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The Ambassador Bridge, the busiest international crossing between the United States and Canada, is privately owned and operated, linking Detroit-Mich., with Windsor, Ontario. Since its inauguration in 1929, the bridge has not gone through any major upgrades or expansions. Due to many national and international developments (North American Free Trade Agreement) and significant increases in commercial traffic, the bridge required a major upgrade and expansion. The owners desired to complete the design and construction of a $3,000,000 truck-exit ramp within 12 months. The owners proposed a turnkey agreement that included several unique demands, such as 100 years of service life with 25 years of maintenance-free structure. Additionally, unique guarantees on costs and schedules, concealed conditions, and indemnifications were requested. The contract negotiated included many of the requested features that can be practically enforceable under the current professional practice, and construction liability laws and regulations. An independent business entity was utilized to address many of the owners' requirements, including hiring a construction company through a bidding process. The project was designed and built, according to state and federal standards, within the budget and the tight schedule of 12 months. The project was subsequently expanded under the same design/build contract to include an additional two phases at the cost of $8,500,000. The owners and consultants received many accolades and awards from civic and professional groups, including ASCE.

Employee performance appraisal is a dynamic and evolving process for many civil engineering firms. As a tool to advance the interests of the civil engineering industry, a survey was conducted in 1981 to find out how various civil engineering firms manage their employee-appraisal programs. This paper summarizes the results of a follow-up survey recently conducted to track new trends in the performance-appraisal process. The findings of the survey were interesting in that many firms felt the employee-appraisal process helped enhance the performance of both the employee and the organization. The survey found that more firms today have formal employee-appraisal programs in place, and the majority of respondents believe appraisals help increase productivity and motivation if handled properly. The survey identified areas of the appraisal process that need to be improved: consistency in the process and timing; improved training; good follow-up; firm commitment from the top management; and more open, sincere discussions.

Purpose: To provide a summary of the Third International Consultation on Bladder Cancer recommendations for the management of non-muscle invasive bladder cancer (NMIBC).Methods: A detailed review of the literature was performed focusing on original articles for the management of NMIBC. An international committee assessed and graded the articles based on the Oxford Centre for Evidence-based Medicine system. The entire spectrum of NMIBC was covered such as prognostic factors of recurrence and progression, risk stratification, staging, management of positive urine cytology with negative white light cystoscopy, indications of bladder and prostatic urethral biopsies, management of Ta low grade (LG) and high risk tumors (Ta high grade [HG], T1, carcinoma in situ [CIS]), impact of BCG strain and host on outcomes, management of complications of intravesical therapy, role of alternative therapies, indications for early cystectomy, surveillance strategies, and new treatments. The working group provides several recommendations on the management of NMIBC.Results: Recommendations were summarized with regard to staging; management of primary and recurrent LG Ta and high risk disease, positive urine cytology with negative white light cystoscopy and prostatic urethral involvement; indications for timely cystectomy; and surveillance strategies.Conclusion: NMIBC remains a common and challenging malignancy to manage. Accurate staging, grading, and risk stratification are critical determinants of the management and outcomes of these patients. Current tools for risk stratification are limited but informative, and should be used in clinical practice when determining diagnosis, surveillance, and treatment of NMIBC. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the recovery window (RW) between neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) affects 90‐day postoperative morbidity and incidence of lymph node metastasis. Patients and methods: We reviewed patients treated with NAC and RC from 1995 to 2013 for ≤cT4N0M0 bladder cancer. The association of the RW with 90‐day perioperative morbidity and lymph node metastasis was determined. Generalised linear models were used to determine predictors of each endpoint. Patients were stratified into four RWs by 21‐day intervals (18–42; 43–63; 64–84; and ≥85 days) from last day of NAC to RC. Results: We evaluated 306 patients with RW information during the study period. The median (range) RW was 46 (18–199) days. There was no difference in overall morbidity, re‐admission, or major complication rates amongst the four RWs. In the multivariable analysis extravesical disease was an independent predictor of overall morbidity (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.16–3.26; P = 0.011). Age (OR 1.05, 95% CI: 1.02–1.09; P = 0.004), and surgical duration ≥7 h (OR 2.87, 95% CI: 1.52–5.42; P = 0.001) were independent predictors of major complications. Only surgical duration ≥7 h was a predictor of re‐admission (OR 2.24; 95% CI: 1.26–3.98; P = 0.006). A RW of ≥85 days had the highest incidence of node‐positive disease (pN+; 40%). In a separate multivariable model that included clinical predictors for pN+, a RW of ≥85 days was an independent predictor of nodal metastasis (OR 2.92, 95% CI: 1.20–7.09; P = 0.018). Conclusion: Patients treated with NAC for bladder cancer can undergo RC between 18 and 84 days (2.5–12 weeks) after NAC with no difference in the risk of perioperative morbidity. Delaying surgery beyond 12 weeks was associated with a significant risk of lymph node metastasis. [ABSTRACT FROM AUTHOR]

Purpose Level I evidence supports the usefulness of neoadjuvant cisplatin based chemotherapy for muscle invasive bladder cancer. Since dose dense MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) has mostly replaced traditional MVAC, we compared pathological response and survival rates in patients with locally advanced bladder cancer who received neoadjuvant chemotherapy with dose dense MVAC vs gemcitabine and cisplatin. Materials and Methods We retrospectively reviewed the records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at a total of 20 contributing institutions from 2000 to 2015. Patients with cT3-4aN0M0 disease were selected for this analysis. The rates of ypT0N0 and ypT1N0 or less were compared between the gemcitabine and cisplatin, and dose dense MVAC regimens. Two multivariable Cox proportional hazards regression models of overall mortality were generated using preoperative and postoperative data. Results Of the patients who underwent neoadjuvant chemotherapy and radical cystectomy during the study period 319 met our inclusion criteria. A significantly lower rate of ypT0N0 was observed in the gemcitabine and cisplatin arm than in the dose dense MVAC arm (14.6% vs 28.0%, p = 0.005). The rate of ypT1N0 or less was 30.1% for gemcitabine and cisplatin compared to 41.0% for dose dense MVAC (p = 0.07). The mean Kaplan-Meier estimates of overall survival in the gemcitabine and cisplatin, and dose dense MVAC groups were 4.2 and 7.0 years, respectively (p = 0.001). On multivariable cox regression analysis based on preoperative data patients who received gemcitabine and cisplatin were at higher risk for death than patients who received dose dense MVAC (HR 2.07, 95% CI 1.25–3.42, p = 0.003). Lymph node invasion (HR 1.97, 95% CI 1.15–3.36, p = 0.01) and hydronephrosis (HR 2.18, 95% CI 1.43–3.30, p <0.001) were also associated with higher risk of death. Conclusions In our retrospective cohort of patients with locally advanced bladder cancer dose dense MVAC was associated with higher complete pathological response and improved survival rates compared to gemcitabine and cisplatin. A clinical trial is warranted to validate these hypothesis generating results to test the superiority of neoadjuvant dose dense MVAC in patients with locally advanced bladder cancer. [ABSTRACT FROM AUTHOR]

Background: Bladder cancer is a disease of the elderly that is associated with high morbidity in those treated with radical cystectomy. In this observational study of patients with bladder cancer undergoing radical cystectomy, we analyzed and compared patient-reported outcomes from those treated with Enhanced Recovery After Surgery (ERAS) methods versus those who received traditional perioperative care.Methods: We enrolled patients who underwent radical cystectomy at a high-volume tertiary care referral center from November 2013 to December 2016, when the ERAS concept was being introduced into postoperative care at our institution. Patients reported symptom outcomes using the MD Anderson Symptom Inventory preoperatively and on postoperative days 1 to 5. Mann-Whitney U tests were used to compare symptom burden between the ERAS and traditional-care groups. General linear mixed-effects models were used for longitudinal data; linear regression models were used for multivariable analysis.Results: Patients (N = 383) reported dry mouth, disturbed sleep, drowsiness, fatigue, pain, and lack of appetite as the most severe symptoms. Compared with the traditional-care group, the ERAS group had significantly less pain (est. = -0.98, P = .005), drowsiness (est. = -0.91, P = .009), dry mouth (est. = -1.21, P = .002), disturbed sleep (est. = -0.97, P = .01), and interference with functioning (est. = -0.70, P = .022) (adjusted for age, sex, surgical technique, and neoadjuvant chemotherapy status).Conclusions: These results suggest that ERAS practice significantly reduced immediate postoperative symptom burden in bladder cancer patients recovering from radical cystectomy, supporting the use of patient-reported symptom burden as an outcome measure in perioperative care. [ABSTRACT FROM AUTHOR]

Objective To compare the risk of hospitalisation and associated costs in patients after treatment for prostate cancer. Patients and Methods We identified 29 571 patients aged 66-75 years without significant comorbidity from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database who were diagnosed with localised prostate cancer between 2004 and 2009. We compared the rates of all-cause and treatment-related hospitalisation that occurred within 365 days of the initiation of definitive therapy. We used multivariable logistic regression analysis to identify determinants associated with hospitalisation. Results Men who underwent radical prostatectomy (RP) rather than radiotherapy (RT) had lower odds of being hospitalised for any cause after therapy [odds ratio (OR) 0.80, 95% confidence interval (CI): 0.74-0.87]. Patients who underwent RP rather than RT had higher odds of being hospitalised for treatment-related complications (OR 1.15, 95% CI: 1.03-1.29). However, men who underwent external beam RT (EBRT)/intensity modulated RT (IMRT) (OR 0.84, 95% CI: 0.72-0.99) had a 16% lower odds of hospitalisation from treatment-related complications than patients undergoing RP. Using propensity score-weighted analyses there was no significant difference in the odds of hospitalisation from treatment-related complications for men who underwent RP vs RT (OR 1.06, 95% CI: 0.92-1.21). Patients hospitalised for treatment-related complications after RT were costlier than patients who underwent RP (Mean $18 381 vs $13 203, P < 0.001). Conclusions With the exception of men who underwent EBRT/IMRT, there was no statistically significant difference in the odds of hospitalisation from treatment-related complications. Costs from hospitalisation after treatment were significantly higher for men undergoing RT than RP. Our findings are relevant in the context of penalties linked to hospital readmissions and bundled payment models. [ABSTRACT FROM AUTHOR]

Objective To analyse survival in patients with clinically localised, surgically resectable micropapillary bladder cancer ( MPBC) undergoing radical cystectomy ( RC) with and without neoadjuvant chemotherapy ( NAC) and develop risk strata based on outcome data. Patients and Methods A review of our database identified 103 patients with surgically resectable (≤ cT4acN0 cM0) MPBC who underwent RC. Survival estimates were calculated using Kaplan-Meier method and compared using log-rank tests. Classification and regression tree ( CART) analysis was performed to identify risk groups for survival. Results For the entire cohort, estimated 5-year overall survival and disease-specific survival ( DSS) rates were 52% and 58%, respectively. CART analysis identified three risk subgroups: low-risk: cT1, no hydronephrosis; high-risk: ≥ cT2, no hydronephrosis; and highest-risk: cTany with tumour-associated hydronephrosis. The 5-year DSS for the low-, high-, and highest-risk groups were 92%, 51%, and 17%, respectively ( P < 0.001). Patients down-staged at RC < pT1 regardless of the use of NAC had the best survival (5-year DSS of 96% vs 45% for those not down-staged; P < 0.001), while those who were not down-staged despite NAC had 5-year DSS of only 17%. Conclusion In patients with surgically resectable MPBC, NAC appears to confer benefit to patients with muscle-invasive disease without hydronephrosis, while patients with cT1 disease can proceed to upfront RC. Patients with hydronephrosis do not appear to respond well to NAC and have poor prognosis regardless of treatment paradigm. However, further external validation studies are needed to support the proposed risk stratification before treatment recommendations can be made. [ABSTRACT FROM AUTHOR]

Introduction: Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC). Methods: A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review. Results: Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients. Conclusion: There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here. [ABSTRACT FROM AUTHOR]

Objectives To determine the frequency of disease reclassification and to identify clinicopathological variables associated with it in patients with favourable-risk prostate cancer undergoing active surveillance ( AS). Patients and Methods We assessed 191 men, selected by what may be the most stringent criteria used in AS studies yet conducted, who were enrolled in a prospective cohort AS trial. Clinicopathological characteristics were analysed in a multivariate Cox proportional hazards regression model. Key features were an extended biopsy with a single core positive for Gleason score ( GS) 3 + 3 (<3 mm) or 3 + 4 (<2 mm) and a prostate-specific antigen ( PSA) level <4 ng/ mL (adjusted for prostate volume). Biopsies were repeated every 1-2 years and clinical evaluations every 6 months. Disease was reclassified when PSA level increased by 30% from baseline, or when biopsy tumour length increased beyond the enrolment criteria, more than one positive core was detected or any grade increased to a dominant 4 pattern or any 5 pattern. Results Disease was reclassified in 32 patients (16.8%) including upgrading to GS 4 + 3 in five patients (2.6%). The median (interquartile range) follow-up time among survivors was 3 (1.9-4.6) years. Overall, 13 of the 32 (40.6%) had incremental increases in GS. Tumour length (hazard ratio 2.95, 95% confidence interval [ CI] 1.34-6.46; P = 0.007) and older age (hazard ratio 1.05, 95% CI 1.00-1.09; P = 0.05) were identified as significant and marginally significant predictors of disease reclassification, respectively. Disease remained stable in 83.2% of patients. Conclusion The need persists for improvements in risk stratification and predictive indicators of cancer progression. [ABSTRACT FROM AUTHOR]

Background. Perioperative blood transfusions are associated with poor survival in patients with solid tumors including bladder cancer. Objective. To investigate the impact of perioperative blood transfusions on oncological outcomes after radical cystectomy. Design. Systematic review and meta-analysis. Setting and Participants. Adult patients who underwent radical cystectomy for bladder cancer. Intervention. Packed red blood cells transfusion during or after radical cystectomy for bladder cancer. Outcome Measurements and Statistical Analysis. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). We calculated the pooled hazard ratio (HR) estimates and 95% confidence intervals by random and fixed effects models. Results and Limitation. Eight, seven, and five studies were included in the OS, CSS, and RFS analysis, respectively. Blood transfusions were associated with 27%, 29%, and 12% reduction in OS, CSS, and RFS, respectively. A sensitivity analysis supported the association. This study has several limitations; however the main problem is that it included only retrospective studies. Conclusions. Perioperative BT may be associated with reduced RFS, CSS, and OS in patients undergoing RC for BC. A randomized controlled study is needed to determine the causality between the administration of blood transfusions and bladder cancer recurrence. [ABSTRACT FROM AUTHOR]