Background: Cardiopulmonary resuscitation (CPR) is an important advance directive (AD) topic in patients with progressive cancer; however such discussions are challenging. Objective: This study investigates whether video educational information about CPR engenders broader advance care planning (ACP) discourse. Methods: Patients with progressive pancreas or hepatobiliary cancer were randomized to an educational CPR video or a similar CPR narrative. The primary end-point was the difference in ACP documentation one month posttest between arms. Secondary end-points included study impressions; pre-and post-intervention knowledge of and preferences for CPR and mechanical ventilation; and longitudinal patient outcomes. Results: Fifty-six subjects were consented and analyzed. Rates of ACP documentation (either formal ADs or documented discussions) were 40% in the video arm (12/30) compared to 15% in the narrative arm (4/26), OR = 3.6 [95% CI: 0.9-18.0], p = 0.07. Post-intervention knowledge was higher in both arms. Posttest, preferences for CPR had changed in the video arm but not in the narrative arm. Preferences regarding mechanical ventilation did not change in either arm. The majority of subjects in both arms reported the information as helpful and comfortable to discuss, and they recommended it to others. More deaths occurred in the video arm compared to the narrative arm, and more subjects died in hospice settings in the video arm. Conclusions: This pilot randomized trial addressing downstream ACP effects of video versus narrative decision tools demonstrated a trend towards more ACP documentation in video subjects. This trend, as well as other video effects, is the subject of ongoing study.

Objective To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy and urinary diversion. Patients and Methods We conducted a retrospective review of 1097 radical cystectomies performed for the treatment of bladder cancer between 1992 and 2005. All data were entered prospectively into a hospital-based complications database. We used multivariable logistic regression to assess the association between preoperative serum albumin and complications and mortality within 90 days of surgery, while controlling for preoperative patient and disease characteristics. Results Low preoperative serum albumin was identified in 14% of the cohort. Preoperative serum albumin was a predictor of postoperative complications (adjusted odds ratio [OR] per unit increase in albumin: 0.61, 95% confidence interval [CI] 0.42–0.90) and 90-day mortality (OR 0.33, 95% CI 0.14–0.75) when controlling for sex, race, age-adjusted Charlson score, body mass index, prior history of abdominal surgery, clinical stage, and neoadjuvant chemotherapy. As serum albumin decreased, the risk of complications and mortality increased. Conclusions In addition to age-adjusted Charlson score, low preoperative serum albumin is a significant predictor of complications and mortality after radical cystectomy. Serum albumin testing can be used to identify individuals at high-risk for morbidity and mortality.

Purpose Surgical treatment options for renal masses include radical versus partial nephrectomy and the open versus laparoscopic approach. Using American Board of Urology case log data, we investigated contemporary trends in these treatment options and how surgeon and practice characteristics may influence these trends. Materials and Methods Annualized case log data for nephrectomies were obtained from the American Board of Urology for all urologists certifying or recertifying, from 2002 to 2010. We evaluated the trends in nephrectomy use. Logistic regressions were used to evaluate surgeon and practice characteristics as predictors for partial and laparoscopic procedures. Results From the 3,852 case logs submitted by non-pediatric urologists, 48,384 nephrectomies were analyzed. From 2002 to 2010, the proportion of annual nephrectomies that were performed as open radical nephrectomies gradually decreased from 54% to 29%. During the same period, there was a moderate gradual increase of laparoscopic radical nephrectomy usage, from 30% to 39%. The proportion of open partial nephrectomy remained stable at 15% while laparoscopic partial nephrectomy increased from 2% to 17%. On multivariable analysis, usage of partial nephrectomy and laparoscopy was predicted by a urologist’s annual nephrectomy volume, initial or recertification status, subspecialty, practice area size, and geographic region. Conclusions Since 2002, usage of laparoscopic nephrectomy and partial nephrectomy has increased. However, the diffusion of these techniques is not uniform. Initial certification, higher surgical volume, and practicing in areas over 1,000,000 and northeast region were associated with higher usage of laparoscopy and partial nephrectomy. Factors that affect the adoption of these techniques require further research.

Purpose Evidence suggests statins may influence pathways of RCC proliferation, though no study has examined the influence of statin medications on progression of RCC in humans. Materials and Methods We identified 2608 patients with localized RCC who were treated surgically between 1995–2010 at our tertiary referral center. Competing risks Cox proportional hazards models were used to evaluate the relationship between statin use and time to local recurrence or progression (metastases or death from RCC) and overall survival. Statin use was modeled as a time-dependent covariate as a sensitivity analysis. Models were adjusted for clinical and demographic features. Results Of 2608 patients, 699 (27%) were statin users at surgery. Statin users had similar pathological characteristics compared to nonusers. With a median follow-up of 36 months, there were 247 progression events. Statin use was associated with a 33% reduction in the risk of progression after surgery (HR 0.67, 95% CI 0.47–0.96, p=0.028) and an 11% reduction in overall mortality that was not significant (HR 0.89, 95% CI 0.71–1.13, p=0.3). Modeling statin use as time-dependent covariate attenuated the risk reduction in progression to 23% (HR 0.77, p=0.12) and augmented the risk reduction in overall survival (HR 0.71; p=0.002). Conclusions In our cohort, statin use was associated with a reduced risk of progression and overall mortality, though this effect was sensitive to method of analysis. If validated in other cohorts, this finding warrants consideration of prospective research on statins in the adjuvant setting.

Objective To evaluate the feasibility of an electronic symptom-tracking platform for patients recovering from ambulatory surgery. Method We assessed user response to an electronic system designed to self-report symptoms. Endpoints included compliance, postoperative symptoms, patient satisfaction. An 8-item symptom inventory (pain, nausea, vomiting, shortness of breath, fever, swelling, discharge, redness) was developed and made available on postoperative days (POD) 2–6. Responses exceeding defined thresholds of severity triggered alerts to healthcare providers. Symptoms, alerts, actions taken, urgent care center (UCC) visits, hospital admissions were tracked until POD 30. Patient satisfaction was evaluated on POD 7. A patient was defined as “responder” if at least 5/8 items on at least 3 PODs were completed. The assessment method was deemed successful if 64/100 patients responded. Results 97/102 patients were evaluable; 65 met “responder” criteria (67% responder rate; 95% CI 57–76%). 321 surveys were completed (median 4/patient), 248 (77%) in ≤2 min. Involving caregivers and allowing additional symptom-reporting improved the responder rate to 72% (95% CI 58–84%). Most commonly-reported moderate, severe, very severe symptoms were pain, nausea, swelling; 71% reported moderate to very severe pain on POD 2. Phone calls and adjustment of medications adequately addressed most symptoms. Two patients (2%) presented at UCC before, 6 (6%) after, POD 6; 1 (1%) was admitted. Most agreed or strongly agreed that electronic symptom-tracking was helpful, easy to use, and would recommend it to others. Conclusion Electronic symptom-tracking is feasible for patients undergoing ambulatory gynecologic cancer surgery. Symptom burden is high in the early postoperative period. Addressing patient-reported symptoms in a timely, automated manner may prevent severe downstream adverse events, reduce UCC visits and admission rates, and improve outcomes.