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Will you bury your Bentley for pleasures in your ‘after life’?

Last year in September, a Brazilian multi-millionaire Count Scarpa, announced to his followers on Facebook that he would bury his most favorite car, a black Flying Spur Bentley costing half a million Dollars, in his backyard! He expressed his intention to be buried next to the Bentley when he died. He explained that this desire arose after he had watched a documentary on the Egyptian Pharaohs and how they buried themselves with their beloved items, so that they can be used during the afterlife. Count Scarpa had stared death in the face on two occasions. He was in a coma after over-whelming sepsis that nearly killed him following an operation to reduce weight. In fact, a priest gave him the last rites on two occasions. However, he recovered to continue with his business. As you would expect, the announcement of the Bentley burial caused uproar in the Brazilian national media and also caught the international media’s attention reported in the UK by Daily Mail and the Metro. His Facebook account was flooded with comments most of which were derogatory and questioning his intentions.

Count Scarpa even posted photos of him digging the grave and of his favourite Bentley waiting to be buried.

He invited the media for the D-day when the event would take place. The car was being driven into the grave, when Count Scarpa stopped the process and invited the entire media team inside his multi-million Dollar mansion. Once inside, he mentioned that he is not crazy to bury his Bentley but exclaimed ‘everyone thought it was absurd when I said I was going to do that.’ ‘Absurd is bury their organs, which could save many lives. Nothing is more valuable. Be a donor, tell your family.’ (See the video here). The publicity stunt certainly worked. A photo of the Count holding a sign reading “I am an organ donor. Are you?” had spread like wildfire over social media sites, being shared over 40,000 times in just 24 hours! The power of Social Media!

The reason for writing this blog stemmed from reading a very touching article in the UK’s Guardian newspaper. The article quotes that there has been a 30.5% increase in transplants in the past five years, there are still more than 7,000 on the transplant list, and last year more than 1,300 people either died while on the waiting list or became too sick to receive a transplant! There is an urgent need worldwide to raise awareness about organ donation. In the UK, there is a drive by the NHS for organ donation. The organ donations website has very interesting statistics regarding donation as well as that of the recipients. The “Did you Know?” page sheds light on some interesting facts including renal transplantation. It is estimated that 30% of people on the NHS Organ Donor Register are aged between 16-25 when they join. A further 24% are aged between 26-35. Only 9% are 65 or over when they join. More women (54%) than men (46%) have signed up on the NHS Organ Donor Register. There is also a need to raise awareness among the ethnic minorities in the Western World as Black people are three times as likely as the general population to develop kidney failure and the need for organs in the Asian community is three to four times higher than that of Caucasians. 

Government agencies of various countries should take note of the way Count Scarpa took the advantage of the power of Social Media such as Facebook to raise awareness. In fact, an initiative by John’s Hopkins along with Facebook to increase the organ donation was a huge success. The findings were published in the American Journal of Transplantation. On May 1, 2012, Facebook allowed members to specify their organ donor status on their profile. Members were then offered a link to their state registry to complete an official designation, and their “friends” in the network were made aware of the new status as a donor. Those considering the new organ donor status were provided educational links regarding donation. On the first day, astonishingly there were 13,054 new online registrations, representing a 21.1-fold increase over the baseline average of 616 registrations!

Just as BJUI has capitalized social media among the Urologists, we should encourage our respective Governments to use the various channels effectively to spread the word about Organ Donation.  

Amrith Raj Rao is a Consultant Urological and Robotic Surgeon at Wexham Park Hospital, Wexham, UK. Twitter: @urorao

 

Face to interface

Cast your mind back to college physics and recall that an interface is a boundary between two phases of matter, for example gas and liquid. The interface is where interaction occurs between the disparate parts, there may be an exchange of molecules, or a conversion of molecules from one state to the other such as evaporation. Information, such as light or sound is always upset when it reaches an interface and some of the message may be bounced off while some is transmitted across the interface to the other state. This is why we might see our reflection in a pond, as some of the incident light bounces of the liquid interface and back to our eyes. So far, so dry and irrelevant.

If we think about interfaces between people, the equivalent to phases of matter is two disparate minds attempting to transmit information across the interface of human communication. It seems logical that minds that are more familiar and perhaps similar due to experience and level of sophistication lose less information due to reflection (think of the ease of communication between close family members versus explaining theoretical physics to a three year old).

There is always an interface with communication, be it speech, gestures, semaphore, or Twitter. Our intention is to effectively get across sufficient information to understand and be understood. Each modality has pros and cons, for example a letter allows a distillation of thought and a poetry that is absent in a phone call, while Skype allows you to see a loved one in real time. Due to a lack of vocal inflection, facial expression, and physical gestures, many public figures have claimed a misunderstanding after making inflammatory statements on social media.

We certainly are getting used to communication through physical separation. The ability to keep in touch when you want to while geographically apart is undoubtedly a boon, and in the medical sphere isolated patients are benefiting from teleconferenced and video-linked consultations, along with podcasts, tweets, and YouTube videos that make medical advice more and more accessible.

But here is the problem. The interface between a doctor and a patient has a very high surface tension. That means that information struggles to breach the membrane from doctor to patient and vice versa. Without conscious effort, by default information thoughtlessly spouted will bounce off and be lost. The minds of the doctor and patient are usually disparate, with one an expert in their own experience of a disease, and the other an expert on pathophysiology and evidence based practice. Both are complex subjects, difficult to communicate to the non-expert in the conversation. With the addition of a screen, or phone line to the interface, we have to beware of the surface tension becoming impenetrable. As medicine becomes increasingly electronic, we need to remember that dispensing advice to the internet is different from communicating with a patient. Every communication interface has its weakness, and we need to be aware of avoiding pitfalls that compromise care. Humour often does not work as well in an email as it would in person, accompanied with a cheeky grin. Speech over an internet connection may be distorted, intermittent, and as a result, irritating to listen to, making us want to curtail conversations prematurely. To shamelessly direct you to my other work on the role of technology in medicine and life we need to add value as doctors above what a digital algorithm can provide to justify our work.

Why? The usual arguments (it is good business to keep the client happy, specially if you use Salesforce help, the prestige of being a preferred doctor, the opportunity to expand ones sphere of influence), but also I think most of us sacrificed our youth training in order to make people better, and we cannot do that if patients cannot hear us.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

 

Digital Doctor Conference 2013

Digital consumerism is progressing relentlessly and whilst the advantages of new technology are evident in our personal lives, there is a palpable air of concern amongst the medical profession. “The Digital Doctor” team are positively embracing the benefits of moving healthcare into a new era and hope to direct the use of new technology in a constructive manner that will benefit both healthcare professionals and patients. To achieve these aims the “Digital Doctor Conference 2013”, was held for its second year last November, again kindly sponsored by the British Computer Society and held at their excellent headquarters in Covent Garden, London. The conference was attended by IT professionals, doctors, medical students and patients; thus group sessions contained some perspective on every aspect of healthcare technology. The organisers are also an eclectic mix of doctors and IT professionals, united by their interest in improving Health IT.

The conference included plenary talks, interactive group sessions and workshops. Eminent plenary speakers included Martin Murphy, Clinical Director at NHS Wales Information Service.

Martin challenged us to redefine our relationship with our patients in a new era where clinical information will be in control of patients and access to healthcare professionals can be as easy as a click away. How can we do all this safely in the light of the Snowden revelations? References to Stevan Wing’s (one of the organisers) two favourite books George Orwell’s 1984 and Aldous Huxley’s A Brave New World remind us of the superstition that underlie the beliefs, fears and challenges of society.

Software mediated care – implications for our patients and ourselves from Digital Doctor on Vimeo.

Popular teaching sessions at the conference were daily life IT tools, including the “Inbox Zero” philosophy, how to collaborate online, keeping up to date with RSS readers and Stevan Wing gave an introduction to the open-source “R project” for statistics. Other sessions focused on how to develop IT systems. This insight is useful both to allow healthcare professionals to construct their own IT solutions but also to help translate ideas to IT professionals. One such example being Sarah Amani, who used her experience as a mental health nurse to develop a mental health app for young people, called “My Journey”. In her inspiring plenary, co-presented with Annabelle Davis who developed the Mind of my Own app, she makes the point that the vast majority of young people rely on email, social media and online services therefore this is the best place to reach them. A session giving the methods and practicalities of developing IT systems was given by Rob Dyke, Product Development Manager of Tactix4. To help delegates get their ideas to reality Ed Wallitt, one of the organisers and the founder of Podmedics, built on earlier sessions about how to code, how a website works and information design, explaining how to use wireframes and prototypes, to achieve professional design of websites and apps.

Existing NHS IT systems were explained using the example of an emergency patient admission. Tracking the patient journey from home to hospital, via A+E, then transfer to ward, rehab back home, with GP clinic the final destination. At each stage a different IT system is employed such as the emergency 999 network and the N3 private network. Concepts such as the NHS spine were introduced and explained. A complex web of systems were shown to be in use, with numerous safety mechanisms; providing some explanation as to the difficulties faced by employees in the NHS.

Delegates were able to implement this teaching in the “App factory”, to solve problems they face in daily life or work. Three app ideas were created and presented by separate teams. These were a teaching log for doctors to record teaching sessions and simultaneously get feedback from students, a productivity app to provide useful information for new doctors to know about any hospital, however the winning idea was a patient facing app for use in hospital, to track updates in ongoing care.

In another session Matthew Bultitude, an Associate Editor of BJUI, was invited by Nishant Bedi (another organiser) for his vision of the future of medical journals. Journals are key in shaping the way medical practice is conducted and the dissemination of information is as important as ever in the digital age. Paperless journals may be the future however traditional business models rely on paper journals for revenue and many journals have yet to feel confident in moving all of their content exclusively online. Yet there are signs of change with European Urology adopting a paperless format for members from Jan 2014, now surely others will follow?

Under new leadership, the BJUI has recently focused on revolutionising its online presence, starting with a complete website overhaul. Amongst many changes to its design, the website now hosts an article of week, user poll, blogs and picture quiz. Numerous metrics for the website now show significant improvement in website visitors, duration of visit (1 to 3 min) and “bounce” rate. The increasing importance of social media for health professionals is demonstrated by the fact that more than ¼ of website traffic now arrives from Twitter and Facebook, having previously been dominated by search engines. Matthew finished by discussing alternatives to impact factor, such as the journal’s “Klout” score or “individual article” metrics, which are likely to be increasingly important as medical journals develop more web and social media presence. Extremely accurate individual “article level metrics” are calculated by checking number of views, tweets and re-tweets, and mentions in review sites (such as F1000 Prime). It is clear to see how powerful this could be, for example when discussing viewing numbers and duration of reading, Matthew can inform us that currently BJUI Blog articles are each read for a total of 5 min, with even the 15th most popular article receiving almost 500 views.

This talk was paired with one from the futuristic journal “F1000 Prime”. This journal provides an extra layer of expert peer review, using scientific articles that are already published in other journals. Thus articles selected by F1000 Prime direct users to the most significant developments in their chosen field, the expert reviews of the articles include an article rating, relevance to practice and whether there are any new findings. Research has shown that selection of an article by F1000 Prime, is an accurate indicator of future impact factor. Users may also receive email alerts of recommended relevant papers and they are able to nominate articles, follow the recommendations of an expert reviewer. Also refreshingly, any submissions to the journal, receive a completely transparent peer review process, openly available to any user.

Conference attendees were given the patients’ perspective of Health IT, by a panel chaired by Anne-Marie Cunningham (another organiser). These real life stories, gave insight into the mindset of people suffering from demanding chronic disease, both at home and in the hospital. Importance is given to people taking ownership of their health; both rare and common diseases were mentioned including Addison’s disease, asthma and mental health issues, where 24 hour support is an unfulfilled requirement and there is a need for a more integrated approach. Positive examples were given with one patient gaining reassurance by regular home peak-flow monitoring that can be reviewed remotely by her respiratory consultant. This helps to determine optimal timing for clinic review, with other similar examples seen in home blood pressure or blood sugar monitoring. Importantly social media and support groups can provide 24 hour advice and connect patients with expert doctors or similar sufferers all over the world. It was clear that the lack of hospital WiFi disconnects some patients from their online support networks, when they are actually most vulnerable. Other complaints centred around the underuse of email appointments and text alerts, which could empower patients to chase their own appointments or scans. 

Delegate feedback suggests this conference is unique and covers a rapidly expanding area of Medicine. We look forward to the next conference in 2014. The Digital Doctor 2013 conference program and highlights are available from the website or directly on our vimeo chanel. For updates and upcoming events follow us on Twitter @thedigidoc and the podcast is available from iTunes or our website. 

Mr. Nishant Bedi
Core Surgical Trainee (Urology), West Midlands Deanery

Dr Stevan Wing
Academic Neurology Registrar, East of England and The University of Cambridge 

 

Annabelle Davis

Out with the old; In with the new. Stats and metrics: The BJUI website 2013

Is it already over twelve months since the new Editor took over and the new BJUI web journal was launched? The old one had served its purpose well but the editorial board had decided the change of leadership dictated a clean new website would be launched in January 2013. Decisions were hard. Out went non-journal content such as case reports and in its place we created four main content areas with the aim of maintaining fresh, regularly changing content. These (article of the week; BJUI blogs; picture quiz of the week; BJUI poll) you will by now be familiar with, but how has the new web journal performed? Let’s look at the metrics over the last year.


The BJUI website prior to 2013

Firstly, most of the figures referred to in this article are for the www.bjui.org site only. They do not include direct access to the journal articles in the Wiley Online Library where the issues are stored. Thus analysing overall visitor numbers is not that valid and doesn’t allow for meaningful comparison. However, it appears there has been an increase in web visits of at least 10%. When we drill deeper, this is where we really notice a change. Readers now spend on average over 3 minutes on the site per visit. This is a dramatic change from previously – in 2012 the mean visit duration was just 87 seconds!

More and more people today decide to get involved with an online business, due to the fact that having a business operated through the internet offers a lot of advantages over doing it the traditional way. Online business means that you can do business right at the comforts of your own home. Thus, there is no need for you to get dress and step out of your house to earn a living. However, there are many important things that you need to learn more about in getting your online business off the ground. One of which is the creation of your own website, and the need to obtain hosting, in order to get it launched onto the World Wide Web.

Knownhost web hosting can be obtained through a company who have its own servers, where websites are hosted. In other words, a hosting service is one of the necessities in getting your own website visible through the internet. For sure, there are many ways that you can have your own web page today, such as creating a free blog or a free website. However, in most cases, these types of services are limited and having one of those pages does not mean that you entirely own them, since another website is actually hosting it.

In a nutshell, website hosting is very important because you simply could not launch your own website without having it. The hosting service provider is the one that will provide you with the space where you can upload your files that are related to your site, and they are also the ones who will ensure that your website is visible to people when they type your site’s address on their favorite web browsers.

Since there are a lot of web hosting service providers available in the market today, selection is very important in order to get associated with a reliable one. When you are able to obtain a hosting account from a reliable provider, you will be able to avoid loss of sales caused by downtimes. There are actually hosting service providers, which do not have reliable servers. In other words, they encounter a lot of downtimes, and because of that, your business would lose a lot of sales opportunities. This is because server downtimes mean that your website would not be visible on the net during those times. Thus, people who are suppose to make certain purchases, may decide to buy the items from your competitors.

In relation to that, aside from the importance of hosting for your online business, you should also become more aware of the importance of selecting a reliable web host; and one of the best ways to do that is by learning about the features of the hosting account that they can offer to you.

Geographically, the top country by visit is the United States with 22% of all visits, closely followed with the UK (21.6%) with Australia third. In total there were visits from 189 countries with both India and Japan making the top 10 (numbers of visitors) emphasising the journal’s global reach. This is truly an international journal.

 
Global subscriptions to BJUI represented as a “heat map”

Another major difference we have noticed is in bounce rate. This refers to the percentage of people who leave immediately after visiting the page they landed on i.e. if everyone only looks at the first page they come to then the bounce rate would be 100%. In 2012 the bounce rate was 66% – and this has improved significantly to 50% in 2013. This rate is never going to be very low – people come directly to a blog, quiz or just go straight onto the author guidelines or an article on Wiley Online Library. But to see such a reduction is encouraging and vindicates the approach we have taken with the web.

When we look at traffic sources, again we see another big change. This is how the visitor came to the site i.e. do they type in the web address, use a search engine or get driven to the site by social media. As you might expect, the largest single source of traffic (45%) is from Google – these visitors also spend over 3 minutes on the site with a bounce rate of 40% – so the site is not being found by accident and readers move onto other pages. 24% of traffic is direct but what is new behaviour is that 12% is from Twitter and 6% from Facebook – so social media is now driving nearly 20% of all website traffic. Facebook visitors also spend over 4 minutes on the site – they come for a reason! Of course there are the quirks – a men’s health magazine drove 1% of visits to a specific article on penis extenders! Those readers aren’t urologists as they only spend 16 seconds on the site with a bounce rate of 99.4% – this, however, does give credibility to the use of these statistics.

Apart from the homepage, the majority of social media-driven traffic is to the blogs. This has been highly successful with regular topical blogs and comments. Blog traffic has been high with the most popular (Melbourne Consensus Statement) receiving over 6500 views and 58 comments. Whilst this is clearly the highest, the top 8 blogs all have over 1000 views. Time spent on these blogs is high with several being read for an average of over 6 minutes. In January 2014 we added widgets to our blogs that allow you to see the number of reads each blog has received, and also  to allow tweeting and Facebook liking directly from the blog. Blogs posted prior to this time also have these features but the number of reads prior to January 2014 are not displayed. With this section being so popular are Letters to the Editor dead?

In a recent poll, we asked you what single feature you had liked best. Exactly equal with 34% were the blogs and the free Articles of the Week (which have also been popular in the web metrics with over 13,000 views). Picture quizzes have been successful with over 10,000 views. These demonstrate a shorter time on the page as one would expect (100 secs) but also a lower bounce rate (48%) – these readers often go elsewhere on the site. The video section has also been popular with over 2000 views although obtaining good quality videos is challenging and we encourage authors to submit video with their articles to further drive this section.

 

How does this translate to actual journal article downloads? Interestingly our approach has led to an increase of over 35% in full text downloads from Wiley Online Library compared with 2012. This is exciting and shows the web journal has been very successful not only in driving website activity as described above but also in promoting core journal content.

So for 2014 we have a new App to view the journal. Currently only on the Apple platform (80% of mobile devices used in 2013 to view the website were Apple), this is free to download although requires a log-in to view full content (available via your institutional subscription, from Wiley or from your society). It works really well on the iPhone as well as the iPad and allows access to not only the monthly journal but ‘Early View’ articles as well. This is already my preferred method for reading the journal and I highly recommend trying it.

With high-quality web and mobile interfaces, the question has to be are we ready to go paperless? As the Web Editor I should of course say yes. We discussed this at length at our first board meeting in November 2012. Due to our diverse international readership it was felt to be too early for such innovation. This will inevitably happen and another major urology journal has taken this step in 2014 (€60 supplement for the print version of European Urology). It is surely only a matter of time until digital is the standard platform. Hopefully you, the readers, will tell us when the time is right.

Matthew Bultitude
Associate Editor, Web

Why I care about social media – and why you should too

I was born in the ‘Eighties’. I was a teenager when the Internet first became accessible to the general public and a medical student when Facebook was launched in 2004. It seems improbable and surreal that my time spent ‘liking’ and ‘poking’ Facebook posts from college acquaintances would someday be of any use to my career and research. Indeed, ‘I was there’ at the very beginnings of social media, but I had little idea of what it would become.

The social media revolution started in the early millennium, with the emergence of blogs: microsites consisting of topical entries usually displayed in reverse chronological order. Blogs, such as Deadspin or Gizmodo, became pillars of the new era, breaking news at an unprecedented pace and gaining millions of page views by the second. Meanwhile, the print media were slow to adopt a digital strategy, often branding the aforementioned websites as ‘hacks’ or ‘teenagers with a lack of journalistic integrity’. Almost simultaneously, a website called Wikipedia was launched on 15 January 2001 by Jimmy Wales and Larry Sanger, a ‘social’ alternative to bulky reference books, such as the Encyclopaedia Britannica. Fleetingly, Wikipedia rose to fame and grew at an exponential rate, drawing along a significant chunk of web traffic. It caught idlers with such haste that some felt the need to ban the website from classrooms. Oh my, have things changed. In September 2010, Arthur Sulzberger Jr, Chairman and publisher of The New York Times, announced that the prestigious journal would cease to exist in print, sometime in the not-so-far future. In related news, the Chicago-based company behind the Britannica announced that it would stop printing the revered reference encyclopaedia after >200 years in press.

The adoption of new technology in any and every field follows a simple bell curve, as described in a sociological model by Joe Bohlen et al. at Iowa State University. The hypothesis indicates that the first group of individuals to use a new product is called ‘innovators’, followed by ‘early adopters’. The early and late majorities follow these, and the last group to ultimately adopt a product is called ‘laggards’. ‘Medicine’ as a collective crowd is usually the laggard. On one hand, it is reasonable and understandable that a field with such enormous responsibilities be as meticulous and practical in the process of adopting new drugs, technologies or paradigms. It is entirely within the realm of comprehension that a new drug must succeed at many stages of testing to show unequivocal safety and efficacy before being accepted into medical practice. Yet, on the other hand, most would safely agree that institution, tradition and dogma dominate the world of medicine, and most notoriously in surgical sub-specialties. Not unlike our most recent history in adopting robotic surgery, met initially with ferocious and apocalyptic discontent, many contemporary leaders in our field display excessive scepticism towards social media, even when its dissemination is widespread through all echelons of society. In an era where wars and revolutions are being fought over Twitter, and where the likelihood of experiencing an influenza pandemic can be accurately predicted based on relevant social media buzz, I am not sure what doctors are waiting for to accept social media for what it is – an inevitable revolution in how we communicate.

As many of you ponder whether or not to embrace social media, there is good evidence that medicine has finally absorbed the latest innovation. I could cite many factual titbits to demonstrate that this is in fact true. I could provide propensity-matched-instrumental-variable-adjusted analyses to show its benefits. Yet, wise men once said that stories, not statistics, drive change: here are some stories of how social media has already transformed our field.

The ‘uro-twitterverse’ is now a rich and engaging planet of its own. Since November 2012, >100, I am not making the numbers up, users engage in a monthly Urology journal club on Twitter, enhanced by the presence of the lead investigator of the study open for discussion. Even the most prestigious of first-tier Ivy League institutions would not be able to attract lead authors to attend every single journal club, even less to convince a pool of key opinion leaders from around the world to comment and critique these studies.

Every day, I know that I can turn to my fellow ‘Twitterati’ to ask a hard clinical question. Should I perform a lymph node dissection in this patient with prostate cancer? What is the value of positron-emission tomography-CT to assess recurrence in a patient with bladder cancer? What is the recommended evaluation for a patient with suspected interstitial cystitis? Across 24 standard time zones, I know that an answer is a couple of seconds away. Somewhere in the world, a knowledgeable authority is answering my tweet, either while reading the morning news at breakfast, between two major cases in the operating theatre, or checking the Internet right before going to sleep. Having Twitter on my smartphone is a click away from being at a grand rounds talk, with everyone – from Benjamin Davies to Stacy Loeb – in attendance.

Every year, physicians travel thousands of miles to attend medical conferences. Many academics converge at these meetings with the hope of building relationships with potential collaborators. Twitter has brought the academic world under a single digital roof. Most of my research collaborators are on Twitter. I exchange direct messages with them every day to discuss research, grant and collaborative opportunities. I met several of my peers and collaborators on Twitter before actually gathering in person. In fact, many have questioned the need for so-called ‘formal’ medical conferences in the new digital era. While I am not ready to cancel my annual trip to the AUA and the European Association of Urology meetings – especially when they are being held at exotic destinations, such as San Diego and Milan, these social phenomena suggest that change is inevitable.

As much as we like the world we are accustomed to living in, there is little doubt that scientific journals, professional societies, and medical institutions need to adapt to this growing revolution. And, as regrettably experienced by traditional portals, e.g. the print media, those who do not will struggle to remain relevant. Of course, there are caveats to social media. How do we set boundaries between patient care and personal endeavours? Regardless of these issues, society has dreamt forever of the open and free opportunities provided by social media. The world cannot wait.

At BJUI, we are using social media, especially Twitter and Facebook, to highlight the most important international studies published in the journal, e.g. July’s ‘Article of the Month’ from Taiwan comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy.

Quoc-Dien Trinh
BJUI Associate Editor Health Services Research,
Department of Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.

 

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Canadian Urological Association annual meeting at Niagara Falls

The Canadian Urological Association held its annual meeting in the city of Niagara Falls, Ontario from June 22-25, 2013. Traditionally this meeting signals the start of summer in Canada and after a prolonged cool and wet spring the hot weather arrived as everyone convened. The central location in our vast country assured that the meeting was well attended with attendance far exceeding expectations. Even though I probably have seen this place two dozen times since childhood the physical spectacle of this natural wonder of the world never fails to awe.

Even renewing acquaintances with the venerable old Maid of the Mist after many years provided a memorable experience.

The meeting started on Saturday and as with other international societies, many specialty sections held their meeting on this day. These included the Canadian Urological Oncology Group (CUOG) as well as the Canadian Endourological Group (CEG). A Multi-Disciplinary Collaborative meeting for Genitourinary Cancers also took place. Canadian urology has long enjoyed a fruitful and respectful relationship with our radiation and medical oncology colleagues. The featured speaker of CEG was Dr. Brian Matlaga from @brady_urology who spoke about the role of technology assessment and health economics and how they will intersect to alter care in the treatment of urolithiasis over the next decade. I suspect the same debate will occur in many other domains of our specialty. The first of many Educational Forums also began on Saturday with a review of the management of castrate-resistant prostate cancer.

Sunday served as the formal start to the meeting with the first plenary sessions and a number of abstracts presented. Dr. Patrick Walsh from Hopkins was the keynote speaker to start things off and gave an outstanding evidence-based review as well as personal account of where we are in prostate cancer care and how we can work to improve things.

Day 1 ended with the annual CUA fun night. The CUA annual meeting has always enjoyed a reputation for being a very social meeting. Our country is relatively small and the urological community is well connected. While everyone took advantage of walking behind the falls in tunnels within the Niagara Escarpment the highlight of the night was the debut of the band “The Void”. Six talented urologists from across the country held court and provided a very high-calibre performance to the delight of everyone. They have been hired back for #cua14 in St Johns Newfoundland and I suspect will offer a member’s discount.

Monday June 24 brought more great abstracts and vigorous discussion. A major highlight for me was an outstanding talk given by @Robert_Uzzo of @FCCCUroOncology on the management of renal cell carcinoma in the elderly. It was a tour-de-force that was in large part philosophical discussion on managing risk and probability in clinical decision-making supported with good evidence. It was a talk that could easily be applied to most of what we do as urologists.

Dr. Andrew Macneilly the long-time program director at the University of British Columbia gave the CUA Scholars Fund address that surveyed training of residents and implications in a future environment where job prospects may be tight and where concerns about whether we have adequate volumes to teach operative skills will continue to grow.

As with the AUA and EAU the Canadian Urological Association has a well-established set of guidelines. New guidelines approved at this meeting include:

1. Management of Castrate Resistant Prostate Cancer
2. Postoperative Surveillance of Upper Urinary Tract Urothelial Carcinoma
3. Management of the Small Renal Mass

The President’s dinner on Monday night was very well attended. Dr. Klotz teamed up with half of the other member of The Void as well as Dr. Andrew Hussy from Stratford, Ontario to form a proficient jazz quartet. Four CUA Scholars Awards were given that night. Congratulations to Dr. Robert Hamilton of University of Toronto, Dr. Geoff Gotto from the University of Calgary, Dr. Lysanne Campeau from McGill University and Dr. Andrew Fiefer aka @urologymd1, also of the University of Toronto. The major disappointment of the night for me personally was the late collapse in the Stanley Cup Finals of my beloved Boston Bruins.

The final day brought with it more great educational forums and abstract presentations. A highlight for me was an address given by Dr. James Orbinski, the co-founder of Dignitas International and former president of Medicins Sans Frontieres. It was a brilliant overview on humanitarianism, global health and our role as urologists and citizens of the developed world. I think we have a strong obligation to promote these themes in our specialty.

Finally #cua13 was the year that the use of Social Media arrived in full force at the CUA.

A twitter board was set up in the main meeting hall to provide a real-time update of the conversation.

A good WIFI connection, which has been an issue at other recent meetings, served everyone very well. With a growing number of Canadian urologists now on twitter (joining early adopters including @_theurologist_, @urooncmd, @qdtrinh and myself). As these analytics show, 78 people participated via twitter during the actual meeting.

Many international colleagues joined in and @mattbultitude even made the top 10 from across the pond.

This form of communication has greatly enhanced our ability to connect and exchange ideas with colleagues from around the world. All urologists would be well advised to explore this technology. A nice primer with a Canadian perspective by @cmaer on the use of social media and twitter for physicians can be found here. At the recent #USANZ13 meeting use of Social Media for Urology was part of the scientific agenda as this presentation by @declangmurphy illustrates. I would like to see the number of participants at #cua14 surpass 200!

Of course living in Toronto made leaving on Tuesday from Niagara Falls about as easy an escape as one can make from any meeting. As we approach summer (at least in the Northern Hemisphere) I wish everyone a safe and restful time and look forward to continuing to engage with colleagues over the next year.

Dr Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.
Follow him on Twitter @DrRKSingal

 

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Uro-oncology Highlights from #BAUS13

The BAUS annual meeting in Manchester proved hugely enjoyable and notable for the high level of educational content and the quality of the speakers involved. There was a clear emphasis on the increasing role of the web and social media in urological education in the UK, and it was exciting to hear @prokarurol lay out his vision for the BJUI in this regard.

All subspecialties were well represented at BAUS, but I would like to focus particularly on urologic oncology, which was the subject of a number of excellent sessions.

Before that, I would like to show you some the Symplur data on social media traffic at #baus13:

This figure shows that 88 people people engaged with the #baus13 hashtag, many of many of whom were not in Manchester or even in the UK. Using the complex algoritim on their website, they calculate that the 556 tweets sent led to over 340,000 impressions in social media and other digital spaces. 

The traffic each day was impressive and the largest spike happened during the BJUI Social Media Course. Well done to all who tweeted from the meeting.

Professor Ben Lee from Tulane University, New Orleans gave two fascinating talks on Tuesday and Thursday morning regarding novel imaging techniques to facilitate uro-oncologic diagnosis and treatment. He quoted work from Dr. Peter Pinto from @theNCI demonstrating the utility of MRI-TRUS fusion targeted biopsies which detected cancer in 37% of patients with a negative initial TRUS, 11% of whom had high-grade disease. He also discussed novel imaging techniques that may enter uro-oncology practice in the future, including diffuse reflectance imaging and confocal microscopy with fluorescein staining. These techniques may allow intraoperative assessment of oncologic margins at the histological level, and there has been some success with this in the field of breast lumpectomy. One final innovation is the development of a patient-specific simulator for minimally invasive renal surgery. This allows a patient’s CT imaging to be reconstructed into a virtual 3d model, allowing the surgeon to practice that individual patient’s procedure prior to putting knife to skin for real.

Wednesday morning’s session, chaired by Tim O’Brien, aimed to address a variety of contemporary issues across urological oncology. Mr. Ed Rowe and Dr. Stephen Tolchard from Bristol presented their experience of CPEX testing prior to radical cystectomy. Their series demonstrated that CPEX testing was highly predictive of the risk of post-op complications, whereas ASA grade performed poorly. The ability to assess risk pre-operatively is clearly going to be vital to the publication of properly risk-adjusted individual surgeon outcomes, and CPEX testing may be a useful way to do this.

Professor Tom Treasure from UCL was asked to make sense of pulmonary metastasectomy. He pointed to the difficulty of selection bias towards fitter patients with low volume disease who are likely to survive for longer regardless of the effect of the surgery. Prospective randomised trials are needed, but lacking.

Professor Markus Graefen won widespread acclaim for his presentation of the merits of the very high volume radical prostatectomy practice at the Martini clinic in Hamburg. Particularly impressive was the use of continuous statistical monitoring of results, so that incremental technical improvements could be identified and disseminated between surgeons.

The morning session concluded with Dr. Arthur Grollman giving an intriguing account of how Aristolochia herb ingestion was finally established as the underlying cause for Balkan endemic nephropathy.

Wednesday saw another session organised by the Section of Oncology, this time chaired by Mr. Simon Brewster and focussing on active surveillance (AS) for prostate cancer. The session format made use of short, punchy presentations from a variety of speakers addressing controversies in patient selection and protocols for active surveillance.

Professor Graefen returned to discuss surgical and pathological outcomes following delayed RP after active surveillance. He quoted work led by Ruth Etzioni that used a simulation model derived from large active surveillance and radical prostatectomy cohorts to predict comparative outcomes for immediate and deferred treatment. Only very modest reductions in cancer-specific survival with deferred treatment were predicted, with treatment able to be deferred for a median of 6.4 years.

Those data relate to men with low-risk prostate cancer, but what about active surveillance for intermediate-risk disease? Dr. Parker argued the case for, pointing to only 2 of 88 men in the Royal Marsden series developing PSA failure, and one death. @declangmurphy argued for caution however, pointing to the fact that 12 of 92 men in this category from the Göteborg screening study had progressed to require androgen deprivation therapy at a median follow-up of 6 years, which has to be regarded as a poor outcome from surveillance. There was general agreement however that intermediate-risk cancers are a heterogeneous group and that more sophisticated risk stratification is required. Biomarkers may be part of the answer, and Professor Martin Gleave gave an eloquent update including the new multiple gene expression panels that are becoming commercially available in the US.

Further presentations addressed the topic of how to evaluate men entering active surveillance. Mr. Brewster stressed the pitfalls in relying on PSA kinetics alone, given that they perform poorly as a predictor of adverse pathology or recurrence following radical prostatectomy for progression on biopsy-based criteria. Mr. Declan Cahill strongly advocated transperineal template biopsies as routine prior to enrolment and for repeat biopsies, pointing to an upgrading rate of 1/3 at Guy’s where all patients entering AS are offered transperineal biopsies. Professor Freddy Hamdy made the case for avoiding routine repeat transrectal biopsies, given that changes in grade/volume may be an artefact of inadequate sampling, and therefore unhelpful. Finally, Professor Mark Emberton discussed the current role of imaging, making the case for pre-biopsy multiparametric MRI which can exclude tumour foci down to a size of 0.2cc with 95% accuracy and allows targeted biopsies as mentioned earlier. Whether a man with a raised PSA and a negative MRI can safely avoid a biopsy however, remains an open question. MRI may also prove to be a safe, non-invasive way to monitor tumours for progression on AS, reducing the need for repeat biopsy.

Professor Gleave then switched the focus to castrate-resistant disease in the Prostate Cancer UK Guest lecture. Along with a masterful overview of androgen receptor pathways and novel endocrine therapies, he urged us as urologists to get involved in the administration of these agents. Whilst presently utilised post-chemotherapy, they are likely to move into the pre-chemo setting and possibly even replace LHRH analogues for hormone-naïve patients.

Thursday saw an oncologically-orientated @BJUI sub-plenary session chaired by @prokarurol. @jdhdavis provided some great insights into the utility and technique of robotic extended pelvic lymph node dissection in prostate cancer. @qdtrinh gave a fascinating insight into the complexities of health services research, as well as outlining some recent data regarding complications of robotic vs. open radical prostatectomy. Finally, Professor Rob Pickard discussed the recent health technology assessment addressing the relative cost-effectiveness of robotic and laparoscopic radical prostatectomy. Whilst the model requires a number of assumptions, it seems clear that centralisation of robotic surgery into high-volume centres is much more likely to result in acceptable cost-effectiveness, not to mention improved outcomes for patients.

In summary this has been a fantastic BAUS meeting for uro-oncological topics in particular and one I have thoroughly enjoyed attending. It seems the future uro-oncologist will need to be able to interpret and integrate advanced imaging techniques into their practice, make sophisticated decisions about when and how to defer treatment for prostate cancer, utilise a broad range of non-surgical treatments, and provide the very best surgical outcomes in a new era of transparency. I’m looking forward to the challenges ahead.

Ben Jackson
ST7 in Urological Surgery, Royal Derby Hospital
@Ben_L_jackson

 

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BAUS 2013 Conference Report – Day 1-2

This year’s BAUS Annual Meeting was held in Manchester’s International Convention Centre and attended by almost 1200 delegates from all over the world. There has been a lot of anticipation this year following great attendance and atmosphere at the USANZ13, EAU13 and AUA13; much of the success and excitement coming from those conferences was echoed by the delegates on Twitter.

This was my first BAUS conference and I was particularly excited about my place on a urology skills course using fresh frozen cadavers, along with teaching sessions on Paediatric Urology and Urogenital emergencies and a “Walk with Experts” session around the academic posters.

The conference started with 3 parallel sessions on Monday morning:

  • Andrology and Genito-Urethral surgery key updates were discussed with a joint academic session in the afternoon to include the latest basic science research into Peyronie’s pathophysiology, artificial sperm, post-prostatectomy ED and genital tissue Bioengineering.
  • The BAUS Female, neurological and Urodynamic Urology Section focused mainly on the latest updates for urological fistulae, with other Keynote addresses over the following day covering mesh erosions and recurrent stress incontinence.
  • The Academic Session consisted of presentations from the six best abstracts submitted to BAUS this year. As our chairman Professor Dasgupta pointed out, all these presentations were based on clinical research rather than basic science. Is this a bias towards the clinical or is the standard of clinical work higher? The session finished with the awarding of the prestigious BJUI John Blandy Prize, received by the best and most cited BJUI article over the last two years. This year Dr Jérémie Haffner from France won the prize and £5000, for his work titled [the] “Role of MRI for Prostate Cancer Screening”, which he presented in fluent English.

In the afternoon the Exhibition arena provides the opportunity to see some of the latest innovations from the pharmaceutical and equipment industry representatives, and even have a play with 3D laparoscopy. However most trainees are understandably drawn to the Da Vinci stand where a robotic console is the main attraction. Delegates got the chance to use the robot to test their basic skills. 

My walk with the experts was really informative; each group consisted of approximately six trainees and two consultants. It was comfortable to ask questions and really maximised how much you can learn from the posters.

Day two started with a great update on laparoscopy, followed by the BAUS President, Mr Adrian Joyce, who gave his official address and awards as follows;

  • St. Peter’s Medal was awarded to Mr Malcolm Lucas, Swansea, UK.
  • St. Paul’s Medal was awarded to Professor Glenn Preminger, Durham, USA.
  • The BAUS Gold Medal was awarded to Mr Justin Vale, London, UK.

Social media is increasingly present in professional conferences allowing worldwide coverage and dissemination of all the conference content. Recent success was publicised from other Urology conferences, see other BJUI blogs.

BAUS has embraced this emerging technology and the “uro-twitterati” by establishing a twitter hashtag #BAUS13 and having updates throughout the conference. Furthermore a sold-out teaching course on Social Media run by Associate Professor Declan Murphy (@declangmurphy) and Professor Dasgupta (@prokarurol), was held at BAUS this year, which must surely be one of the first at any surgical conference? The session aimed to raise awareness of social media and advise delegates on the safe and best uses of social media in light of the recently drawn GMC guidance on the issue. Members were also helped by the unveiling of a set of BJUI guidelines on social media.

A range of experience was shown by the group, with about 50% using Twitter and other social media professionally at the present time.

Teaching new things in new ways

The BJUI supports BAUS regarding social media and demonstrated their rapid uptake of social media by posting the highest “influence” of any urology journal with a Klout score of 56.
 

During the conference BAUS president Mr Adrian Joyce, blogged his response to a newspaper article demonstrating that BAUS are developing an interest in social media and are using the expertise of their friends at BJUI to help them get their message out. It is an exciting time for all and I think we will see much more activity in social media in urology.

Other changes for the future were raised at the BURST session, where simulation in Urology training was discussed. Simulation will be used more in training and may not just include surgical skills but extend to non-technical skills including leadership, and working with distraction and disruptions.  

The conference has a great educational element, produced by Miss Tamsin Greenwell, with numerous small skills and teaching sessions running on every day of the conference. This allows every delegate to tailor their experience to their interests and needs. In particular the skills session gave us the rare chance for realistic surgical simulation using fresh frozen cadavers, with significant sponsorship at a fraction of the cost. These courses ranged from PCNL access and TURP to basic cystoscopy, ureteric stenting and supra-pubic insertion.

The BAUS social programme is rightly famous, with great events planned every night. The main event from Day 1 was the regional football competition, which was again competitive and well attended with congratulations to the Newcastle Trainees for winning the Cup.

With so much to do and see I am sure that many had a completely different experience to me and I am already looking forward to next year.

Dr Nishant Bedi is a Core Surgical (Urology) Trainee in the West Midlands Deanery, UK.
@nishbedi

 

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