Impact of Anaesthetist Volume on Radical Cystectomy Outcomes.

BACKGROUND: Radical cystectomy (RC) is a gold standard treatment for aggressive bladder cancer. Higher surgical volumes through centralisation are associated with improved RC outcomes. The impact of anaesthetist experience and RC volume on outcomes is less clear. OBJECTIVE: We sought to examine RC outcomes stratified by anaesthetist volume using a contemporary homogenous series. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of a prospectively collected, single-surgeon database of RC patients over a 10-yr period. INTERVENTION: Four hundred and fifty-three consecutive patients underwent RC, including 430 (95%) with anaesthetist annotation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Anaesthetists were stratified into low- (<10 cases) and high-volume (≥10 cases) classes. Primary outcomes were blood loss, transfusion rates, length of stay (LOS), and postoperative mortality. RESULTS AND LIMITATIONS: In total, 63 anaesthetists were included for analysis (median two RCs per anaesthetist). Of 63 anaesthetists, 56 (88.9%) and seven (11.1%) were classified, respectively, into low and high volume, and these provided cover for 110 (25.6%) and 320 (74.4%) patients, respectively. When comparing high- versus low-volume anaesthetists, there were shorter LOS (median [interquartile range {IQR}]: 10 [6-14] vs 12 [7-19] d, p = 0.008), lower blood loss (median [IQR]: 600 [384-1000] vs 800 [500-1275] ml, p<0.001), and lower transfusion rate (23/320, 7.2% vs 22/110, 20%; p < 0.001). There was no difference in disease-specific mortality, overall mortality, or readmission rates. In multivariable analysis, a high anaesthetist volume was independently associated with transfusion rate (odds ratio 0.24 [0.07-0.83], p = 0.02). CONCLUSIONS: Higher-volume anaesthetists have lower transfusion rates for RC patients. Whilst LOS and blood loss may also differ with experience, there is no difference in mortality after RC. PATIENT SUMMARY: Radical cystectomy is a major operation. Experienced anaesthetists give fewer blood products to patients undergoing this operation. They may also help reduce blood loss and speed recovery. However, all other recovery measures were similar.

Occupational bladder cancer: A cross section survey of previous employments, tasks and exposures matched to cancer phenotypes.

OBJECTIVES: Up to 10% of Bladder Cancers may arise following occupational exposure to carcinogens. We hypothesised that different cancer phenotypes reflected different patterns of occupational exposure. METHODS: Consecutive participants, with bladder cancer, self-completed a structured questionnaire detailing employment, tasks, exposures, smoking, lifestyle and family history. Our primary outcome was association between cancer phenotype and occupational details. RESULTS: We collected questionnaires from 536 patients, of whom 454 (85%) participants (352 men and 102 women) were included. Women were less likely to be smokers (68% vs. 81% Chi sq. p<0.001), but more likely than men to inhale environmental tobacco smoke at home (82% vs. 74% p = 0.08) and use hair dye (56% vs. 3%, p<0.001). Contact with potential carcinogens occurred in 282 (62%) participants (mean 3.1 per worker (range 0-14)). High-grade cancer was more common than low-grade disease in workers from the steel, foundry, metal, engineering and transport industries (p<0.05), and in workers exposed to crack detection dyes, chromium, coal/oil/gas by-products, diesel fumes/fuel/aircraft fuel and solvents (such as trichloroethylene). Higher staged cancers were frequent in workers exposed to Chromium, coal products and diesel exhaust fumes/fuel (p<0.05). Various workers (e.g. exposed to diesel fuels or fumes (Cox, HR 1.97 (95% CI 1.31-2.98) p = 0.001), employed in a garage (HR 2.19 (95% CI 1.31-3.63) p = 0.001), undertaking plumbing/gas fitting/ventilation (HR 2.15 (95% CI 1.15-4.01) p = 0.017), undertaking welding (HR 1.85 (95% CI 1.24-2.77) p = 0.003) and exposed to welding materials (HR 1.92 (95% CI 1.27-2.91) p = 0.002)) were more likely to have disease progression and receive radical treatment than others. Fewer than expected deaths were seen in healthcare workers (HR 0.17 (95% CI 0.04-0.70) p = 0.014). CONCLUSIONS: We identified multiple occupational tasks and contacts associated with bladder cancer. There were some associations with phenotype, although our study design precludes robust assessment.

Improving the medical 'take sheet'.

The GMC states that "Trainees in hospital posts must have well organised handover arrangements, ensuring continuity of patient care[1]". In the Belfast City Hospital throughout the day there can be multiple new medical admissions. These can be via the GP Unit, transfers for tertiary care, and transfers due to bed shortages in other hospitals. Over the course of 24 hours there can be up to four medical SHOs and three registrars that fill in the take sheet. Due to the variety of admission routes and number of doctors looking after the medical take information can be lost during handover between SHOs. In the current format there is little room to write and key and relevant information on the medical take sheet about new and transferring patients. I felt that this handover sheet could be improved. An initial questionnaire demonstrated that 47% found the old proforma easy to use and 28.2% felt that it allowed them to identify sick patients. 100% of SHOs and Registrars surveyed felt that it could be improved from its current form. From feedback from my colleagues I created a new template and trialled it in the hospital. A repeat questionnaire demonstrated that 92.3% of responders felt the new format had improved medical handover and that 92.6% felt that it allowed safe handover most of the time/always. The success of this new proforma resulted in it being implemented on a permanent basis for new medical admissions and transfers to the hospital.