The association of gender and persistent opioid use following an acute pain event: A retrospective population based study of renal colic.

INTRODUCTION: This study aims to explore gender-related differences in persistent opioid use following an acute pain episode and evaluate potential explanatory variables. METHODS: This retrospective population-based study using administrative databases included all opioid-naïve patients in Ontario with renal colic between 2013 and 2017. The primary outcome was to assess any association between persistent opioid use at 3-6 months by gender. Key confounding covariates and explanatory variables examined included both care- and patient-related factors, specifically past evidence of mental health diagnoses. RESULTS: The dataset of 64,240 males and 37,656 females demonstrated that 8.7% of males and 9.6% of females had evidence of persistent opioid use 3-6 months after presentation (OR 1.11, 95% CI 1.05, 1.17). Females had a higher incidence of mental health services utilization [44.5% vs 29.6% (p<0.001)] and were more likely to be on a provincial disability program [5.1% vs 3.8% (p<0.001)]. Age, income quintile, mental health diagnoses and dose of opioid prescribed were associated with the primary outcome in both genders. On adjusted analysis for multiple confounding and explanatory variables, females were still more likely than males to demonstrate persistent opioid use (OR 1.07, 95% CI 1.01, 1.13) with even more pronounced associations at 1-2 years. INTERPRETATION: After controlling for key covariates, females are at slightly higher risk of demonstrating long term opioid use following an episode of renal colic. Evidence of prior mental health service utilization and acute colic care did not appear to significantly explain these observations.

Safety and Effectiveness of Sedation With Adjunctive Ketamine Versus Nonketamine Sedation in the Medical Intensive Care Unit.

BACKGROUND: Ketamine, an N-methyl-d-aspartate receptor antagonist with sedative and analgesic properties, is becoming more popular as an adjunctive sedative in the critically ill patients. METHODS: We conducted a single center, retrospective cohort study of patients admitted to the medical intensive care unit (MICU) between 2013 and 2018. Patients who received continuous infusion ketamine or nonketamine sedatives (NKS) including dexmedetomidine, fentanyl, midazolam, or propofol were identified. The primary outcome was percentage of Richmond Agitation-Sedation Scale (RASS) scores at goal in patients receiving ketamine as adjunct to NKS compared to those on NKS alone. RESULTS: A total of 172 patients were included (n = 86 ketamine, n = 86 NKS). Baseline characteristics were similar with the exception of antipsychotic use, which was higher in the ketamine group (P = .008). Percentage of RASS scores at goal was not different between groups (78.7% vs 81.4%, P = .29). Fewer patients in the ketamine group received continuous infusion fentanyl (76.7% vs 94.2%, P = .002). Patients on adjunctive ketamine required fewer days of intermittent benzodiazepines (0 [0-1] vs 1 [1-2], P < .0001). Patients receiving ketamine required less norepinephrine, receiving a median of 6.32 mg (2.4-20) versus 11.7 mg (5.2-45.2; P = .03). There was no difference in receipt of new antipsychotics or occurrence of arrhythmias. CONCLUSION: Addition of ketamine did not increase the percentage of RASS scores at goal versus NKS but was well tolerated. Ketamine was associated with reductions in norepinephrine requirements, days of intermittent benzodiazepine administration, and number of patients receiving continuous infusion fentanyl. Continuous infusion ketamine appears safe and effective for sedation in the MICU.

Analgesic prescribing habits and patterns of Canadian chief urology residents: A national survey.

INTRODUCTION: Prior studies have identified significant knowledge gaps in acute and chronic pain management among graduating urology residents as of five years ago. Since then, there has been increasing awareness of the impact of excessive opioid prescribing on long-term narcotic use and development of adverse narcotic-related events. However, it is unclear whether the attitudes and experience of graduating urology residents have changed. We set out to evaluate the attitudes and experience of graduating urology residents in prescribing opioid/non-opioid analgesia for acute (AP), chronic non-cancer (CnC), and chronic cancer (CC) pain. METHODS: Graduating urology residents were surveyed at a review course in 2018. The survey consisted of open-ended and close-ended five-point Likert scale questions. Descriptive statistics, Mann-Whitney U-test, and Student's t-test were performed. RESULTS: A total of 32 postgraduate year-5 (PGY5) urology residents completed our survey (92% response rate). The vast majority agreed that formal training in managing AP/CnC/CC is valuable (91/78/81%). Most find their training in CnC/CC management to be inadequate and are unaware of any opioid prescribing guidelines; 66% never counsel patients on how to dispose of excess opioids. In general, 88% are comfortable prescribing opioids, whereas most are very uncomfortable prescribing cannabis or antidepressants (100% and 78%, respectively). Residents reported the acute pain service as the highest-rated resource for information, and dedicated textbooks the least. CONCLUSIONS: This survey demonstrated that experience in pain management remains variable among urology residents. Knowledge gaps remain, particularly in the management of CC/CnC pain.

Persistent Opioid Use Among Patients with Urolithiasis: A Population based Study.

BACKGROUND: Urolithiasis can result in acute, short-lived pain for which opioids are often prescribed. The risk of persistent opioid use following an initial presentation for urolithiasis is unknown. OBJECTIVE: To describe rates of opioid prescription and identify risk factors for persistent opioid use among patients with urolithiasis. DESIGN, SETTING, AND PARTICIPANTS: This was a population-based study of all patients diagnosed with urolithiasis in Ontario between 2013 and 2017 using administrative databases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was persistent opioid use, defined as dispensing of opioids between 91 and 180 d after presentation. Multivariable logistic regression and Cox proportional hazard models were used to identify factors associated with outcomes. RESULTS AND LIMITATIONS: Of 101 896 previously opioid-naïve patients, 66% were prescribed opioids at diagnosis and 41% of those were dispensed more than 200 oral morphine equivalents (OMEs). For those patients prescribed opioids, 9% had continued use. In adjusted analysis, the number of health care visits and having a stone intervention were associated with a higher risk of persistent opioid use (p< 0.0001). Total OME dispensed at presentation was highly associated with persistent use: for >300 OME the odds ratio (OR) was 1.59 (95% confidence interval [CI] 1.41-1.79). Among those who had an intervention, the number and type of procedure were also associated with persistent use: the OR for shockwave lithotripsy compared to ureteroscopy was 1.65 (95% CI 1.42-1.92). This study is limited by the accuracy of the diagnostic and procedural administrative codes available. CONCLUSIONS: The majority of urolithiasis patients were prescribed opioids and 9% of previously opioid-naïve patients exhibited persistent opioid use 91-180 d after their initial urolithiasis visit. PATIENT SUMMARY: In this study we found that 9% of patients prescribed opioids at presentation for kidney stones filled an additional prescription 3-6 mo later. Risk factors for this continued use included a higher dose of opioids prescribed in the initial period and the type of kidney stone surgery.

Anesthetic technique and oncological outcomes in urology: A clinical practice review.

INTRODUCTION: There is increasing awareness that different anesthetic and analgesic techniques may impact outcomes after oncological surgery, generally through modifying effects on the immune system but potentially via other mechanisms including mitigating the surgical stress response. This narrative review aims to summarize the mechanisms underlying the effect of perioperative factors on oncological outcomes, with an emphasis on the available urologic literature. METHODS: Literature on anesthetic technique (i.e., general vs. regional) and oncological outcomes were reviewed with a particular focus on urological studies. RESULTS: In prostate cancer surgery, the risk of mortality has been reported to be reduced with the use of regional (i.e., neuraxial) anesthesia, but there was no association between anesthetic technique and progression-free or biochemical recurrence-free survival. In nonmuscle invasive bladder cancer, regional anesthesia has been associated with lower recurrence rates and longer time to recurrence following transurethral resection of bladder tumor. CONCLUSIONS: This review highlights the role of regional anesthesia to improve oncoimmunological responses after surgery, potentially through decreased use of volatile anesthetics and opioids, decreased activation of the surgical stress response, and a direct local anesthetic-mediated anti-inflammatory effect. Available urological literature suggests an association of anesthetic type and outcomes for nonmuscle invasive bladder cancer and prostate cancer surgeries but the evidence is limited. Prospective studies are needed to further investigate the relationship between anesthetic technique and urologic oncological outcomes.

Hepatitis C Contamination of Medication Vials Accessed with Sterile Needles and Syringes.

BACKGROUND: Health care-associated hepatitis C virus outbreaks from contaminated medication vials continue to be reported even though most practitioners deny reusing needles or syringes. The hypothesis was that when caring for hepatitis C virus-infected patients, healthcare providers may inadvertently contaminate the medication vial diaphragm and that subsequent access with sterile needles and syringes can transfer hepatitis C virus into the medication, where it remains stable in sufficient quantities to infect subsequent patients. METHODS: A parallel-arm lab study (n = 9) was performed in which contamination of medication vials in healthcare settings was simulated using cell culture-derived hepatitis C virus. First, surface-contaminated vials were accessed with sterile needles and syringes, and then hepatitis C virus contamination was assessed in cell culture. Second, after contaminating several medications with hepatitis C virus, viral infectivity over time was assessed. Last, surface-contaminated vial diaphragms were disinfected with 70% isopropyl alcohol to determine whether disinfection of the vial surface was sufficient to eliminate hepatitis C virus infectivity. RESULTS: Contamination of medication vials with hepatitis C virus and subsequent access with sterile needles and syringes resulted in contamination of the vial contents in sufficient quantities to initiate an infection in cell culture. Hepatitis C virus remained viable for several days in several commonly used medications. Finally, a single or 2- to 3-s wipe of the vial diaphragm with 70% isopropyl alcohol was not sufficient to eliminate hepatitis C virus infectivity. CONCLUSIONS: Hepatitis C virus can be transferred into commonly used medications when using sterile single-use needles and syringes where it remains viable for several days. Furthermore, cleaning the vial diaphragm with 70% isopropyl alcohol is not sufficient to eliminate the risk of hepatitis C virus infectivity. This highlights the potential risks associated with sharing medications between patients.

An Underappreciated and Prolonged Drug Interaction Leads to Ineffective Anticoagulation.

A poorly understood significant drug-drug interaction compounded by ineffective communication among providers at times of care transition most likely contributed to multiple thromboembolic events in an 81-year-old patient. Increased awareness of drug interactions with direct oral anticoagulants (DOACs), as well as improved communication among inpatient and outpatient providers at the time of discharge is essential in maximizing efficacy and safety outcomes in patients requiring chronic anticoagulation. When rifampin is coadministered with apixaban, a reduction in apixaban exposure results in decreased efficacy and increased risk for thromboembolic events. The delayed effect of rifampin deinduction should be considered with regard to potential drug interactions even after its discontinuation. Equally as important, patients with multiple comorbidities and polypharmacy are at significant risk from adverse drug events during the transition from hospital to home. All efforts to improve continuity of care at times of transition, including medication reconciliation, prompt delivery of discharge summaries to outpatient providers, effective communication among providers, and patient education are components of a best practices model that has the potential to lower costs, improve medication adherence, decrease adverse drug events, and reduce hospital readmissions.

Cognitive load theory as a framework for simulation-based, ultrasound-guided internal jugular catheterization training: Once is not enough.

OBJECTIVE: The main objective of this study was to use the principles of cognitive load theory to design a curriculum that incorporates a progressive part practice approach to teaching ultrasound-guided (USG) internal jugular catheterization (IJC) to novices. A secondary objective was to compare the technical proficiency of residents trained using this curriculum with the technical proficiency of residents trained with the current local standard of a single simulation session. METHODS: The experimental group included 16 residents who attended three 2-hour sessions of progressive part practice in a simulation lab. The control group included 46 residents who attended the current local standard of a single 2-hour simulation session just prior to their intensive care unit rotation. Technical proficiency was assessed using hand motion analysis and time to procedure completion. RESULTS: After three sessions, median scores for right hand motion (RHM) (34.5; [27.0-49.0]), left hand motion (LHM) (35.5; [20.0-45.0]), and total time (TT) (117.0 s; [82.7-140.0]) in the experimental group were significantly better than the control group (p<0.001). Results for eight experimental group residents who were assessed for retention at a later date revealed median scores for RHM (45.0; [32.0-58.0]), LHM (33.5; [20.0-63.0]), and TT (150.0 s; [103.0-399.6]), which were significantly better than those of the control group (p=0.01, p<0.01, and p=0.02, respectively). CONCLUSION: These results support multiple sessions of progressive part practice in a simulation lab as an effective competency-based approach to teaching USG IJC in preparation for the clinical setting.

A survey of medication preparation and administration practices among members of the Canadian Anesthesiologists' Society.

PURPOSE: Recommendations for safe medication injection practices to eliminate the risk of patient-to-patient transmission of blood-borne infections have been in place for many years. The purpose of our study was to evaluate the medication administration practices of Canadian anesthesiologists relative to current safe practice guidelines. METHODS: An anonymous 17-question online survey was sent to all members of the Canadian Anesthesiologists' Society (CAS) via the membership email list. Data pertaining to respondent demographics, practice characteristics, and medication preparation and administration practices were collected and analyzed descriptively using frequencies and percentages as well as Fisher's exact tests followed by post hoc multiple comparisons. RESULTS: Of the 2,656 CAS members, 546 (21%) responded. The practice of reusing needles (2%) and/or syringes (7%) between patients is reported by only a minority of practitioners; however, sharing a medication vial between more than one patient using new needles and syringes is still widely practiced with 83% doing this sometimes or routinely. The main reasons for sharing medications include the desire to reduce medication waste and the associated costs. CONCLUSION: Sharing medication vials between multiple patients is common practice in Canada, with new needles and syringes used for each patient. Unfortunately, a small minority of anesthesiologists continue to reuse needles and/or syringes between patients, and this may pose a significant risk of patient-to-patient infection transmission.

Development and Evaluation of an Epidural Analgesia Workshop for Senior Nursing Students.

BACKGROUND: Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes. METHOD: A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests. RESULTS: Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions. CONCLUSION: This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359-365.].

Epidural Hematoma Following Cessation of a Direct Oral Anticoagulant: A Case Report.

OBJECTIVE: In this case report, we describe a case of epidural hematoma following epidural analgesia in a patient with recent cessation of a direct oral anticoagulant (DOAC). CASE REPORT: An 89-year-old woman requiring upper abdominal surgery presented with multiple comorbidities, including a prior cerebrovascular accident resulting in a left-sided hemiparesis and atrial fibrillation requiring anticoagulation with rivaroxaban. In accordance with our departmental guidelines at the time of procedure, rivaroxaban was discontinued 4 days preoperatively. A thoracic epidural was placed at T8/9 immediately prior to induction. Venous thromboembolism prophylaxis was provided with compression devices, and every-12-hour unfractionated heparin initiated 5.5 hours after epidural placement. On postoperative day 2, the patient was noted to have a bilateral motor block, and imaging demonstrated a thoracic epidural hematoma extending from T6 to T11. Preexisting neurological deficits may have delayed detection. With patient agreement, neurosurgery recommended observation rather than surgical decompression because the patient was a poor surgical candidate and limited neurologic recovery was expected. The patient had modest motor recovery over the next few months. CONCLUSIONS: Guidelines for cessation of DOACs prior to neuraxial techniques are based on pharmacologic half-lives rather than accumulated experience. This case adds to the experience of neuraxial analgesia complications while following these guidelines. Patient risk may be increased by the combination of recent cessation of a DOAC, as well as the cumulative effect of multiple small risk factors. Continued vigilance and reporting of cases of epidural hematomas will enhance our understanding and ultimately improve patient care. Elderly patients and/or patients with prior neurological deficits may present further challenges for early detection and require frequent assessments with comparison to baseline status.

Spinal Anesthesia is Associated with Lower Recurrence Rates after Resection of Nonmuscle Invasive Bladder Cancer.

PURPOSE: We sought to determine whether anesthetic type (general vs spinal) would influence cancer recurrence following transurethral resection of bladder tumors. MATERIALS AND METHODS: With institutional ethics board approval we examined the electronic medical records of all patients who underwent transurethral bladder tumor resection for nonmuscle invasive urothelial bladder cancer between 2011 and 2013 at a single tertiary care center. Followup information was gathered on all patients in December 2016. The time to first cancer recurrence and the incidence of cancer recurrence were the main outcome measures. RESULTS: A total of 231 patients underwent 1 or more transurethral bladder tumor resections between 2011 and 2013. Of the 231 patients 135 received spinal anesthesia and 96 received general anesthesia. On univariable analysis the 135 patients who received spinal anesthesia had a longer median time to recurrence than the 96 who received general anesthesia (42.1 vs 17.2 months, p = 0.014). As anticipated, adjuvant therapies and risk category were associated with recurrence rates (p = 0.003 and 0.042, respectively). On multivariable analyses incorporating a priori variables of nonmuscle invasive bladder cancer risk stratification and postoperative therapies the patients who received general anesthesia had a higher incidence of recurrence (OR 2.06, 95% CI 1.14-3.74, p = 0.017) and an earlier time to recurrence (HR 1.57, 95% CI 1.13-2.19, p = 0.008) than those who received spinal anesthesia. Anesthetic type was not associated with cancer progression or overall mortality. CONCLUSIONS: Patients who received spinal anesthesia had a lower incidence of recurrence and a delayed time to recurrence following transurethral bladder tumor resection for nonmuscle invasive bladder cancer. These findings should prompt large-scale prospective studies to confirm this association.

Associations Between Pharmacy Students' Attitudes Toward Debt, Stress, and Student Loans.

Objective. To assess graduating pharmacy students' attitudes toward debt and determine associations with stress, student loan debt, financial need, current employment, post-graduation plans, and expected length of time to repay loans. Methods. Survey was conducted using an attitudes-toward-debt scale (sub-scales: tolerant attitudes toward debt; contemplation and knowledge about loans; fear of debt), Perceived Stress Scale, and questions concerning current employment, estimated total student loan debt, post-graduation plans, and expected length of time to repay loans. Federal loan data were collected using financial aid records. Independent samples t-test, ANOVA, and Pearson's r correlations were conducted. Results. There were 147 students (96.7%) who participated. The majority were female (59.2%), white (69.4%), and had federal student loans (90.5%). Mean total loan amount was $153,276 (SD $59,810), which included federal students loans accumulated before and during pharmacy school. No significant differences were noted on attitudes toward debt or stress based on whether respondents had federal student loans. Greater "fear of debt" was correlated with increased stress, estimated total student loan debt, total federal loan debt, and pharmacy school loan debt. Greater "contemplation and knowledge about loans" was correlated with lower estimated total student loan debt, total federal loan amount, and pharmacy school loan amount. Students with higher "contemplation and knowledge" scores expected to repay loans within a shorter time frame than students with lower scores. Conclusion. Increased fear of debt was related to greater perceived stress and higher student loan amounts borrowed, while increased contemplation and knowledge about loans was associated with lower amounts borrowed. Educational programming concerning loans, debt, and personal financial management may help reduce stress and amount borrowed.

A qualitative study exploring the value of a catheter passport.

Many patients leaving hospital with a catheter do not have sufficient information to self-care and can experience physical and psychological difficulties. AIM: This study aimed to explore how a patient-held catheter passport affects the experiences of patients leaving hospital with a urethral catheter, the hospital nurses who discharge them and the community nurses who provide ongoing care for them. METHOD: Qualitative methods used included interviews, focus groups and questionnaires, and thematic analysis. FINDINGS: Three major themes were reported-informing patients, informing nurses; improving catheter care, promoting self-management; and supporting transition. CONCLUSION: The catheter passport can bridge the existing information gap, improve care, promote self-care and help patients adjust to their catheter, especially if complemented by ongoing input from a nurse or other health professional.

Development of an Instrument to Measure Pharmacy Student Attitudes Toward Social Media Professionalism.

Objectives. To develop and validate a scale measuring pharmacy students' attitudes toward social media professionalism, and assess the impact of an educational presentation on social media professionalism. Methods. A social media professionalism scale was used in a pre- and post-survey to determine the effects of a social media professionalism presentation. The 26-item scale was administered to 197 first-year pharmacy (P1) students during orientation. Exploratory factor analysis was applied to determine the number of underlying factors responsible for covariation of the data. Principal components analysis was used as the extraction method. Varimax was selected as the rotation method. Cronbach's alpha was estimated. Wilcoxon signed rank test was used to compare pre- and post-scores of each item, subscale, and total scale. Results. There were 187 (95%) students who participated. The final scale had five subscales and 15 items. Subscales were named according to the professionalism tenet they best represented. Scores of items addressing reading/posting to social media during class, an employer's use of social media when making hiring decisions, and a college/university's use of social media as a measure of professional conduct significantly increased from pre-test to post-test. The "honesty and integrity" subscale score also significantly increased. Conclusion. The social media professionalism scale measures five tenets of professionalism and exhibits satisfactory reliability. The presentation improved P1 students' attitudes regarding social media professionalism.

Association Between Anesthesiology Volumes and Early and Late Outcomes After Cystectomy for Bladder Cancer: A Population-Based Study.

BACKGROUND: Hospital and surgeon volume are related to postoperative complications and long-term survival after radical cystectomy. Here, we describe the relationships between these provider characteristics and anesthesiologist volumes on early and late outcomes after radical cystectomy for bladder cancer. METHODS: Records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with radical cystectomy in Ontario during 1994 to 2008. Volume was divided into quartiles and determined on the basis of mean annual number of hospital/surgeon/anesthesiologist radical cystectomy cases during a 5-year study period. A composite anesthesiologist volume also was used and defined as major colorectal procedures in addition to radical cystectomy given the similar complexity of these cases. Logistic and Cox proportional hazards regression models were used to explore the associations between volume and outcomes while adjusting for potential patient-, disease-, and system-related confounders. The primary outcomes were postoperative readmission rates, postoperative mortality, and 5-year survival. RESULTS: The study included 3585 patients with radical cystectomy between 1994 and 2008. Median annual anesthesiologist radical cystectomy volume was 1 (maximum 8.8 cases/year); lowest volume quartile (Q1) <0.6 cases/year and highest volume quartile (Q4) >1.4 cases/year. The median annual composite anesthesiologist volume was 9 radical cystectomy and colorectal cases (Q1 [range 0.2-6.4 cases/year], Q4 [range 11.8-29.2 cases/year]); subsequent analyses used this composite volume. Anesthesiologist volume was associated with readmission rates at 30 days (P = .02, Q1 mean = 27% vs Q4 mean = 21%) and at 90 days (P = .01, Q1 mean = 39% vs Q4 mean = 31%). In multivariable analysis, including the adjustment for surgeon and hospital volume, the cohort of anesthesiologists who performed the lowest volume of cases annually (Q1) was associated with greater rates of readmission at 30 days (OR 1.36, 95% confidence interval [CI], 1.09-1.71, P = .04) and at 90 days (OR 1.36, 95% CI, 1.11-1.66, P = .03). Anesthesiologist volumes were not associated with postoperative mortality or long-term survival. CONCLUSIONS: Anesthesiologist case volume for radical cystectomy was low, reflecting the lack of subspecialization in urologic procedures in routine clinical practice. Lower volume anesthesia providers were associated with higher readmission rates after radical cystectomy. Further studies are needed to validate this finding and to identify the processes that may explain an association between provider volume and patient outcome.

Peri-operative allogeneic blood transfusion and outcomes after radical cystectomy: a population-based study.

INTRODUCTION: To describe factors associated with peri-operative blood transfusion (PBT) at radical cystectomy (RC) for patients with bladder cancer and evaluate its association on both early and late outcomes. METHODS: Electronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who underwent RC between 2000 and 2008. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox-proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival. RESULTS: Among 2593 patients identified, 62% received an allogeneic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68 to 54%, p < 0.001). Factors associated with PBT included age, sex, greater co-morbidity, stage, and surgeon volume. PBT was associated with inferior outcomes, including median length of stay (11 vs. 9 days, p < 0.001), 90-day re-admission rate (38 vs. 29%, p < 0.001), and mortality (11 vs. 4%, p < 0.001). OS and CSS at 5 years were lower among patients with PBT on multivariate analysis (OS HR 1.33, 95% CI 1.20-1.48; CSS HR 1.39, 95% CI 1.23-1.56). CONCLUSIONS: Although rates are decreasing, these data suggest a very high utilization rate of PBT at time of RC in routine clinical practice. PBT is associated with substantially worse early outcomes and long-term survival. This association persists despite adjustment for disease-, patient-, and provider-related factors, suggesting that PBT is an important indicator of surgical care of RC.

Is there a measurable association of epidural use at cystectomy and postoperative outcomes? A population-based study.

INTRODUCTION: Thoracic epidural analgesia (TEA) is commonly used to manage postoperative pain and facilitate early mobilization after major intra-abdominal surgery. Evidence also suggests that regional anesthesia/analgesia may be associated with improved survival after cancer surgery. Here, we describe factors associated with TEA at the time of radical cystectomy (RC) for bladder cancer and its association with both short- and long-term outcomes in routine clinical practice. METHODS: All patients undergoing RC in the province of Ontario between 2004 and 2008 were identified using the Ontario Cancer Registry (OCR). Modified Poisson regression was used to describe factors associated with epidural use, while a Cox proportional hazards model describes associations between survival and TEA use. RESULTS: Over the five-year study period, 1628 patients were identified as receiving RC, 54% (n=887) of whom received TEA. Greater anesthesiologist volume (lowest volume providers relative risk [RR] 0.85, 95% confidence interval [CI] 0.75-0.96) and male sex (female sex RR 0.89, 95% CI 0.79-0.99) were independently associated with greater use of TEA. TEA use was not associated with improved short-term outcomes. In multivariable analysis, TEA was not associated with cancer-specific survival (hazard ratio [HR] 1.02, 95% CI 0.87-1.19; p=0.804) or overall survival (HR 0.91, 95% CI 0.80-1.03; p=0.136). CONCLUSIONS: In routine clinical practice, 54% of RC patients received TEA and its use was associated with anesthesiologist provider volume. After controlling for patient, disease and provider variables, we were unable to demonstrate any effect on either short- or long-term outcomes at the time of RC.