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Davies SJ, Yates DR, Wilson RJT, Murphy Z, Gibson A, Allgar V, Collyer T. A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185). Perioper Med (Lond) 2019; 8:8. [PMID: 31406569 PMCID: PMC6686254 DOI: 10.1186/s13741-019-0119-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Meta-analysis suggests a possible benefit to this patient group from intravascular volume optimisation. We investigated whether intraoperative fluid and blood pressure optimisation improved complications in this group. Methods Patients with a NHFS ≥ 5 were enrolled into this multicentre observer-blinded randomised control trial. Patients were allocated to either standard care or a combination of fluid optimisation and blood pressure control using a non-invasive system. The primary outcome was the number of patients with one or more complications in each group. Secondary outcomes included hospital length of stay (LOS), incidence of hypotension and fluid and vasopressor usage. Results Forty-six percent of patients in the intervention group suffered one or more complications compared to the 51% in the control group (OR 0.82 (95% CI 0.49–1.36)). Per-protocol analysis improved the OR to 0.73 (95% CI 0.43–1.24). Median LOS was the same between both groups; however, the mean LOS on a per-protocol analysis was longer in the control group compared to the intervention group (23.2 (18.0) days vs. 18.5 (16.5), p = 0.047). Conclusions Haemodynamic optimisation including blood pressure management in high-risk patients undergoing repair of a hip fracture did not result in a statistically significant reduction in complications; however, a potential reduction in length of stay was seen. Trial registration A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185).
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Affiliation(s)
- S J Davies
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - D R Yates
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - R J T Wilson
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - Z Murphy
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - A Gibson
- Clinical Research Network: Yorkshire and Humber, York Teaching Hospitals Foundation Trust, Wigginton Road, York, UK
| | - V Allgar
- 3Hull York Medical School/Department of Health Sciences, University of York, York, UK
| | - T Collyer
- 4Department of Anaesthesia, Critical Care and Perioperative Medicine, Harrogate and District NHS Foundation Trust, Harrogate, UK
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Kanakaraj M, Yates DR, Wilson RJT, Baroni ML, Davies SJ. Prognostic Markers of Outcome in Patients Undergoing Infra-inguinal Revascularisation: A Prospective Observational Pilot Study. Eur J Vasc Endovasc Surg 2017. [PMID: 28625356 DOI: 10.1016/j.ejvs.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim was to investigate whether cardiopulmonary exercise testing (CPET) variables derived from cycle and arm ergonometry correlate, and whether CPET variables and pre-operative N-terminal pro-brain natriuretic peptide (NT-proBNP) have prognostic significance and if the combination of the two has incremental value. METHODS A prospective observational pilot study was conducted; 70 patients who underwent infra-inguinal bypass surgery were recruited. Pre-operatively subjects underwent CPET with both arm and leg ergonometry, to measure peak oxygen consumption, anaerobic threshold (AT), and ventilatory equivalents. In addition pre-operative serum samples of NT-proBNP were obtained. The primary endpoint was 1 year all-cause mortality; in addition, data were collected on complications, morbidity, length of stay, and major adverse cardiac events (MACE). RESULTS The 1 year mortality rate was 6%, the overall complications rate was 23%, and the combined incidence of MACE and 1 year mortality was 10%. Cycle ergonometry peak VO2 14 mL/kg/min (RR 5.5, 95% CI 1.4-22.4, p = .007) and AT < 10mL/kg/min (RR 3.0, 95% CI 1.1-7.0, p = .03) were predictors of post-operative complications. Pre-operative NT-proBNP > 320 ng/L (RR 18, 95% CI 2.5-140 p = .0003) was the sole predictor of 1 year mortality or MACE. CONCLUSION The measurement of pre-operative NT-proBNP in peripheral vascular disease patients undergoing infra-inguinal bypass can predict 1 year mortality and MACE. CPET variables from cycle ergonometry are predictors of post-operative complications in this patient group.
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Affiliation(s)
- M Kanakaraj
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - D R Yates
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - R J T Wilson
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - M L Baroni
- Department of Vascular Surgery, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - S J Davies
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK.
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Bozzini G, Nison L, Colin P, Ouzzane A, Yates DR, Audenet F, Pignot G, Arvin-Berod A, Merigot O, Guy L, Irani J, Saint F, Gardic S, Gres P, Rozet F, Neuzillet Y, Ruffion A, Roupret M. Influence of preoperative hydronephrosis on the outcome of urothelial carcinoma of the upper urinary tract after nephroureterectomy: the results from a multi-institutional French cohort. World J Urol 2012; 31:83-91. [DOI: 10.1007/s00345-012-0964-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 09/24/2012] [Indexed: 11/28/2022] Open
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Seisen T, Vaessen C, Yates DR, Parra J, Bourgade V, Bitker MO, Chartier-Kastler E, Rouprêt M. Résultats de la promontofixation par voie laparoscopique robot-assistée pour la prise en charge des prolapsus urogénitaux : analyse de la littérature. Prog Urol 2012; 22:146-53. [DOI: 10.1016/j.purol.2011.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 09/26/2011] [Accepted: 09/26/2011] [Indexed: 10/15/2022]
Affiliation(s)
- T Seisen
- Service d'urologie de l'hôpital Pitié-Salpêtrière, AP-HP, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, 83, boulevard de l'Hôpital, 75013 Paris, France
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Yates DR, Hupertan V, Colin P, Ouzzane A, Descazeaud A, Long JA, Pignot G, Crouzet S, Rozet F, Neuzillet Y, Soulie M, Bodin T, Valeri A, Cussenot O, Rouprêt M. Cancer-specific survival after radical nephroureterectomy for upper urinary tract urothelial carcinoma: proposal and multi-institutional validation of a post-operative nomogram. Br J Cancer 2012; 106:1083-8. [PMID: 22374463 PMCID: PMC3304431 DOI: 10.1038/bjc.2012.64] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Owing to the scarcity of upper urinary tract urothelial carcinoma (UUT-UC) it is often necessary for investigators to pool data. A patient-specific survival nomogram based on such data is needed to predict cancer-specific survival (CSS) post nephroureterectomy (NU). Herein, we propose and validate a nomogram to predict CSS post NU. Patients and methods: Twenty-one French institutions contributed data on 1120 patients treated with NU for UUT-UC. A total of 667 had full data for nomogram development. Study population was divided into the nomogram development cohort (397) and external validation cohort (270). Cox proportional hazards regression models were used for univariate and multivariate analyses and to build a nomogram. A reduced model selection was performed using a backward step-down selection process, and Harrell's concordance index (c-index) was used for quantifying the nomogram accuracy. Internal validation was performed by bootstrapping and the reduced nomogram model was calibrated. Results: Of the 397 patients in the nomogram development cohort, 91 (22.9%) died during follow-up, of which 66 (72.5%) died as a consequence of UUT-UC. The actuarial CSS probability at 5 years was 0.76 (95% CI, 71.62-80.94). On multivariate analysis, T stage (P<0.0001), N status (P=0.014), grade (P=0.026), age (P=0.005) and location (P=0.022) were associated with CSS. The reduced nomogram model had an accuracy of 0.78. We propose a nomogram to predict 3 and 5-year CSS post NU for UUT-UC. Conclusion: We have devised and validated an accurate nomogram (78%), superior to any single clinical variable or current model, for predicting 5-year CSS post NU for UUT-UC.
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Affiliation(s)
- D R Yates
- Academic Department of Urology of la Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris VI, 47-83 Boulevard de l'Hopital, Paris 75013, France
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Yates DR, Rouprêt M. Contemporary management of patients with high-risk non-muscle-invasive bladder cancer who fail intravesical BCG therapy. World J Urol 2011; 29:415-22. [PMID: 21544661 DOI: 10.1007/s00345-011-0681-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 04/16/2011] [Indexed: 12/13/2022] Open
Abstract
It is advocated that patients with high-risk non-muscle-invasive bladder cancer (NMIBC) receive an adjuvant course of intravesical Bacille Calmette-Guerin (BCG) as first-line treatment. However, a substantial proportion of patients will 'fail' BCG, either early with persistent (refractory) disease or recur late after a long disease-free interval (relapsing). Guideline recommendation in the 'refractory' setting is radical cystectomy, but there are situations when extirpative surgery is not feasible due to competing co-morbidity, a patient's desire for bladder preservation or reluctance to undergo surgery. In this review, we discuss the contemporary management of NMIBC in patients who have failed prior BCG and are not suitable for radical surgery and highlight the potential options available. These options can be categorised as immunotherapy, chemotherapy, device-assisted therapy and combination therapy. However, the current data are still inadequate to formulate definitive recommendations, and data from ongoing trials and maturing studies will give us an insight into whether there is a realistic efficacious second-line treatment for patients who fail intravesical BCG but are not candidates for definitive surgery.
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Affiliation(s)
- D R Yates
- Academic Department of Urology of la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Paris VI, Faculte de Medicine Pierre et Marie Curie and CeRePP, Centre d'Etudes et de Recherche sur les Pathologies Prostatiques, 47-83 Boulevard de l'Hopital, 75013, Paris, France
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Abstract
INTRODUCTION Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. 'Tubeless' or 'nephrostomy-free' PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of 'nephrostomy-free' PCNLs compared to standard PCNL over a 4-year period. PATIENTS AND METHODS Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive 'nephrostomy-free' PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications. RESULTS 'Nephrostomy-free' PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted 'nephrostomy-free' PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the 'nephrostomy-free' group developed a delayed perirenal haematoma. CONCLUSIONS 'Nephrostomy-free' percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.
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Affiliation(s)
- D R Yates
- Department of Urology, Rotherham District General Hospital, Rotherham, UK.
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Catto JWF, Yates DR, Rehman I, Azzouzi AR, Patterson J, Sibony M, Cussenot O, Hamdy FC. Behavior of urothelial carcinoma with respect to anatomical location. J Urol 2007; 177:1715-20. [PMID: 17437794 DOI: 10.1016/j.juro.2007.01.030] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE Urothelial carcinoma is a disease of the entire urothelium. Recent molecular insights suggest that the biology of some upper urinary tract and bladder urothelial carcinoma differ. These differences may affect tumor phenotype. Observational studies conflict as to the significance of anatomical location on the behavior of urothelial carcinoma. We compared the biological outcome in a large series of urothelial carcinoma with respect to anatomical location. MATERIALS AND METHODS We analyzed urothelial carcinoma in 425 patients treated at 4 centers according to stage and anatomical location, including the bladder in 275, the ureter in 67 and the renal pelvis in 79. Relapse surveillance was performed for a median of 46 months (range 2 to 216). A separate invasive bladder urothelial carcinoma population was also included to pathologically balance upper and lower tract urothelial carcinoma cases to allow behavioral comparisons. RESULTS As a whole, upper urinary tract urothelial carcinoma is more invasive and worse differentiated than bladder cancer (chi-square test p<0.0001 and 0.015, respectively). In pathologically matched cohorts recurrence to less aggressive disease, progression to more advanced disease and death occurred in 37%, 40% and 44% of patients with bladder urothelial carcinoma, and in 41%, 44% and 43% of those with upper urinary tract urothelial carcinoma, respectively. Multivariate analysis revealed that tumor stage and grade (Cox p=0.0001 and 0.012, respectively) but not location were associated with behavior. CONCLUSIONS Urothelial carcinoma behaves identically in the upper and lower urinary tracts when stage and grade are considered. The majority of tumors relapse within 5 years of excision. The current move to minimally invasive/nephron sparing techniques for urothelial carcinoma of the upper urinary tract appears safe. Care could be analogous to that for bladder urothelial carcinoma.
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Affiliation(s)
- J W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, United Kingdom.
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Yates DR, Rehman I, Meuth M, Cross SS, Hamdy FC, Catto JWF. Methylational urinalysis: a prospective study of bladder cancer patients and age stratified benign controls. Oncogene 2006; 25:1984-8. [PMID: 16288222 DOI: 10.1038/sj.onc.1209209] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Tumour suppressor gene (TSG) methylation has been proposed as a diagnostic marker for urothelial cancer (UC). Here, we compare the frequency of urinary TSG methylation in young and elderly patients, with and without UC. Urine samples were obtained prospectively from 35 UC patients, 35 benign controls over the age of 70 years and 34 healthy volunteers under the age of 40 years. Methylation analysis was performed for eight gene promoters using quantitative methylation-specific PCR. Methylation was detected in urine DNA from all three patient groups. The highest frequencies were seen in UC patients. Significantly less methylation was present in control samples than UC cases for RASSF1a and APC (P < 0.034). The 'methylation index' and level of methylation was highest in the UC group and lowest in the young control group. A marker panel of RASSF1a, E-cad and APC generated a sensitivity of 69%, a specificity of 60% and a diagnostic accuracy of 86%. TSG methylation is detectable in urine DNA from patients with and without bladder cancer. The frequency and extent of methylation appears to increase with age and malignancy. The lack of tumour specificity suggests that further investigation is required before this test is introduced into clinical practice.
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Affiliation(s)
- D R Yates
- Institute for Cancer Studies, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
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