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Objective: • To determine whether there is a difference in survival in patients with node-negative pT2a vs pT2b urothelial carcinoma of the bladder (UBC), as recent studies suggest that the new American Joint Committee on Cancer substratification may not have prognostic significance., Patients and Methods: • Of 252 patients undergoing radical cystectomy (RC) and extended bilateral pelvic lymphadenectomy (ePLND) between 1999 and 2009, 72 (28.6%), with a mean (range) age of 66 (44-83) years (50 men, 22 women), had pathologically confirmed pT2 UCB. • Fisher's exact test and Cox regression analysis were used for uni- and multivariate analysis of risk factors of recurrence at a median (range) follow-up of 28 (2.2-115.7) months. • Kaplan-Meier plots were used to estimate the impact of pT2 substratification in lymph node (LN)-negative disease on recurrence-free (RFS) and cancer-specific (CSS) survival using log-rank test., Results: • Of the 72 patients, 39 had pT2a (54.2%) and 33 pT2b UCB (45.8%) on definitive histological examination. The median (range) number of LNs removed was 19 (6-38) in pT2a and 22 (4-36) in pT2b (P = 0.31) UCB. • At RC, there was LN-positive disease in one patient with pT2a UCB, whereas seven patients with pT2b UCB had LN-positive disease (P = 0.02). • The median (range) number of LNs removed in LN-positive disease was 18 (11-30) and in LN-negative disease was 20 (4-38) (P = 0.52). • In LN-negative disease, actuarial 5-year RFS was 85.9% in patients with pT2a UCB vs 37.5% in those with pT2b UCB (P < 0.001). Actuarial 5-year CSS was 84.8% in patients with LN-negative pT2a UCB vs 59.6% in patients with LN-negative pT2b UCB (P = 0.01). • In Cox regression analysis, pT2 substratification was the only independent risk factor of recurrence and cancer-specific death (P < 0.001 and P = 0.008)., Conclusions: • In this contemporary series of patients undergoing RC with ePLND, there was a significant difference in RFS and CSS between LN-negative pT2a and pT2b UCB, and pT2 substratification was the only risk factor of recurrence and cancer-specific death. • These data are supportive of the current concept of substratification in LN-negative pT2 UCB., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

In a prospective study of more than 4,000 consecutive patients who underwent any cardiovascular procedure requiring sternotomy incision in a 650-bed tertiary care hospital, a gradual increase in deep sternal infections from 0.8% in 1995 to 2.1% in 1999 was noted. By using a Plan-Do-Check-Act process improvement model, several interventions to decrease the infection rate were planned and implemented based on hypotheses generated from the characteristics of infected patients. These interventions included chlorhexidine preoperative shower, discontinuation of shaving, administration of antibiotics in the holding area, segregation of instruments, and implementation of an insulin protocol. Findings included a decrease in deep sternal and leg infections after implementation of these interventions. Deep sternal infection rates decreased from 2.1% to 1.5% and leg infection rates, from 1.93% to 0.47%. Results were not statistically significant but were clinically relevant. Furthermore, a total of $200,000 was achieved in cost savings in 1 year.

EMS location models are those formulated to address specific problems of emergency medical services systems; context-free location models are those developed without reference to particular applications. The literature on these two types of public facility location models is reviewed, and the development of the maximal covering model from several earlier context-free models is described, with emphasis on problem statements and articulation of service objectives. An application of the maximal covering model to fire truck location points up the ability of this model to handle multiple objectives; its ability to compare alternative solutions gives it great utility for planning and evaluating EMS systems of a wide range of complexity. Potential applications of the maximal covering model are discussed regarding EMS problems involving multiple time standards and service objectives, location of special equipment, and siting of fixed facilities.