Defining factors associated with high-quality surgery following radical cystectomy : analysis of the British Association of Urological Surgeons cystectomy audit

Background Radical cystectomy (RC) is associated with high morbidity. Objective To evaluate healthcare and surgical factors associated with high-quality RC surgery. Design, setting, and participants Patients within the prospective British Association of Urological Surgeons (BAUS) registry between 2014 and 2017 were included in this study. Outcome measurements and statistical analysis High-quality surgery was defined using pathological (absence of positive surgical margins and a minimum of a level I lymph node dissection template with a minimum yield of ten or more lymph nodes), recovery (length of stay ≤10 d), and technical (intraoperative blood loss <500 ml for open and <300 ml for minimally invasive RC) variables. A multilevel hierarchical mixed-effect logistic regression model was utilised to determine the factors associated with the receipt of high-quality surgery and index admission mortality. Results and limitations A total of 4654 patients with a median age of 70.0 yr underwent RC by 152 surgeons at 78 UK hospitals. The median surgeon and hospital operating volumes were 23.0 and 47.0 cases, respectively. A total of 914 patients (19.6%) received high-quality surgery. The minimum annual surgeon volume and hospital volume of ≥20 RCs/surgeon/yr and ≥68 RCs/hospital/yr, respectively, were the thresholds determined to achieve better rates of high-quality RC. The mixed-effect logistic regression model found that recent surgery (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.11–1.34, p < 0.001), laparoscopic/robotic RC (OR: 1.85, 95% CI: 1.45–2.37, p < 0.001), and higher annual surgeon operating volume (23.1–33.0 cases [OR: 1.54, 95% CI: 1.16–2.05, p = 0.003]; ≥33.1 cases [OR: 1.64, 95% CI: 1.18–2.29, p = 0.003]) were independently associated with high-quality surgery. High-quality surgery was an independent predictor of lower index admission mortality (OR: 0.38, 95% CI: 0.16–0.87, p = 0.021). Conclusions We report that annual surgeon operating volume and use of minimally invasive RC were predictors of high-quality surgery. Patients receiving high-quality surgery were independently associated with lower index admission mortality. Our results support the role of centralisation of complex oncology and implementation of a quality assurance programme to improve the delivery of care. Patient summary In this registry study of patients treated with surgical excision of the urinary bladder for bladder cancer, we report that patients treated by a surgeon with a higher annual operative volume and a minimally invasive approach were associated with the receipt of high-quality surgery. Patients treated with high-quality surgery were more likely to be discharged alive following surgery

Pituitary insufficiency after operation of supratentorial intra- and extraaxial tumors outside of the sellar–parasellar region?

Recent studies investigating pituitary function after non-sellar brain tumor surgery showed that up to 38.2% of patients have pituitary insufficiency (PI). It has been assumed that the operation causes the PI, but preoperative hormone testing, which would have been necessary to prove this assumption, was not performed. The objective of this study is to answer the question if indeed microsurgery is the culprit of PI in patients with operatively treated non-sellar brain tumors. In this prospective trial, 54 patients with supratentorial non-sellar tumors were included. The basal levels of cortisol, prolactin, testosterone, estrogen, IGF-1, fT3, fT4, STH, TSH, ACTH, FSH, and LH were recorded preoperatively on days 1 and 7 after surgery. If basal hormone screening revealed an abnormality, a releasing hormone assay was performed. Before surgery, 24 of the 54 patients (44.4%) already had PI. Additional 25 patients showed either hypocortisolism or hypothyreoidism. As those patients had been pre-treated with dexamethasone and l-thyroxine, these findings were considered not to represent PI but drug effects. Hormone testing on days 1 and 7 after surgery revealed no changes. With 44.4% PI is a frequent finding in brain tumor patients already before surgery. The factors causing preoperative PI remain yet to be identified. The endocrine results after surgery are unchanged which rules out that surgery is the cause of PI

Healthcare practice placements: back to the drawing board?

YesBackground: Sourcing healthcare practice placements continues to present a challenge for higher education institutions. Equally, the provision of clinical placements by healthcare providers is not at the forefront of their agenda. In view of this, the historic and traditional models of clinical placements is becoming more difficult to provide. In light of this, new models of clinical placements are being explored. Aims: This literature review explores the differing models of clinical placements in use and examines the merits and limitation of each. Methods: A mixed-methods literature review with a pragmatic approach has been used. Findings: Several placement models were described, including the traditional 1:1 model as well as 2:1, 3:1. The hub and spoke, capacity development facilitator, collaborative learning in practice and role emerging placement models were also discussed. Conclusion: There is a considerable paucity of high-quality evidence evaluating differing placement modules. Further research is required to evaluate the differing placement models from a students, clinical educators and service user’s perspective

Templateâ Directed Solidification of Eutectic Optical Materials

Mesostructured materials can exhibit enhanced lightâ matter interactions, which can become particularly strong when the characteristic dimensions of the structure are similar to or smaller than the wavelength of light. For controlling visible to nearâ infrared wavelengths, the small characteristic dimensions of the required structures usually demand fabrication by sophisticated lithographic techniques. However, these fabrication methods are restricted to producing 2D and a limited range of 3D structures. When a large volume of structured material is required, the primary approach is to use selfâ assembly, and the literature includes many examples of mesostructured optical materials formed via selfâ assembly. However, selfâ organized materials almost always contain structural imperfections which limit their performance. Emerging work, however, is showing that by performing selfâ assembly within a guiding template, the defect density in selfâ assembled structures can be reduced. Particularly interesting is the possibility that utilizing a template can result in the formation of mesostructures not present in either the template or the native selfâ organizing material. In this review, particular emphasis is placed on emerging results showing the effect of mesoscale templates on the microstructure of solidifying eutectic materials, with a specific focus on how templateâ directed solidification may be a powerful approach for fabricating optically active structures, including optical metamaterials.Templateâ directed assembly gives access to structures that are not present in either the template or the native selfâ organizing material. Proofâ ofâ concept works on templateâ directed selfâ organization of solidifying eutectic materials have exhibited intriguing results for photonics and optical metamaterials. This article provides a review of the challenges and opportunities of this technique for forming optically powerful structures.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144275/1/adom201800071_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144275/2/adom201800071.pd

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multi-disciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Not All Managers Are Managerial: A Self-Evaluation of Women Middle-Managers' Experiences in a UK University

The focus of this small-scale self-evaluation is the implementation of a new middle-management role in a post-92 UK university. A realist appreciative inquiry was undertaken with five women who had been promoted to a middle-management role 18 months prior to the inquiry. This evaluation for knowledge offered an opportunity to reflect on experiences in practice and sought to understand the experiences of the women in this role and how they cope with the challenges middle-management brings. Particular challenges (instability-generating) accorded with existing literature and included: lack of role clarity, lack of pre-preparation for management role, colleagues’ views of management, including perceptions of women in management roles and malicious intent of managed academics in rare cases. Supportive factors (provisional-stability-generating) included: personal resilience, informal peer support, external support and reflection. The co-evaluators offered reflections for the future from this co-evaluation. These suggest that training may contribute to provisional-stability in role and should be considered for new entrants to middle-management. The alternative construct of humanistic management is proposed as a way of understanding these women’s values-based decision-making practices in complex situations