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Give the pill, or not give the pill. SUSPEND tries to end the debate

Christopher BayneJune 2015 #UROJC Summary

News of a landmark paper on medical expulsive therapy (MET) for ureteric colic swirled through the convention halls on the last day of the American Urological Association’s Annual Meeting in New Orleans, Louisiana. I watched the Twitter feeds evolve from my desk at home: the first tweets just mentioned the title, then the conclusion, followed by snippets about the abstract. As time passed and people had time to read the manuscript, discussion escalated. Without data to prove it, there seemed to be more Twitter chatter about the SUSPEND trial, even among conference attendees, than the actual AUA sessions.

Robert Pickard and Samuel McClinton’s group utilized a “real-world” study design to publish what many urologists consider to be the “best data” on MET. The study (SUSPEND) randomized 1167 participants with a single 1-10 mm calculi in the proximal, mid, or distal ureter across 24 UK hospitals to 1:1:1 MET with daily tamsulosin 0.4 mg, nifedipine 30 mg, or placebo. The study’s primary outcome was the need for intervention at 4 weeks after randomization. Secondary outcomes assessed via follow-up surveys were analgesic use, pain, and time to stone passage. Though the outcomes were evaluated at 4 weeks after randomization, patients were followed out to 12 weeks.

Some of the study design minutiae are worth specific mention before discussing the results and #urojc chat:

  • Treatment allotment was robustly blinded. Participants were handed 28 days of unmarked over-encapsulated medication by sources uninvolved in the remaining portions of the study
  • Medication compliance was not verified
  • The study protocol didn’t mandate additional imaging or tests at any point
  • Participants weren’t asked to strain their urine
  • Secondary outcomes assessed by follow-up surveys were incomplete: 62 and 49% of participants completed the 4- and 12-week questionnaires, respectively

The groups were well balanced, and the results were nullifying. A similar percentage of tamsulosin- , nifedipine-, and placebo-group patients did not require intervention (81%, 80%, and 80%, respectively). A similar percentage of tamsulosin-, nifedipine-, and placebo-group participants had interventions planned at 12 weeks (7%, 6%, and 8%). There were no differences in secondary outcomes, including stone passage. There was a trend toward significance for MET, specifically with tamsulosin, in women, calculi >5 mm, and calculi located in the lower ureter (see image taken from Figure 2).

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The authors concluded their paper was iron-clad with results that don’t need replication.

“Our judgment is that the results of our trial provide conclusive evidence that the effect of both tamsulosin and nifedipine in increasing the likelihood of stone passage as measured by the need for intervention is close to zero. Our trial results suggest that these drugs, with a 30-day cost of about US$20 (£13; €18), should not be offered to patients with ureteric colic managed expectantly, giving providers of health care an opportunity to reallocate resources elsewhere. The precision of our result, ruling out any clinically meaningful benefit, suggests that further trials involving these agents for increasing spontaneous stone passage rates will be futile. Additionally, subgroup analyses did not suggest any patient or stone characteristics predictive of benefit from MET.”

Much of the early discussion focused on the trend toward benefit for MET in cases of calculi >5 mm in the distal ureter:

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Journal Club participants raised eyebrows to the use of nifedipine and placebo medication in the trial:

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A few hours in, discussion shifted toward the study design, particularly the primary endpoint of absence of intervention at 4 weeks rather than stone passage or radiographic endpoints. The overall consensus was that that this study was a microcosm of “real world” patient care with direct implications for emergency physicians, primary physicians, and urologists.

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The $20 question (cost of 4 weeks of tamsulosin according to SUSPEND) is whether or not the trial will change urologists’ practice patterns. Perhaps not surprisingly, opinions differed between American and European urologists.

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We owe SUSPEND authors Robert Pickard and Sam McClinton special thanks for their availability during the discussion. In the end, the #urojc banter for June 2015 was the largest and most-interactive monthly installment of International Urology Journal Club to date.

June urojc 26Christopher Bayne is a PGY-4 urology resident at The George Washington University Hospital in Washington, DC and tweets @chrbayne.

 

#AUA15 bursts to life in New Orleans

CaptureCreole cuisine, bustling Bourbon street, beads and beignets and 16,000 urologists.  #AUA15 has just drawn to a close in the birthplace of Jazz; New Orleans, Louisiana #NOLA. With 2,598 abstracts being presented, over 2,500 speakers and representation from more than 100 countries it was undoubtedly an educational and action packed five days.

This was my first AUA and while I knew it was going to be a big conference I was stunned by the size of it all. There were urologists everywhere, so much so that jiving to jazz on Frenchman became a game of ‘spot the urologist’ by the signature urology dance moves and stylish….ish dress code!!!! The scientific programme was so extensive it was difficult to find the time to attend all the sessions I wanted to. However, the committee deserve huge credit for developing the AUA2015 app and Daily news snippets that were available throughout the centre which made it easy to optimise your time at the meeting.

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The French Quarter, NOLA

The conference got off to a heated beginning with the Crossfire: Controversies in Urology session sparking plenty of debate. Few topics have ignited as much argument as the question of focal ablation for prostate cancer and the discussion between Mark Emberton MD, UCL, London and Aaron E. Katz, MD,PhD, Winthrop University Hospital was no different. To call it a lively session is an understatement. The question of alpha blockers being sold over the counter for BPH was also discussed during this session. Although the drugs have proven safe over the last 25 years clinicians have concerns that the loss of patient contact as a result of this relabeling would causes a loss of control in the treatment of men with BPH.

Friday drew to a close with the urotwitterati enjoying the social media TweetUp encouraging newbie tweeters to get involved. It clearly worked because #AUA15 set a new record and almost trebled it’s tweeting volume since #AUA13.

Day two, Saturday saw the opening of the Science and Technology hall. A spectacle of testicular, penile devices and stalls I have never seen. I fear what one might have thought had they stumbled into the conference centre by accident!!

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The @BJUIJournal #SoMe awards took place on Saturday evening. @DrHWoo deservedly bagged The Social Media Award 2015 for #UROJC. A well chosen venue there were no issues with Wifi for tweeting!!! Read the #SoMe blog for all award details

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Enjoying the @BJUIjournal cult #SoMe awards

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A personal favourite of mine at the conference was the 4th annual Residents Bowl which took place over three days; with residents engaging in a battle of the brains! Northeastern claimed the trophy in the end and team members on the winning side included this year’s BAUS representative @DerekHennessey.

BAUS, BJUI and USANZ came together on Sunday afternoon for a stellar line-up of speakers and topics. The session was well attended and speakers outlined the most recent data but more importantly shared the experience of techniques and outcomes in their centres and countries. I think this combined society session is a fantastic arena for all to both learn and educate each other on what is working best, where and why? The superb line up included Dan Moon, Jeremy Grummet, Henry Woo, Declan Murphy, David Nicol, Damien Bolton, Stephen Boorjian and Philip D. Stricker who all shared their clinical expertise.
BJUI Guest speaker Ben Challacombe discussed the evidence base for management of RCC by partial nephrectomy. Lower intraoperative complications and WIT were observed at their centre at Guy’s Hospital London, which is similarly reflected by low complication rates in the BAUS mandatory UK national nephrectomy audit. Professor Prokar Dasgupta started his up and down journey for the evidence supporting robotic cystectomy for TCC bladder by reminiscing on where it all began; kite-flying in India as a young boy.

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Much anticipated CORAL trial found that 90 day complication rates and oncological control were comparable in ORC v LRC/RARC.

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Finally the session closed with the presentation of the Coffey-Krane award to Gopa Iyer; Phase III Study of  everolimus in metastatic urothelial cancer collected on Dr Gopa’s behalf by David Quinlan. This award is for trainees who are based in the Americas and judged by a panel as the best publication accepted to the BJUI.

 

Overall, some of the big points of the conference were the amendments to AUA guidelines including Castration-Resistant Prostate Cancer, which was updated from just last year. Perhaps, the most significant was the first ever draft of AUA Peyronie’s disease guidelines; outlining recommendations from medical therapy to surgery.

The huge rise in social media at urology conferences was demonstrated again by record-breaking figures via @symplur showing that the use of Twitter among the urology community continues to grow:

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#AUA15 was both an educational and social experience. I had a blast, learned loads and also got to experience the culinary delights of Muffuletta and Gumbo, take the trolley up St. Charles to the Garden district and simply encounter the warmth and friendliness of both the Louisiana folk and the huge family of Urology. The AUA Scientific Committee deserve a huge congratulations on the success of a stimulating, enjoyable and extensive scientific programme. I know I heard echoes of ‘best AUA yet’ in my company.

Áine Goggins

Medical Student; Queens University Belfast, Ireland

@gogsains

 

The 3rd BJUI Social Media Awards – #AUA15 in New Orleans

Murphy-2015-BJU_InternationalWhat a fun destination we had for the 3rd Annual BJUI Awards! As you may know, we alternate the occasion of these awards between the annual congresses of the American Urological Association (AUA) and of the European Association of Urology (EAU). Our first awards ceremony took place at the AUA in San Diego in 2013, followed last year in Stockholm at the EAU. This year, we descended on New Orleans, Louisiana to join the 16,000 or so other delegates attending the AUA Annual Meeting and to enjoy all that the “Big Easy” had to offer. What a fun city; a true melting pot of food, music and culture all borne out of the eclectic French, American and African cultures on show. I think I met more key opinion leaders in the clubs on Frenchman Street than I did in some of the prostate cancer poster sessions!

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You can read more about all that in our #AUA15 Conference Highlights blog, so on now to the Awards. The AUA Annual Meeting plays host to intense social media activity and it is fitting that the BJUI Social Media Awards gets to acknowledge the rapidly growing number of Uro-Twitterati in attendance. Over 100 of the most prominent tweeters turned up to the Ritz-Carlton to enjoy the hospitality of the BJUI and to hear who would be recognised in the 2015 BJUI Social Media Awards. Individuals and organisations were recognised across 16 categories including the top gong, The BJUI Social Media Award 2015, awarded to an individual, organization or innovation who has made an outstanding contribution to social media in urology in the preceding year. The 2013 Award was won by the outstanding Urology Match portal, followed in 2014 by Dr Stacy Loeb for her outstanding contributions.  This year our Awards Committee consisted of members of the BJUI Editorial Board (Declan Murphy, Prokar Dasgupta, Matt Bultitude as well as BJUI Managing Editor Scott Millar whose team in London drive the content across our social platforms).

 

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The full list of awardees, along with some examples of “best practice” in the urology social media sphere can be found on this Prezi. The winners are also listed here:

 

  • Most Read [email protected] – “Are you ready to go to prison on a manslaughter charge?”. Accepted by Dr Ben Challacombe, on behalf of Prof Roger Kirby, London, UK
  • Most Commented [email protected] – “Prof John Fitzpatrick – Life in the Fast Lane”. Accepted by Dr Ben Challacombe, on behalf of Prof Roger Kirby, London, UK
  • Best Blog Comment – Dr Brian Stork, Michigan, USA
  • Best BJUI Tube Video – Hospital volume and conditional 90 day post-cystectomy mortality. – accepted by Dr Angie Smith on behalf of Dr Matt Neilsen, North Carolina, USA.
  • Best Urology Conference for Social Media – SIU Annual Congress, Glasgow 2014. Accepted by Dr Sanjay Kulkarni on behalf of the SIU
  • Best Social Media Campaign – Dr Ben Davies, Pittsburgh, USA, for highlighting industry issues around BCG shortage
  • “Did You Really Tweet That” Award – Ben Davies, Pittsburgh, USA (three years running!)
  • Best Urology App – The Rotterdam Prostate Cancer Risk Calculator. Accepted by Dr Stacy Loeb on behalf of Dr Monique Roobol, ERSPC, Rotterdam, The Netherlands
  • Innovation Award 2015 – #eauguidelines. Accepted by EAU Guidelines panellists Dr Stacy Loeb and Dr Morgan Roupret, on behalf of Dr James N’Dow, Dr Maria Ribal, and the EAU Guidelines Committee.
  • #UroJC Award – David Canes, Boston, USA
  • Best Selfie – Morgan Rouprêt, Paris, France
  • Best Urology Facebook Site – European Association of Urology. Accepted by Dr Alex Kutikov, Digital Media Editor, European Urology
  • Best Urology Journal for Social Media – Nature Reviews Urology. Accepted by Editor-in-Chief, Annette Fenner
  • Best Urology Organisation – American Urological Association. Accepted by Taylor Titus, AUA Communications Office
  • The BJUI Social Media Award 2015 – International Urology Journal Club #urojc. Accepted by Dr Henry Woo, Sydney, Australia.

 

Most of the Award winners were present to collect their awards themselves, including the omnipresent Dr Henry Woo who received our top gong for his work on the very successful International Urology Journal Club #urojc. The #urojc now has over 3000 followers and its monthly, asynchronous 48hr global journal club has become a huge event. Many other specialties and #FOAMed resources have recognised #urojc and BJUI are delighted to publish a blog summarising each month’s discussions. Well done to Henry, Mike Leveridge and others in setting and maintaining this outstanding example of social media adding real value.

A special thanks to our outstanding BJUI team at BJUI in London, Scott Millar and Max Cobb, who manage our social media and website activity as well as the day-to-day running of our busy journal.

See you all in Munich for #EAU16 where we will present the 4th BJUI Social Media Awards ceremony!

Declan Murphy

Associate Editor for Social Media at BJUI. Urologist in Melbourne, Australia

Follow Declan on Twitter @declangmurphy and BJUI @BJUIjournal

 

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