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Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access.In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention.Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%],We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada.This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes.A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation.This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.

To determine the impact of the COVID-19 pandemic on diagnostic and treatment activity in 2020 across hospital providers of prostate cancer (PCa) care in the English National Health Service.Diagnostic and treatment activity between 23 March (start of first national lockdown in England) and 31 December 2020 was compared with the same calendar period in 2019. Patients newly diagnosed with PCa were identified from national rapid cancer registration data linked to other electronic healthcare datasets.There was a 30.8% reduction (22 419 vs 32 409) in the number of men with newly diagnosed PCa in 2020 after the start of the first lockdown, compared with the corresponding period in 2019. Men diagnosed in 2020 were typically at a more advanced stage (Stage IV: 21.2% vs 17.4%) and slightly older (57.9% vs 55.9% ≥ 70 years; P0.001). Prostate biopsies in 2020 were more often performed using transperineal (TP) routes (64.0% vs 38.2%). The number of radical prostatectomies in 2020 was reduced by 26.9% (3896 vs 5331) and the number treated by external beam radiotherapy (EBRT) by 14.1% (9719 vs 11 309). Other changes included an increased use of EBRT with hypofractionation and reduced use of docetaxel chemotherapy in men with hormone-sensitive metastatic PCa (413 vs 1519) with related increase in the use of enzalutamide.We found substantial deficits in the number of diagnostic and treatment procedures for men with newly diagnosed PCa after the start of the first lockdown in 2020. The number of men diagnosed with PCa decreased by about one-third and those diagnosed had more advanced disease. Treatment patterns shifted towards those that limit the risk of COVID-19 exposure including increased use of TP biopsy, hypofractionated radiation, and enzalutamide. Urgent concerted action is required to address the COVID-19-related deficits in PCa services to mitigate their impact on long-term outcomes.

An injectable ‘biostasis’ drug that could slow organ injury by inducing a state of suspended animation through reversible slowing of metabolic processes would have great value for organ preservation and treatment of badly injured patients at the point-of-care. Using whole-organism screening of metabolism, mobility, and development inXenopus, we identified an existing drug, SNC80, that rapidly and reversibly slows biochemical and metabolic activities while preserving cell and tissue viability, independently of its known delta opioid receptor modulating activity. Metabolic suppression was also achieved using SNC80 in cultured cells and microfluidic human organs-on-chips, as well as in explanted whole porcine hearts and limbs, demonstrating the cross-species relevance of this approach and potential clinical relevance for surgical transplantation. Thermal proteome profiling revealed that SNC80 targets the NCX1/EEAT1 membrane transport system and chemical modulation of NCX1 induces biostasis in non-hibernatingXenopustadpoles. Molecular induction of biostasis may offer a new therapeutic approach for organ preservation, trauma management, and enhancing patient survival in remote and low-resource locations.

Transdisciplinary (TD) working is claimed to be critical to meet future societal needs, with engineers being at the core to provide solutions to these challenges. However, there is little available that enables one to assess whether they or their team have the competencies required. Within this paper, we propose a self-assessment framework to ascertain whether design engineers have the competencies which enable TD working. We describe how the competencies were identified using a systematic literature review (SLR), we then describe how we utilized coded decision trees to classify which disciplinary level a particular competency can enable. In total, 76 competencies were classified; the results of the analysis show 20 of these displaying TD attributes as defined by Jantsch. The novelty of the approach is as follows: (1) In this paper, we propose a novel way to map the identified competencies against the levels of Jantsch’s hierarchical framework. (2) The proposed framework enables self-assessment of individual or team competencies to assess whether they have the competencies which enable TD working. (3) It enables a move towards incorporating TD practices in engineering projects.

Background Chronic endurance exercise has been linked to increased prevalence of coronary artery disease (CAD) in male master athletes. Data are limited regarding the presence of exercise-induced coronary inflammation and its association with atherosclerosis in master endurance athletes. Human coronary inflammation can be detected non-invasively by imaging pericoronary adipose tissue (PCAT). We tested the hypothesis that chronic endurance exercise leads to increased prevalence of atherosclerosis via coronary inflammation. Methods Computed tomography coronary angiogram CTCA scans from 2 cohorts of master athletes and age-matched controls, without known risk factors for CAD, were analysed post-hoc and the PCAT attenuation index was calculated around the proximal right coronary artery (FAIRCA). The athletes and the healthy controls also underwent an electrocardiogram, an echocardiogram, a cardiopulmonary exercise test (CPET), a 24-hour Holter tape and a Cardiac Magnetic Resonance (CMR) scan. Results Scans from 243 masters endurance athletes (62% females) and 58 age and Framingham CAD risk score matched healthy controls were analysed. FAIRCA was significantly higher (less negative) in male masters athletes vs female masters athletes [−61.3 Hounsfield Units (HU) vs −62.8 HU, p=0.01], in male athletes vs male controls (−61.3 HU vs −68.6 HU, p Conclusions Masters athletes show increased markers of coronary inflammation. This effect appears to be greater in male masters athletes and is associated with a higher peak VO2 in female masters athletes. However, we did not identify a link between coronary inflammation and coronary atherosclerosis in this cohort. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiac Risk in the Young, UK

The public reporting of patient outcomes is crucial for quality improvement and informing patient choice. However, outcome reporting in radiotherapy, despite being a major component of cancer control, is extremely sparse globally. Public reporting has many challenges, including difficulties in defining meaningful measures of treatment quality, limitations in data infrastructure, and fragmented health insurance schemes. The National Prostate Cancer Audit (NPCA), done in the England and Wales National Health Service (NHS), shows that it is feasible to develop outcome indicators for radiotherapy treatment, including patient-reported outcomes. The NPCA provides a transparent mechanism for comparing the performance of all NHS providers, with results accessible to patients, providers, and policy makers. Using the NPCA as a case study, we discuss the development of a radiotherapy-outcomes reporting programme, its impact and future potential, and the challenges and opportunities to develop this approach across other tumour types and in different health systems.

Purpose External beam radiation therapy (EBRT) with brachytherapy boost reduces cancer recurrence in patients with prostate cancer compared with EBRT monotherapy. However, randomized controlled trials or large-scale observational studies have not compared brachytherapy boost types directly. Methods and Materials This observational cohort study used linked national cancer registry data, radiation therapy data, administrative hospital data, and mortality records of 54,642 patients with intermediate-risk, high-risk, and locally advanced prostate cancer in England. The records of 11,676 patients were also linked to results from a national patient survey collected at least 18 months after diagnosis. Competing risk regression analyses were used to compare gastrointestinal (GI) toxicity, genitourinary (GU) toxicity, skeletal-related events (SRE), and prostate cancer–specific mortality (PCSM) at 5 years with adjustment for patient and tumor characteristics. Linear regression was used to compare Expanded Prostate Cancer Index Composite 26-item version domain scores (scale, 0-100, with higher scores indicating better function). Results Five-year GI toxicity was significantly increased after low-dose-rate brachytherapy boost (LDR-BB) (32.3%) compared with high-dose-rate brachytherapy boost (HDR-BB) (16.7%) or EBRT monotherapy (18.7%). Five-year GU toxicity was significantly increased after both LDR-BB (15.8%) and HDR-BB (16.6%), compared with EBRT monotherapy (10.4%). These toxicity patterns were matched by the mean patient-reported bowel function scores (LDR-BB, 77.3; HDR-BB, 85.8; EBRT monotherapy, 84.4) and the mean patient-reported urinary obstruction/irritation function scores (LDR-BB, 72.2; HDR-BB, 78.9; EBRT monotherapy, 83.8). Five-year incidences of SREs and PCSM were significantly lower after HDR-BB (2.4% and 2.7%, respectively) compared with EBRT monotherapy (2.8% and 3.5%, respectively). Conclusions Compared with EBRT monotherapy, LDR-BB has worse GI and GU toxicity and HDR-BB has worse GU toxicity. HDR-BB has a lower incidence of SREs and PCSM than EBRT monotherapy.

Background and purpose Little is known about the functional outcomes and health-related quality of life (HRQoL) following external beam radiation therapy (EBRT) combined with a high-dose rate brachytherapy boost (EBRT-BB) for the treatment of prostate cancer. We aimed to compare patient-reported outcomes of EBRT to those of EBRT-BB. Methods and materials Patients diagnosed with intermediate-risk, high-risk or locally advanced prostate cancer (April 2014 to September 2016), who received EBRT in the English National Health Service within 18 months of diagnosis and responded to a national patient questionnaire, were identified from the National Prostate Cancer Audit. Adjusted linear regression was used to estimate differences in functional EPIC-26 domains and HRQoL (EQ-5D-5L) between treatment groups. Non-inferiority of EBRT-BB was determined if the lower 95% confidence limit did not exceed the established minimal clinically important difference (MCID). Results Of the 13,259 included men, 12,503 (94.3%) received EBRT and 756 (5.7%) received EBRT-BB. EBRT-BB was non-inferior compared to EBRT for the urinary incontinence, sexual, bowel and hormonal EPIC-26 domains. EBRT-BB resulted in significantly worse urinary irritation/obstruction scores than EBRT (−6.1; 95% CI: −8.8 to −3.4) but uncertainty remains as to whether this difference is clinically important (corresponding MCID of 5). Conclusions There is no evidence to suggest that EBRT-BB results in any clinically important detriment in functional outcomes or HRQoL compared to men receiving EBRT only. Whilst statistically significantly worse urinary irritation/obstruction outcomes were reported in the EBRT-BB cohort, the threshold for a clinically significant difference was not exceeded and further research is required for confirmation.

To develop and validate a coding framework to identify interventions for upper tract obstructive uropathy (UTOU) in men with locally advanced and metastatic prostate cancer (PCa) using administrative hospital data to assess clinical outcomes. There are no population-based studies on the incidence, treatment, and outcomes of this complication.Patients newly diagnosed with PCa between April 2014 and March 2019 were identified in the English cancer registry. A coding framework based on procedure (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures fourth edition) and diagnostic (International Classification of Diseases, 10th edition) codes was developed and validated. Subsequent clinical outcomes were determined using Hospital Episodes Statistics to determine the utility of the intervention.A total of 77 010 patients newly diagnosed with locally advanced, and 30 083 patients with metastatic PCa were identified. Of these, 1951 (1.8%) patients underwent an intervention for UTOU according to our coding framework: 830 (42.5%) had locally advanced disease and 1121 (57.5%) had metastatic disease. In all, 844 (43.3%) had a percutaneous nephrostomy (PCN), 473 (24.2%) had a PCN with antegrade stent, and 634 (32.5%) had a retrograde stent. The mean follow-up was 43.2 months. The cumulative incidence of the use of these interventions at 1, 3, and 5 years was 2.5%, 3.6% and 4.2% in men with metastases compared to 0.5%, 0.9% and 1.4% in men with locally advanced disease.A new coding framework, developed to identify procedures for UTOU was applied in the largest study to date of UTOU in men with primary locally advanced and metastatic PCa. Results demonstrated that 2% of men with locally advanced PCa and 4% of men with metastatic PCa require an intervention to resolve UTOU within 5 years of their PCa diagnosis.

Aims Randomised controlled trials have shown comparable early oncological outcomes after hypofractionated and conventionally fractionated radiotherapy in the radical treatment of prostate cancer (PCa). The effect of hypofractionation on treatment-related gastrointestinal and genitourinary toxicity remains uncertain, especially in older men and those with locally advanced PCa. Materials and methods A population-based study of all patients treated with radical conventionally fractionated radiotherapy (n = 9106) and hypofractionated radiotherapy (n = 3027) in all radiotherapy centres in the English National Health Service between 2014 and 2016 was carried out. We identified severe gastrointestinal and genitourinary toxicity using a validated coding framework and compared conventionally fractionated and hypofractionated radiotherapy using a competing-risks proportional hazards regression analysis. Results The median age in our cohort was 72 years old and most patients had locally advanced disease (65%). There was no difference in gastrointestinal toxicity (conventionally fractionated radiotherapy: 5.0 events/100 person-years; hypofractionated radiotherapy: 5.2 events/100 person-years; adjusted subdistribution hazard ratio: 1.00, 95% confidence interval: 0.89–1.13; P = 0.95) or genitourinary toxicity (conventionally fractionated radiotherapy: 2.3 events/100 person-years; hypofractionated radiotherapy: 2.3 events/100 person-years; adjusted subdistribution hazard ratio: 0.92, 95% confidence interval: 0.77–1.10; P = 0.35) between patients who received conventionally fractionated radiotherapy and those who received hypofractionated radiotherapy. Conclusions This national cohort study has shown that the use of hypofractionated radiotherapy in the radical treatment of PCa does not increase rates of severe gastrointestinal or genitourinary toxicity. Our findings also support the use of hypofractionated radiotherapy in older men and those with locally advanced PCa.

To assess the complications of transrectal (TR) compared to transperineal prostate (TP) biopsies.Men diagnosed with prostate cancer between 1 April 2014 and 31 March 2017 in England were identified in the National Prostate Cancer Audit. Administrative hospital data were then used to categorize the type of prostate biopsy and subsequent complications requiring hospital admission. Administrative hospital data were used to identify patients staying overnight immediately after biopsy and those readmitted separately for hospital admissions because of sepsis, urinary retention or haematuria. Procedure-related mortality and total length of hospital stay within 30 days were also recorded. Generalized linear models were used to calculate adjusted risk differences (aRDs).A total of 73 630 patients undergoing prostate biopsy were identified. Those undergoing TP biopsy (n = 13 723) were more likely to have an overnight hospital stay (12.3% vs 2.4%; aRD 9.7%, 95% confidence interval [CI] 7.1-12.3), were less likely to be readmitted because of sepsis (1.0% vs 1.4%; aRD -0.4%, CI -0.6 to -0.2), and were more likely to be readmitted with urinary retention (1.9% vs 1.0%; aRD 1.1%, CI 0.7-1.4) than those undergoing a TR biopsy (n = 59 907). There were no significant differences in the risk of haematuria or mortality.Our results showed that TP biopsy had a lower risk of readmission for sepsis but a higher risk of readmission for urinary retention than TR biopsy. Use of the TP route would prevent one readmission for sepsis in 278 patients at the cost of three additional patients readmitted for urinary retention.

ObjectivesTo compare gender diversity between UK surgical specialties, assess trends over time, and estimate when gender parity might be achieved.DesignObservational study.SettingNational Health Service, UK.ParticipantsNHS Hospital & Community Health Service workforce statistics for 2011 to 2020Main outcome measuresLogistic regression was used to compare female representation in 2020 between surgical specialties, and to examine for any significant trends between 2011 and 2020. The method of least squares was used to estimate when female representation of specialty registrars would reach 50% (‘gender parity’) for specialties with ResultsIn 2020, female consultant and specialty registrar representation was significantly different between surgical specialties (both p45%) and Vascular Surgery (representation consistently ConclusionsDespite improvements over the last decade, gender disparity persists in the UK surgical workforce and there are significant differences between surgical specialties. Further work is necessary to establish the reasons for these observed differences with a specific focus on Vascular Surgery, Cardiothoracic Surgery, Neurosurgery, and Trauma and Orthopaedics.

INTRODUCTION: The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term. RESULTS: We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% - aRR 2.57, 95% CI 2.47-2.68; CPG2: 68.6% vs. 52.6% - aRR 1.27, 95% CI 1.25-1.29; CPG3: 76.7% vs. 67.1% - aRR 1.12, 95% CI 1.10-1.13; CPG4: 82.6% vs. 72.4% - aRR 1.09, 95% CI 1.08-1.10; CPG5: 78.2% vs. 71.7% - aRR 1.06, 95% CI 1.04-1.07) CONCLUSIONS: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.

Objectives To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery. Methods Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function). Results We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery. Conclusion In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.

Background Healthy male master endurance athletes have a greater prevalence of high coronary calcium (CAC) scores compared to healthy sedentary counterparts, and some demonstrate high-risk plaque features. A number of theories have been postulated but reasons remain unclear. Concurrently atherosclerotic coronary artery disease (CAD) is the most common cause of sudden cardiac death in male master athletes drawing much public and scientific interest and making this an important public health issue. Purpose To examine the relationship of age, resting systolic blood pressure (SBP), exercise dose and sporting discipline with high-risk CAD markers in male master endurance athletes. Methods A prospective study undertaken over 19 months evaluated 214 male master (40–65 years) endurance athletes, free from known cardiovascular risk factors, symptoms or relevant health conditions. Clinical evaluation included cardiopulmonary exercise test, resting blood pressure (BP) and coronary computed tomogram angiography (CCTA). CCTA assessed CAC score, significant stenosis, (>50%) and plaque vulnerability markers. Exercise dose was defined by years of endurance exercise and average MET-hours/week (lifetime exercise volume multiplied by the metabolic equivalent scores). Resting BP was the average of 3 consecutive supine measures after at least 5 minutes rest. Results Athletes (mean age 51, SD 70.1) exercised for minimum 6 hours/week (median 8.5) for a median of 15 years (2–26). Almost half (60.2%) were multi-endurance athletes i.e. any combination swimming, cycling and running. The remainder were runners (22.4%) and cyclists (15.4%). Median Framingham risk score 3.2% (1.8–5.8). The mean resting BP was 129/80 mmHg and a quarter (26%) of athletes were hypertensive (≥140/90 mmHg) at rest. A CAC score >100 Agatston units (AU) was present in 16% of athletes. There was a total of 15 stenotic lesions in 11 (5%) athletes. 13% had plaque vulnerability markers. Logistic regression evaluated whether age, resting SBP, exercise dose measures and sporting discipline were predictive for a CAC score >100 AU, significant stenosis and plaque vulnerability markers (table 1). CAC score was associated with age, years of endurance exercise and resting SBP. A Stenosis >50% and plaque vulnerability markers were associated with resting SBP and cycling compared with all other sporting disciplines. Conclusion Despite correcting for age, higher exercise dose (years endurance exercise) is associated with CAC score >100 AU but does not predict significant stenosis or plaque vulnerability markers. Resting SBP and cycling strongly predict high-risk disease. Cycling enables a greater intensity of exercise compared with other endurance sports, which may be associated with prolonged rises in SBP. Resting SBP and cycling are important determinants for high-risk CAD in middle-aged male endurance athletes and should be considered when risk stratifying in pre-participation evaluation. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Improvements in short-term outcomes have been reported for hospitals with higher radical prostatectomy (RP) volumes. However, the association with longer-term functional outcomes is unknown. All patients diagnosed with non-metastatic prostate cancer in the English NHS between 2014 and 2016 who underwent RP (N = 10,089) were mailed a survey ≥18 months after diagnosis. Differences in patient-reported urinary continence and sexual function (EPIC-26 on scale from 0 to 100) by hospital volume group (≤60, 61–100, 101–140, >140 RPs/year) were estimated using multilevel linear regression. Overall, 7702 men (76.3%) responded. There were no statistically significant differences in urinary continence (p = 0.08) or sexual function scores with increasing volume group (p = 0.2). When modelled as a linear function, we found a non-significant increase of 0.70 (95% CI −0.41 to 1.80; p = 0.22) in urinary continence and a significant increase of 1.54 (0.62–2.45; p = 0.001) in sexual function scores for a 100-procedure increase in hospital volume, which did not meet the threshold for a minimal clinically important difference (10–12 points). The results were similar for robotic-assisted RP (5529 men [71.8%]). These results do not support further centralisation of RP services beyond levels in England where four in five hospitals perform >60 RPs/year.

BACKGROUND: Many factors are implicated in the potential 'under-treatment' of prostate cancer but little is known about the between-hospital variation. METHODS: The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model. RESULTS: 53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P

Many factors are implicated in the potential ‘under-treatment’ of prostate cancer but little is known about the between-hospital variation. The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model. 53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P

INTRODUCTION AND OBJECTIVE:There is debate about the effectiveness and toxicity of pelvic lymph node (PLN) irradiation when used for disease recurrence following radical prostatectomy. This study c...

INTRODUCTION AND OBJECTIVE:No direct comparison has been made between England and the US with respect to the diagnosis and treatment of men with prostate cancer over one contemporary time period. W...

Background Cancer stage can be missing in national cancer registry records. We explored whether missing prostate cancer stage can be imputed using specific clinical assumptions. Methods Prostate cancer patients diagnosed between 2010 and 2013 were identified in English cancer registry data and linked to administrative hospital and mortality data (n = 139,807). Missing staging items were imputed based on specific assumptions: men with recorded N-stage but missing M-stage have no distant metastases (M0); low/intermediate-risk men with missing N- and/or M-stage have no nodal disease (N0) or metastases; and high-risk men with missing M-stage have no metastases. We tested these clinical assumptions by comparing 4-year survival in men with the same recorded and imputed cancer stage. Multi-variable Cox regression was used to test the validity of the clinical assumptions and multiple imputation. Results Survival was similar for men with recorded N-stage but missing M-stage and corresponding men with M0 (89.5% vs 89.6%); for low/intermediate-risk men with missing M-stage and corresponding men with M0 (92.0% vs 93.1%); and for low/intermediate-risk men with missing N-stage and corresponding men with N0 (90.9% vs 93.7%). However, survival was different for high-risk men with missing M-stage and corresponding men with M0. Imputation based on clinical imputation performs as well as statistical multiple imputation. Conclusion Specific clinical assumptions can be used to impute missing information on nodal involvement and distant metastases in some patients with prostate cancer.

Many factors are implicated in the potential 'under-treatment' of prostate cancer but little is known about the between-hospital variation.The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model.53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P 0.001) for patients aged ≥80 years (ICC: 0.235) compared to patients aged 75-79 years (ICC: 0.070), 70-74 years (ICC: 0.041), and70 years (ICC: 0.048). Comorbidity and socioeconomic deprivation did not influence the between-hospital variation.Radical local treatment of high-risk localised or locally advanced prostate cancer depended strongly on age and comorbidity, but also on socioeconomic deprivation and ethnicity, with the between-hospital variation being highest in older patients.

Improvements in short-term outcomes have been reported for hospitals with higher radical prostatectomy (RP) volumes. However, the association with longer-term functional outcomes is unknown.All patients diagnosed with non-metastatic prostate cancer in the English NHS between 2014 and 2016 who underwent RP (N = 10,089) were mailed a survey ≥18 months after diagnosis. Differences in patient-reported urinary continence and sexual function (EPIC-26 on scale from 0 to 100) by hospital volume group (≤60, 61-100, 101-140,140 RPs/year) were estimated using multilevel linear regression.Overall, 7702 men (76.3%) responded. There were no statistically significant differences in urinary continence (p = 0.08) or sexual function scores with increasing volume group (p = 0.2). When modelled as a linear function, we found a non-significant increase of 0.70 (95% CI -0.41 to 1.80; p = 0.22) in urinary continence and a significant increase of 1.54 (0.62-2.45; p = 0.001) in sexual function scores for a 100-procedure increase in hospital volume, which did not meet the threshold for a minimal clinically important difference (10-12 points). The results were similar for robotic-assisted RP (5529 men [71.8%]).These results do not support further centralisation of RP services beyond levels in England where four in five hospitals perform60 RPs/year.

The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres.In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit).A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment.There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

OBJECTIVES To evaluate the accuracy and completeness of surgeon-reported radical prostatectomy outcome data across a national health system by comparison with a national dataset gathered independently from clinicians directly involved in patient care. PATIENTS AND METHODS Data submitted by surgeons to the British Association of Urological Surgeons (BAUS) radical prostatectomy audit for all men undergoing radical prostatectomy between 2015 and 2016 were assessed by cross linkage to the National Prostate Cancer Audit (NPCA) database. Specific data items collected in both databases were selected for comparison analysis. Data completeness and agreement were assessed by percentages and Cohen's kappa statistic. RESULTS Data from 4707 men in the BAUS and NPCA databases were matched for comparison. Compared with the NPCA, dataset completeness was higher in the BAUS dataset for type of nerve-sparing procedure (92% vs 42%) and postoperative margin status (89% vs 48%) but lower for readmission (87% vs 100%) and Charlson score (80% vs 100%). For all other variables assessed completeness was comparable. Agreement and data reliability were high for most variables. However, despite good agreement, the inter-cohort reliability was poor for readmission, M stage and Charlson score (κ < 0.30). CONCLUSIONS For the first time in urology we show that surgeon-reported data from the BAUS radical prostatectomy audit can reliably be used to benchmark peri-operative radical prostatectomy outcomes. For comorbidity data, to assist with risk analysis, and longer-term outcomes, NPCA routinely collected data provide a more comprehensive source.

International audience; Dealing with electronic devices for high reliability applications in terrestrial environments, neutron-induced Single Event Effects must be investigated. In this paper, the experimental observation of an atmospheric-like neutron-induced Single Event Burnout (SEB) on a packaged commercial SiC power MOSFET is presented after irradiation at ISIS-ChipIr. The effects of the SEB in the electrical properties of the MOSFET are established, and the SiC damaged zone is observed by scanning electron microscopy. Based on this failure analysis at the die level, the distinct stages during the SEB mechanism can be defined. The sensitive volume where the secondary particle deposited enough energy to trigger the SEB mechanism is identified and located inside the SiC n-drift epitaxial layer near the epitaxial layer/substrate junction.

Cell phone use while driving (CPWD) increases the risk of crashing and is a major contributor to injuries and deaths. The objective of this study was to describe the evaluation of a multifaceted, evidence-based population health strategy for the reduction of distracted driving.A multipronged campaign was undertaken from 2014 to 2016 for 16- to 44-year-olds, based on epidemiology, focused on personal stories and consequences, using the "Es" of injury prevention (epidemiology, education, environment, enforcement, and evaluation). Education consisted of distracted driving videos, informational cards, a social media AdTube campaign, and a movie theater trailer, which were evaluated with a questionnaire regarding CPWD attitudes, opinions, and behaviors. Spatial analysis of data within a geographic information system was used to target advertisements. A random sample telephone survey evaluated public awareness of the campaign. Increased CPWD enforcement was undertaken by police services and evaluated by ARIMA time series modeling.The AdTube campaign had a view rate of10% (41,101 views), slightly higher for females. The top performing age group was 18- to 24-year-olds (49%). Our survey found 61% of respondents used handheld CPWD (14% all of the time) with 80% reporting our movie trailer made them think twice about future CPWD. A stakeholder survey and spatial analysis targeted our advertisements in areas of close proximity to high schools, universities, near intersections with previous motor vehicle collisions, high traffic volumes, and population density. A telephone survey revealed that 41% of the respondents were aware of our campaign, 17% from our print and movie theater ads and 3% from social media. Police enforcement campaign blitzes resulted in 160 tickets for CPWD. Following campaign implementation, there was a statistically significant mean decrease of 462 distracted driving citations annually (p = 0.001).A multifaceted, evidence-based population health strategy using the Es of injury prevention with interdisciplinary collaboration is a comprehensive method to be used for the reduction of distracted driving.Therapeutic, level IV.

Background The National Prostate Cancer Audit (NPCA) reports publicly performance indicators for all hospitals in England and Wales providing radical prostate cancer treatment, identifying those with results that fall outside the ‘accepted range’ as ‘potential negative outliers’. Hospitals with outlying results are requested to provide a formal response. This ‘outlier process’, targeting a limited number of hospitals, mirrors a ‘high-risk approach’ of preventing poor quality care in contrast to a ‘population approach’ that would target all hospitals. We invited clinicians to a national workshop to learn how the outlier process contributes to quality improvement. Methods The workshop started with presentations on reducing the ‘toxicity’ of radical prostate cancer treatment. Then, clinicians from three hospitals identified as outliers shared their experience of the process and the changes in practice they had made as a result. We collected data in three ways. First, an online platform was used to gather comments from participants during the workshop. Second, a number of participants were interviewed about the outlier process as a means to improve quality of care. Third, feedback was sought after the workshop from all participants. Responses were collated and analysed for themes. Results Sixty-nine clinicians attended including urologists, oncologists, radiographers and nurses, representing a spread of hospitals across England and Wales. There were 6 interviews, 21 online comments and 31 responses after the workshop. The clinicians representing outlying hospitals highlighted the negative (stigma, work load, negative impact on reputation) and the positive impact (detailed review of procedures, implementation of targeted approaches) of the outlier process. Participants felt that sharing experiences of outlying hospitals helps others to improve. They also suggested a ‘buddy system’ between better and worse performing hospitals. Many highlighted the importance of ‘networks’ to share experiences, either good or bad, as a vehicle for improving practice. Discussion The outlier process was generally accepted as a possible mechanism to improve practice. However, participants indicated that effective dissemination is key to ensuring that identifying poor outcomes in some hospitals (e.g. high-risk approach) can stimulate country-wide quality improvement (population approach).