Achieving Benchmarks for National Quality Indicators Reduces Recurrence and Progression in Non-muscle-invasive Bladder Cancer.

BACKGROUND: Noncompliance with evidence-based interventions and guidelines contributes to significant and variable recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). The implementation of a quality performance indicator (QPI) programme in Scotland's National Health Service (NHS) aimed to improve cancer outcomes and reduce nationwide variance. OBJECTIVE: To evaluate the effect of hospitals achieving benchmarks for two specific QPIs on time to recurrence and progression in NMIBC. DESIGN, SETTING, AND PARTICIPANTS: QPIs for bladder cancer (BC) were enforced nationally in April 2014. NHS health boards collected prospective data on all new BC patients. Prospectively recorded surveillance data were pooled from 12 collaborating centres. INTERVENTION: QPIs of interest were (1) hospitals achieving detrusor muscle (DM) sampling target at initial transurethral resection of bladder tumour (TURBT) and (2) use of single instillation of mitomycin C after TURBT (SI-MMC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary and secondary endpoints were time to recurrence and progression, respectively. Kaplan-Meier and Cox multivariable regression analyses were performed. KEY FINDINGS AND LIMITATIONS: Between April 1, 2014 and March 31, 2017, we diagnosed 3899 patients with new BC, of which 2688 were NMIBC . With a median follow up of 60.3 mo, hospitals achieving the DM sampling target had a 5.4% lower recurrence rate at 5 yr than hospitals not achieving this target (442/1136 [38.9%] vs 677/1528 [44.3%], 95% confidence interval [CI] = 1.6-9.2, p = 0.005). SI-MMC was associated with a 20.4% lower recurrence rate (634/1791 [35.4%] vs 469/840 [55.8%], 95% CI = 16.4-24.5, p < 0.001). On Cox multivariable regression, meeting the DM target and SI-MMC were associated with significant improvement in recurrence (hazard ratio [HR] 0.81, 95% CI = 0.73-0.91, p = 0.0002 and HR 0.66, 95% CI = 0.59-0.74, p < 0.004, respectively) as well as progression-free survival (HR 0.62, 95% CI = 0.45-0.84, p = 0.002 and HR 0.65, 95% CI = 0.49-0.87, p = 0.004, respectively). We did not have a national multicentre pre-QPI control. CONCLUSIONS: Within a national QPI programme, meeting targets for sampling DM and SI-MMC in the real world were independently associated with delays to recurrence and progression in NMIBC patients. PATIENT SUMMARY: Following the first 3 yr of implementing a novel quality performance indicator programme in Scotland, we evaluated compliance and outcomes in non-muscle-invasive bladder cancer. In 2688 patients followed up for 5 yr, we found that achieving targets for sampling detrusor muscle and the single instillation of mitomycin C during and after transurethral resection of bladder tumour, respectively, were associated with delays in cancer recurrence and progression.

Clinical Characterization of Patients Diagnosed with Prostate Cancer and Undergoing Conservative Management: A PIONEER Analysis Based on Big Data.

BACKGROUND: Conservative management is an option for prostate cancer (PCa) patients either with the objective of delaying or even avoiding curative therapy, or to wait until palliative treatment is needed. PIONEER, funded by the European Commission Innovative Medicines Initiative, aims at improving PCa care across Europe through the application of big data analytics. OBJECTIVE: To describe the clinical characteristics and long-term outcomes of PCa patients on conservative management by using an international large network of real-world data. DESIGN, SETTING, AND PARTICIPANTS: From an initial cohort of >100 000 000 adult individuals included in eight databases evaluated during a virtual study-a-thon hosted by PIONEER, we identified newly diagnosed PCa cases (n = 527 311). Among those, we selected patients who did not receive curative or palliative treatment within 6 mo from diagnosis (n = 123 146). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patient and disease characteristics were reported. The number of patients who experienced the main study outcomes was quantified for each stratum and the overall cohort. Kaplan-Meier analyses were used to estimate the distribution of time to event data. RESULTS AND LIMITATIONS: The most common comorbidities were hypertension (35-73%), obesity (9.2-54%), and type 2 diabetes (11-28%). The rate of PCa-related symptomatic progression ranged between 2.6% and 6.2%. Hospitalization (12-25%) and emergency department visits (10-14%) were common events during the 1st year of follow-up. The probability of being free from both palliative and curative treatments decreased during follow-up. Limitations include a lack of information on patients and disease characteristics and on treatment intent. CONCLUSIONS: Our results allow us to better understand the current landscape of patients with PCa managed with conservative treatment. PIONEER offers a unique opportunity to characterize the baseline features and outcomes of PCa patients managed conservatively using real-world data. PATIENT SUMMARY: Up to 25% of men with prostate cancer (PCa) managed conservatively experienced hospitalization and emergency department visits within the 1st year after diagnosis; 6% experienced PCa-related symptoms. The probability of receiving therapies for PCa decreased according to time elapsed after the diagnosis.

Tonsillar carcinoma in dogs: Treatment outcome and potential prognostic factors in 123 cases.

BACKGROUND: Tonsillar carcinomas are rarely reported in dogs. Information on outcome after treatment is sparse and prognosis is guarded to poor. HYPOTHESIS/OBJECTIVES: Assess treatment outcome and potential prognostic factors in a population of dogs with cytological or histopathological diagnosis of tonsillar carcinoma. ANIMALS: A total of 123 client-owned dogs with diagnosis of tonsillar carcinoma confirmed by cytology or histopathology. METHODS: Retrospective, multi-institutional study. Medical records of 12 institutions were reviewed from 2012 to 2021. RESULTS: Treatment included surgery, chemotherapy (conventional, tyrosine kinase inhibitors or metronomic chemotherapy), radiotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs) or a combination of these. Surgery was performed in 68 cases, chemotherapy was administered in association with NSAIDs in 64 cases, NSAIDs were used alone in 14 cases and in association with surgery in 21 cases, whereas radiotherapy was used alone or in combination with surgery or chemotherapy in 20 cases. Overall survival time (OST) was 126 days (95% confidence interval [CI], 88-164). Significantly longer survival (P < .001) was seen in dogs without evidence of metastatic disease (median survival time, 381 days; 95% CI, 116-646). Other significant positive prognostic factors included absence of clinicals signs at presentation, surgery (tonsillectomy), use of adjuvant chemotherapy and use of NSAIDs. CONCLUSION AND CLINICAL IMPORTANCE: Asymptomatic dogs, those treated with surgery, those that received adjuvant chemotherapy, and those that received NSAIDs may have a better prognosis than previously expected, but overall survival remains short for dogs with tonsillar carcinoma.

Do men with bladder stones benefit from treatment of benign prostatic obstruction?

OBJECTIVE: To identify whether men aged ≥40 years with bladder stones (BS) benefit from treatment of benign prostatic obstruction (BPO). PATIENTS AND METHODS: A regional, retrospective study of patients undergoing BS surgery between January 2011 and December 2018 was performed using a prospectively collected database. The primary outcome was BS recurrence after successful removal. Kruskal-Wallis and chi-squared statistical tests were used. RESULTS: A total of 174 patients underwent BS removal and 71 (40.8%) were excluded due to BS formation secondary to causes other than BPO. Hence, 103 men aged ≥40 years had BS successfully removed, of which 40% had a history of upper tract urolithiasis. These men were divided into three groups: those undergoing contemporaneous medical, surgical, or no BPO treatment. Age, diabetes, previous urolithiasis and previous BPO surgery were well matched between the BPO treatment groups. In all, 18 of these men (17%) had BS recurrence after 46 months follow-up. Recurrences were significantly lower following BPO surgery; one of 34 (3%) men versus five of 28 (18%) with no BPO treatment (P = 0.048) and 12 of 41 (29%) with medical BPO treatment (P = 0.003). Recurrences after medical and no BPO treatment were similar (P = 0.280). In all, 34 men (33%) had BPO complications that were similar between groups (P = 0.378). CONCLUSION: This is the largest reported cohort of men, with the longest follow-up after BS removal. Most men aged ≥40 years with BS benefit from BPO surgery. However, the study findings also support a multifactorial aetiology for BS, which questions the dogma that BS are an 'absolute indication' for BPO surgery, as is stated in the Non-neurogenic Male Lower Urinary Tract Symptoms European Association of Urology Guideline. Assessment and management of all causative factors is likely to enable selection of which men will benefit from BPO surgery and to reduce BS recurrence rates.

Tranexamic acid-induced ureteric clot obstruction in a patient with urothelial cell carcinoma resulting in upper urinary tract perforation.

This is the first report of upper urinary tract (UUT) perforation secondary to tranexamic acid (TXA) induced ureteric clot obstruction. A 77-year-old woman was referred to the urology department with intermittent, painless visible haematuria from a lesion in the right upper calyx, suspicious of urothelial cell carcinoma. She did not have any flank pain or blood clots in her urine. Preoperatively, her haemoglobin level dropped from 113 g/L to 95 g/L and was prescribed oral TXA by her general practitioner, which led to extensive clot formation within the right kidney and ureter resulting in pain and ureteric obstruction. At ureteroscopy, a large ureteric blood clot was extracted and perforation close to the tumour with resultant urinary extravasation was noted. The patient subsequently underwent a successful nephroureterectomy, but risk of potential perforation-related complications such as tumour seeding, sepsis and urinoma formation could have been avoided. TXA in haematuria from the UUT should be strongly discouraged due to the risk of ureteric clot obstruction and UUT perforation.

Does a multidisciplinary approach have a beneficial effect on the development of a structured patient handover process between acute surgical wards in one of Scotland's largest teaching hospitals?

BACKGROUND: Effective handover is key in preventing harm.1 In the Acute Surgical Receiving Unit of Ninewells Hospital, Dundee, large numbers of patients are transferred daily. However, lack of medical handover during transfer means important tasks are missed. Our aim was to understand and reflect on the current system and test changes to improve medical handover. AIM: Our aim was to ensure that 95% of patients being transferred from the Acute Surgical Receiving Unit receive a basic medical handover within 2 months. METHODS: Initially, we collated issues that were missed when patients were transferred. These data coupled with questionnaire data from members of the team fed into the creation of a handover tool. We proposed to link our tool with the nursing handover, hence creating one unified handover tool. We completed six full Plan-Do-Study-Act (PDSA) cycles (two on communication to aide handover and four on the tool itself) to assess and develop our tool. RESULTS: By our final PDSA cycle, 84% (33/39) of the patients had a handover, meaning no tasks were missed during transfer. After 4 months, 9 out of 10 staff felt that the introduction of the handover sheet made the handover process smoother and 8 out of 10 felt that the handover sheet improved patient safety and quality of care. CONCLUSIONS: Improving handover can be challenging. However, we have shown that a relatively simple intervention can help promote better practice. Challenges are still present as uptake was only 84%, so work still has to be done to improve this. A wider cultural change involving communication and education would be required to implement this tool more widely.