thousand four hundred ninety-four patients (45%) had undergone surgery for their arterial disease (lower limbs, coronary or cerebral arteries). Forty-nine percent were aware of the risk of amputation. Overall adherence to drug therapy was good for 82% of the patients. Patients were treated basically with vasoactive and platelet antiaggregates (95 and 82% of the patients respectively). Seventy-nine percent of the patients were former smokers (38% continued to smoke). Fifty-six percent had a specific regular physical activity compared with 42% prior to their disease. Seventeen percent of the patients had already tried a Mediterranean type diet (with a success rate of 69%). Among the 3, 294 patients, 950 (28.8%) followed hygiene and dietary rules well. The main reasons and/or conditions differentiating those who were successful and those who were not were, for each item: personal motivation, family support, and perception of the influence of lifestyle on disease course. These differences were highly significant (p <0.001). CONCLUSION: Considering the importance of following good hygiene and dietary rules for secondary prevention of chronic arterial occlusive disease of the lower limbs, it was interesting to assess with precision the percentage of diseased patients who follow such rules. Only about 30% of the patients were successful in correcting all behaviors.