==inizio objective==

Neutrophil-to lymphocyte ratio (NLR) has been considered an useful biomarker of systemic inflammatory response in several tumor types from several studies. In patients with muscle invasive bladder cancer (MIBC) undergoing cystectomy a higher preoperative NLR has been associated with poor prognosis and pathologic upstaging but its predictive value in non-muscle-invasive bladder cancer (NMIBC)up to date has been rarely studied with uncertain results. An independent association of NLR with unfavorable clinical outcome in selected patients with high-risk NMIBC, identifying patients failing intravesical immune therapy has been recently found by D’Andrea and coll (1) .
Our study had the aim to evaluate whether NLR could predict pathologic upstaging and recurrence in unselected patients undergoing transurethral resection (TUR) for primary NMIBC.

==fine objective==

==inizio methodsresults==

We reviewed th medical records of 162 consecutive patients submitted to TUR for primary NMIBC between January 2013 and December 2015. Informed consent and ethical committee approval were obtained. Exclusion criteria were presence of other malignancies, known autoimmune or inflammatory diseases, clinical evidence of advanced bladder cancer.
Statistical analysis: numeric values were compared by Wilcoxon-Mann-Whitney test. Chi-square test was used for the comparison of the non-numeric values. A NLR cut-off value of 3 according to recent literature was adopted (1). A p value <0.05 was considered statistically significant (Software R version 3.4.2) ==fine methodsresults== ==inizio results== The study cohort comprised 142 (87.7%) men and 20 women with a median age of 70 (23-90) years. Fifty four (33.3%) patients were active smokers, 73 (45.1%) former smokers with a median number of 20 cigarettes per day and a median smoking period of 25 years, while 35 (21.6%) patients never smoked. Out of 142 patients 32 (19.8%) received a pathological diagnosis of MIBC while130 (80.2%) of NMIBC. Particularly, high-grade tumors were found in 76 (46.9%) patients. Among NMIBC, 30 T1 (23%), 3 Tis (1.9%) and 42 (32.3%) high-grade tumors were diagnosed. Tumors were multiple in 131 patients (80.9%). Tumor size was <2cm, between 2 and 5 and more than 5 cm in 81 (50%), 77 (47.5%) and 4 (2.5%) patients, respectively.The median NLR was 2.7 (range: 0.2-42.1). At a median follow-up of 25 months (range: 3-48 ) 54 (39.9%) patients recurred. Mean time to recurrence was 12.9 months We didn't find any correlation between NLR (cut-off of 3) and age (p=0.85), gender (p=0.38), smoking status (p=0.50), G-grade (p=0.24), tumor size (p=0.77) and the adoption of adjuvant intravesical therapy (p=0.48). Moreover, no correlation was detected between NLR and recurrence (p=0.17) However, a statistically significant association was detected between NLR and multiplicity (single vs multiple) (p=0.018) and with T-stage (NMIBC vs MIBC) (p<0.005). ==fine results== ==inizio discussions== Recent studies suggest that NLR could be an independent prognostic value in advanced bladder cancer and in high risk NMIBC. In our experience in consecutive patients undergoing TUR for a clinical diagnosis of NMIBC we found a statistically significant association of NLR with multiplicity and T-stage, both factors enhancing host immune response. However, we did not detect any relation between NLR and patients’ outcome in terms of recurrence. ==fine discussions== ==inizio conclusion== NLR seems not to have a predictive value for recurrence in unselected NMIBC treated in common clinical practice, even if related with tumor multiplicity and T-stage. ==fine conclusion== ==inizio reference== 1. D'Andrea D et al.Clin Genitourin Cancer. 2017;15:e755-e764. Acknowledgments: We wish to thank the GSTU Foundation for the statistical support ==fine reference==

==inizio objective==

The medical care manager maintains the integration with social health services and with other professionals, takes into account the cost-quality ratio required by the system and offers the patient the most favorable solutions for his clinical care condition. We have applied these concepts to the activity of the Assistance and Services Center (CAS), a structure to which all patients with first diagnosis of cancer refer to as indicated by the Oncology Network of Piedmont and Valle d’Aosta. The activity of the medical care manager is flanked by the nursing case manager who is the one who manages the case. His role is to improve effectiveness and efficiency of health care, according to coordination of resources. Our goal is not only to guarantee to oncologic patient a linear path and to solve quickly his health problems but also to create an institutionalized figure to which the patient can always refer to.(1,2,3)

==fine objective==

==inizio methodsresults==

At the CAS the patient with first diagnosis of cancer is welcomed by the case manager who collects anamnestic information concerning physical-psychological and social condition. Then the patient is entrusted to the care manager: according to clinical data and type of cancer the care manager sets the diagnostic path based on guidelines used in our reality (AIOM 2017 guidelines integrated by EAU guidelines). The case manager programs examinations using preferential courses dedicated to CAS patients. The outcomes are collected and presented again to the care manager and then to the Interdisciplinary Care Group (GIC); during GIC there is collegial and multidisciplinary evaluation with the participation of urologists, oncologists, radiotherapists and, if necessary, specialists in palliative care or other specialists for the most appropriate therapeutic path. The results are then communicated by the care manager to the patient; if surgical intervention is indicated, the care manager organizes the pre hospitalization and the insertion in operative note according to waiting times and to specific indicators of the Oncology Network. CAS case manager interfaces with case manager of the department delivering the nursing card so that the data already collected can be used during care activity in the hospitalization and returned back at the end of the hospitalization itself. Care manager follows the patient during hospitalization, if possible participates in surgical intervention, follows the course plans, delivers the histological examination after GIC discussion, communicates to the patient the planned follow-up, plans the next Uro-Oncological check. During first access to CAS, the patient is provided with a mobile phone number to contact the care manager from Monday to Friday between 8 and 17. On holidays and during times not indicated, if necessary, the patient can contact the available urologist. (4,5,6,7)

==fine methodsresults==

==inizio results==

In period 1/9/2016 – 30/11/2017 were assessed at the two urological CAS of ASL CN 1 (SS. Annunziata Hospital of Savigliano and Regina Montis Regalis Hospital of Mondovì) 221 Patients divided as follows:

Cancer location Age range Men Women
Prostate 51-85 101 ————-
Testis 18-27 10 ————-
Kidney 45-85 30 9
Urothelium 42-93 59 12
Totali 18-85 200 21

To be noted: one case of single ureteral neoplasm, one case of association between prostatic and renal cancer and one case of bilateral synchronous renal cancer.

==fine results==

==inizio discussions==

Care and case managers must investigate multiple aspects of patient involved in the diagnostic and therapeutic process. It must not be a subjective judgment, but must provide objective information based on: careful observation, medical history and physical examination, interviews with the family (if accepted by patients), involving psycho-oncologist and social assistant if needed and activating “protection of fragile families” path if necessary. This is the moment in which a “therapeutic alliance” is created between the patient and the family, bringing into play the human factor that allows to create a path of care by rationalizing sequences and resources. During the interview it is very important to find a point of conjunction between the two parties. Sometimes the disease totally changes life of the patient and life of the people around him. Care and the case manager must help to redesign the patient’s future in a concrete way. The planning of interventions represents the central function of these figures, through the rationalization of measures and the forecast of future needs in relation to the and evolution of the care process, avoiding waste. Wastes are considered: increase in days of hospitalization, repetition of examinations, double or triple steps in different surgeries. Finally of fundamental importance: the moment of hospital discharge with therapeutic education about management of therapies when necessary; the monitoring to check that the planned interventions have been effective for the achievement of the objective, the evaluation that allows (at the end of the diagnostic-therapeutic-assistance path) to verify the correspondence between the expected objectives and the achieved results.(8,9,10)

==fine discussions==

==inizio conclusion==

A fundamental and inspiring moment of the described activity is the indications of the Oncology Network of Piedmont and Valle d’Aosta. In particular the network was born as an organizational model and is not a rigid bureaucratic instrument of uniformity. It is the opportunity to do a different type of oncology: the Net teaches us to work together, to do better and better and not to treat an illness but to take care of a sick person, accompanying patient not only in a diagnostic and therapeutic path, but also in a course of psychological, social and assistance support. The existence of the Network improves daily experience of people that manage the care and people that face the care itself. The operators are proud to be part of the Network because of its “values” and because of inspiring principles of our activity: a reference asset for our identity and for the citizens who approach it. The “Compass of Values” of the Oncology Network of Piedmont and Valle d’Aosta is a cultural reference model for operators to align behaviors, organizational models and operational procedures. Finally, it declines all the individual values that inspire the Net in behaviors that concretize them and in responsibilities that guarantee them.

==fine conclusion==

==inizio reference==

1) L’infermiere Case Manager . Chiari P., Santullo A., McGraw-Hill, seconda edizione, Milano 2011;
2) L’infermieristica basata su prove di efficacia. Chiari P.,. Mosci D, Naldi E., McGraw-Hill, Milano, 2006;
3) Giornale Italiano di Case Management. Bascelli E. volume 1, numero 1, settembre 2012;
4) Case management quale modalità organizzativa per la presa in carico e l’integrazione professionale: revisione della letteratura. Stuani N., Signorotti L. (2008), Tempo di Nursing, 52: pp. 13-24;
5) Case management philosophy. The case management knowledge. Bascelli E. (2012), AICM Journal in pillole.
6) Case management quale modalità organizzativa per la presa in carico e l’integrazione professionale.Bevilacqua P., Pasotti E. A. (2008), Tempo di Nursing, 52: pp. 13-24;
7) Dal case manager al care manager . De Rossi V. XV° congresso Nazionale FADOI Bologna 2010
8) Da “care” a “case” manager,Aboutpharma Online 15 febbraio 2015
9) Ecco il care manager, l’angelo custode della salute. Quotidiano sanità.it 19 dicembre 2017
10) La prassi del case management infermieristico in Emilia-Romagna: Berti L., Infermiere Case manager – Ausl di Piacenza Rivista L’Infermiere N°2 – 2013

==fine reference==