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Would you really do a radical prostatectomy on a man with known metastatic prostate cancer?

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This year’s final #urojc concluded with intense discussions on the role of local treatment (LT) in metastatic prostate cancer. One study author, @mbwilliams95 joined the conversation to provide valuable insights.

 

 

 

Despite the fact only a small number of Stage IV patients had LT between 2004-2010 (post docetaxel era), this population based study revealed statistically significant differences between overall survival (OS) and disease specific survival (DSS).

Treatment Patient number 5 yr OS (%) DSS (%)
Radical prostatectomy
(RP)		 245 67.4 75.8
Brachytherapy(BT) 129 52.6 61.3
No surgery or radiation (NSR) 7811 22.5 48.7

 

So, can this be the start of a paradigm shift?

We may need to question our conventional approach.

Although some would consider performing RP in this population,

Others disagreed

Tzelepi et al (J Clin Oncol 2011 Jun 20;29(18):2574-81) suggested that potentially lethal cancers persist in the primary tumor and may contribute to progression. This is a possible explanation for this study’s findings, which echoed earlier results by Swanson et al (J Urol. 2006 Oct;176: 1292-8) and Shao et al (Eur Urol 2013 May 21. [Epub ahead of print]). However, SEER lacks information regarding the extent of bony metastasis, an entity that undoubtedly influences patient survival. Furthermore, patients treated with RP were 10 yrs younger than the NSR group (62 vs 72), and had a higher proportion of those with PSA <20.

To reduce bias produced by significant comorbidities, authors excluded those dying within a year of diagnosis and found the 5-yr OS continued to be higher in patients undergoing RP (76.5%) or BT (58.2%). However, patients with three or more of: age ≥70 yr, cT4 disease, PSA ≥20 ng/ml, high-grade disease, and pelvic lymphadenopathy had a 5-yr OS survival (38.2%) and a DSS probability (50.1%) similar to NSR patients.

Several contributors identified that Will Rogers phenomenon may be at play

Ultimately, the jury is still out on what is the most effective treatment of significant prostate cancer

Studies (in addition to the follow-on cohort study arising from this review), are underway

To conclude, it has been

In spite of the global participation, much of the banter involved our US urological colleagues.  On this basis, the Best Tweet Prize has been awarded to a provocative tweet from our UK colleague Ben Challacombe (@benchallacombe).

Thank you to European Urology (@EUPlatinum) for allow open access to the article discussed this month.  Thank you to Nature Reviews Urology for supporting the Best Tweet prize, which is a complimentary 12 months on-line subscription to the journal.

We look forward to seeing you at the January #urojc.

 

Dr Janice Cheng is an Australian Urology Trainee, currently based at Western Hospital. She has an interest in teaching, and enjoys laparoscopies, endoscopies, as well as male/female incontinence management. Twitter @JustUro

The bashful bladder: can we ever truly define?

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Commemorating the #urojc one year mark, Brian Stork reflected on the year that was, with a fun visual diagram on the most common words used during this period.

A fitting paper for moving into Season 2 of the #urojc, with the November International Journal Club discussion on Twitter was based on the paper “Detrusor Underactivity and the Underactive Bladder: A New Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology, Aetiology, and Diagnosis” by Osman et al from European Urology, 26 October 2013.

Osman et al, attempted to provide clarity around the nonobstructive impairment of voiding function, referred to as detrusor underactivity and the underactive bladder, as a clinical entity, and provide consensus on the standardising of current concepts. In their attempt to achieve this aim, a wide ranging literature review was conducted on varying terms commonly pertaining to detrusor underactivity.

So, does definition matter when discussing bashful bladders?

Early discussion centred on how frustrating detrusor underactivity was as an entity in part due to lengthy and complex mathematical equations, 

difficult in defining, with Amrith Rao, adding another term into the mix,

and often concomitant disease processes.

Surgical intervention for a bashful bladder is not a new concept, with Amrith Rao noting a partial cystectomy for hypotonic bladder was offered in the 1970’s.

This lead to a clinical discussion with participants asked who would perform a TURP on a man with an underactive bladder as suggested by urodynamics? Nadir Osman brought to our attention a study published in The Journal of Urology by Djavan et al in 1997, which concluded patient age was the key factor in treatment failure. However, with no solid evidence, participants agreed it often came down to patient choice.

Although a smaller group of participants for this month’s discussion, conclusions included:

The main messages I took from this discussion were:

  1. This is an often forgotten and overlooked aspect of Urology practice
  2. To succeed in overcoming these obstacles, a standardised definition for DU / UD is needed

This month had a strong showing from Sheffield urologists and alumni including Nadir Osman, Kate Linton, Jake Patterson, Jim Catto, Henry Woo and Chris Chapple who was listening in from his newly created Twitter account. The winner of the best tweet prize for the November #urojc is Jake Patterson.  BMC Urology have kindly donated a complimentary manuscript submission to this open access journal (of course pending peer review process).

Whilst these non-oncology topics see smaller participation, these topics will continue to be supported to provide variety and to maintain interest to the general #urojc audience.

Helen Freeborn is an Australian Urology Trainee, currently completing a General Surgical year at Cairns Base Hospital, QLD. She is interested in surgical leadership and the power of social media in connecting health professionals. Twitter @DrHelenF

One year on and “The International Urology Journal Club on Twitter” still going strong

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November marked the first anniversary of the International Urology Journal Club on Twitter. As far as we are aware, our #urojc was the first journal club on Twitter using the asynchronous format. Prior to our commencement and unknown to us, a very successful real time journal club had been established with great success. Our major challenge was to enable engagement from our global community and clearly the way forward was to use the asynchronous chat format. This has since proved to be the innovation that has enabled true global participation. Other specialties have since followed our model.

When we started, we were fortunate to be in a specialty group where there were already significant numbers on Twitter and we were able to rally up the troops for the first #urojc discussion in November 2012. In the first month of our existence, we had around 50 followers and since then there has been a steady growth in those following the #urojc account and as we reached our one year anniversary, we had hit the magic 1000 follower mark.

Before all is relegated to faint memory, it is important to acknowledge the supporters and Best Tweet (Hall of Fame) winners over the past 12 months.

A couple of the novel prizes, were not sur‘prize’ingly from Urology Match.

Thanks to all of you who have supported this project as participants and followers of the #urojc discussions. A shout out to BJUI for allowing us to have the audience of the BJUI Blogs to communicate and publicize our activities. Thank you to the supporters of the Best Tweet Prizes and the journals who have kindly allowed open access of articles discussed. A special thanks to authors who have been kind enough to make themselves available for the discussion – having author insights adds a special touch that is simply not possible with any other journal club format.

We have been off to a strong start for our second year and look forward to the continued success of this novel form of CME by social media.

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

The Surgical Spectacle: Blurred Lines

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October’s #urojc discussion marks a number of important milestones– not only the 1st anniversary of the online, international Twitter-based Journal Club, but this month we reached 1000 followers on Twitter – an achievement indeed! We also saw a record number of participants in demonstration of the #urojc concept going from strength to strength.

Fittingly, this month’s paper “The Surgical Spectacle: A Survey of Urologists Viewing Live Case Demonstrations” by Elsamra et al, with free online access provided by BJUI for the duration of the discussion, looks not so much at advances in our theoretical knowledge but rather at the way technological advances are changing our ability to obtain surgical ‘know-how’.

 

Elsamra et al undertook a survey of all those who attended the live surgery sessions at the Atlanta AUA Meeting in 2012 and the 2013 Paris 3rd International Challenges in Endourology Meeting, to gauge the perceived educational benefits of live case demonstrations (LCD) particularly when compared with taped case demonstrations (TCD). There were a number of problems highlighted in the paper itself:

David Chen won the best Tweet Prize, free registration at EAU 2014, kindly donated by @EUPlatinum, with the following:

Interestingly, while 78% of survey respondents felt that LCDs were ethical and only 26% that interactive discussion may lead to distraction of the surgeon and potential morbidity, only 58% would allow themselves or a family member to undertake their own surgical management as an LCD.

Live case demonstrations are by no means a new concept – they have been undertaken since the advent of surgery for the purpose of education and learning.

Recent innovations have seen a blowout in the size of the viewing audience, with live streaming to conference audiences and potentially worldwide viewers, live tweeting and more recently, as pointed out by Dr Brian Stork, the use of Google Glass for both live surgery and the purpose of remote assistance. LCDs have become the drawcard of many surgical conferences, are often the most packed sessions, arguably for the educational benefit and more importantly for the buzz and thrill of seeing ‘the masters’ deal with difficult situations in real time… while answering questions from the audience simultaneously… “so that bleeding sir, where is it coming from exactly?!?!”

It seems that there is no argument that case demonstrations are of great educational benefit and there are some perceived advantages of live vs taped sessions, as summarized by Amrith Rao in a recent BJUI blog.

The vast majority of those involved in this #urojc discussion, however, seemed to suggest that it was hard to argue that the benefits of LCD outweighed those of TCD. Are we simply promoting a surgical circus? Does the perceived stress of operating to a live large audience have a potential negative impact on patient outcomes? Declan Murphy has already blogged about his own personal experience with LCD.

As for the ethical conundrum regarding the patient?

As suggested by Henry Woo:

In 2012 the EAU released guidelines with respect to the use of live case demonstrations within its own jurisdiction. Importantly, this has highlighted the need for regulation by means of submitting outcomes to a data registry, so as to provide a means of analyzing complications and patient safety outcomes.

Position statements or guidelines have also been released by the Royal College Surgeons (UK), American Urological Association and the Royal Australasian College of Surgeons, to name a few.

Where to from here? Will we continue the trend for ‘reality TV’?

There is certainly evidence out there to suggest that recording of basic operations and comparing with peers is potentially a useful means of assessing surgeon proficiency.

I think it very much remains a case of watch this space!

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

Chemoprevention of Prostate Cancer – Is it justified?

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The September #urojc International Urology Journal Club discussion on twitter was based on the paper “Long-Term Survival of Participants in the Prostate Cancer Prevention Trial” published in the New England Journal of Medicine a few weeks earlier.

In 2003, the Prostate Cancer Prevention Trial (PCPT) proved what it set out to do. It significantly reduced the risk of PCa. Unfortunately, the champagne was never even taken off ice, as finasteride was also associated with an increased risk of high-grade prostate cancer. In June 2011, US FDA ordered the drug’s warning label to be updated to state that finasteride may increase the risk of high grade prostate cancer. As a primary prevention drug for PCa, despite many published, favorable subgroup analyses, finasteride was quite flaccid in the eyes of many urologists.

 

Now, ten years after the PCPT was published and with up to 18 years of follow-up, would these long-term results be the catalyst to force an FDA backflip? Or would the specter of erectile dysfunction rise? Amongst the first tweets that were fired (no prizes to guess who it was)

Tweeted link by @LoebStacy

 

To summarise, this post hoc analysis – that wasn’t pre-specified in the original protocol – analysed rates of survival among all original PCPT study participants including those with prostate cancer. Prostate cancer incidence amongst PCPT candidates was collected for an additional year after the original report and the Social Security Death Index was searched to assess survival status until 31st October 2011.

In all 18,880 men, PCa was diagnosed in 10.5% of the finasteride group and 14.9% of the placebo group (RR in finasteride group, 0.70; 95% CI, 0.65 to 0.76; P<0.001). Furthermore, 333 (3.5%) in the finasteride group and 286 (3.0%) in the placebo group had high-grade cancer (GS, 7 – 10, RR, 1.17; 95% CI, 1.00 to 1.37; P=0.05). Fifteen-year survival rates of 78.0% (finasteride) and 78.2%, (control) were reported in the men who died. Unadjusted hazard ratio for death in the finasteride group was not significant. Ten-year survival rates were 83.0% (finasteride) 80.9% (placebo) with low-grade PCa and 73.0% and 73.6%, respectively, with high-grade prostate cancer.

The authors as well as the #urojc community were quick to identify limitations.

 

 

Indeed, since information regarding the mode of death for patients who passed away was unavailable, PCa specific mortality could not be reported by this study. In amongst the discussion regarding limitations, it was important to see twitter etiquette observed.

There was some discussion on whether high grade “finasteride” prostate cancer was morphologically identical to “placebo” prostate cancer or different?

 But at the end of the day, it doesn’t matter how it is discussed, packaged or assembled…

 

In an underpowered study, not designed to look at PCa-specific mortality, there was always going to be conjecture as to the benefit of reducing low grade PCa by 30% (in an era of increased active surveillance) whilst giving 1 in every 200 men offered finasteride high grade PCa.

Erectile dysfunction was an ever present factor during our discussion, although was generally thought of as #firstworldproblems

At times, when drawing conclusions, our intellectual, verbatim-driven minds give way to pictorial clarity; in other words a picture tells a thousand words. I still wonder how many a tweet is worth… In my very humble opinion, my conclusions are

1) 5 ARIs decrease low grade PCa, but low grade PCa doesn’t necessarily equal death, so…

2) Primary prevention for PCa would need to be robust, 5ARIs are too far from the mark

 

3) I thought appropriately chosen patient with bothersome LUTS, a large prostate with elevated PSA (proved to be cancer free or low volume GS 6) should go green (I can already feel the holmium lasers, microwave emitters and diode beams aimed behind my head, but that is a conversation for another time…)

 

The king summed it up well I think,

This month’s prize has been generously donated by Urological Society of Australia and New Zealand, one full registration to USANZ ASM 2014 in Brisbane! There was a clear winner who was novel in tweeting an image that said it all.

Congratulations to Dr Todd Morgan!

 

A warm thank you is extended to all who participated in this month’s #urojc discussion. All of you are encouraged to participate in next month’s discussion starting on 4th-5th October depending on your time zone.

Analytics for for this month’s discussion:

 

 

Dr George Koufogiannis is an Australian Urology Trainee, currently based at Port Macquarie Hospital. @DrVasano78 Vasano = torment, 78 = 1978, the year I began to torment my mother, who gave me the nickname.

Fish Oil Causes Prostate Cancer: fact or fishy tale?

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Following the recent fish oil and prostate controversy (which BJUI Chairman Dr David Quinlan recently blogged about, the August International Urology Journal Club discussion on Twitter was based on the recent high-profile (and controversial) paper “Plasma Phospholipid Fatty Acids and Prostate cancer risk in the Select trial”, available by advance access from the Journal of the National Cancer Institute, June 10, 2013.

In the recent weeks, many concerned patients had attended urologist and GP clinics, enquiring about the reports that fish oil supplements increase the risk of prostate cancer. This has led to lengthy discussions between patients and their doctors during consultations, and even caused some clinics to run overtime.

So, does fish oil really lubricate prostate cancer growth, or is this all just a fishy tale?

In summary, this case–cohort study set out to examine the association between plasma phospholipid fatty acids and prostate cancer risk among participants in the Selenium and Vitamin E Cancer Prevention Trial. 834 men diagnosed with prostate cancer formed the prostate cancer group. 1393 men chosen at random, and matched according to age and race, formed the non-cancer group. The study reports that men in the lowest quartiles of LCω-3PUFA, compared with men in the highest quartile, had increased risks for low-grade (HR = 1.44, 95% CI = 1.08 to 1.93), high-grade (HR = 1.71, 95% CI = 1.00 to 2.94), and total prostate cancer (HR = 1.43, 95% CI = 1.09 to 1.88). Similar associations were reported for individual long-chain ω-3 fatty acids. Higher linoleic acid (ω-6) was associated with reduced risks of low-grade (HR = 0.75, 95% CI = 0.56 to 0.99) and total prostate cancer (HR = 0.77, 95% CI = 0.59 to 1.01); however, there was no dose response. This study therefore concluded that increased prostate cancer risk among men with high blood concentrations of LCω-3PUFA was confirmed. The authors went on to say that the consistency of these findings suggests that these fatty acids are involved in prostate tumorigenesis, and that recommendations to increase LCω-3PUFA intake should consider these risks.

There has been a lot of media hype surrounding this paper, with the claim that fish oil supplements may increase one’s risk of prostate cancer. This has led to many anxious patients. It is not the first time that sensational claims of natural therapies either causing or preventing cancer has received a lot of media attention.

However, as doctors who have patients and colleagues asking us for sound advice on the matter, it is important that we don’t simply dismiss such hype (and questions from anxious patients) without looking into the matter more deeply, examining the evidence for ourselves, and forming a sensible opinion.


Early in the discussion, the methodology of the study was criticised as being observational by Kate Linton and Faisal Ahmed agreed. The study lacked a proper control group, and did not adequately address confounding factors. Associations were attributed to causation.


Stacy Loeb pointed out that the study did not record the amount of fish oil supplements ingested by any of the men in the study and instead on the basis of a single serum level. Yet the media extrapolates the study’s findings to make recommendations about fish oil supplements, which can be delivered in various formulations and doses.


There was also concern for the assay method used in measuring plasma lipids.


This study’s conclusions might have interesting commercial ramifications. I wonder whether there has been a drop in fish oil supplement sales this week?

However, it is worthwhile to note that there have been other prospective studies and metanalyses that have shown an inverse association between fish oil and prostate cancer. Helen Nicholson brought to our attention, a paper published in Cancer Epidemiology, Biomarkers and Prevention in 2007, which concluded that higher blood levels of long-chain n-3 fatty acids, mainly found in marine foods, and of linoleic acid, mainly found in non-hydrogenated vegetable oils, are associated with a reduced risk of prostate cancer.

To conclude the discussion, several participants stated

My take home message from the August #urojc discussion is;

1.Although interesting, this study is limited by its methodology – it was not a randomised controlled trial of fish oil supplements versus no fish oil supplements. Therefore it cannot answer this question.

2.This study does not provide sufficient evidence to confirm whether omega-3 fatty acids conclusively lead to increased risk of prostate cancer.

3.Media hype = anxious patients. But we can tell our patients the science.

The winner of the best tweet prize for the August #urojc was Kate Linton for the following tweet which highlighted a significant shortcoming of the paper.

 

 

The August #urojc prize was kindly supported by the Asian Journal of Andrology.

We thank everyone who participated in the August #urojc, and to the many other on-lookers.

We look forward to your input in the next great International Urology Journal Club discussion, in early September 2013. The topic will soon be announced. If you would like any specific papers to be discussed, please DM us @iurojc – we always welcome your suggestions and feedback.

 

Dr Amanda Chung is an Australian Urological Surgeon in Training, currently based at The Wollongong Hospital, New South Wales. @AmandaSJChung

Bladder Cancer: a stagnant foe?

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This month’s topic for the Twitter-based International Urology Journal Club #urojc was bladder cancer, with a paper titled ‘Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades’ by Zehnder et al, published online in July 2013. Open access to the paper was kindly provided by the BJUI.

 Zehnder and colleagues undertook a retrospective analysis of the University of Southern California cohort and identified 1488 patients with muscle invasive bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection between 1998 and 2005. They also included 190 patients from the University of Bern cohort to determine outcomes in patients with clinical N0 disease who were upstaged on pathology to node positive disease. Analysis, performed based on decade of intervention, showed no significant difference in overall survival (OS) or recurrence free survival (RFS) over the three decades. 10-year RFS was 78-80% for organ confined, lymph node negative, 53-60% in locally advanced, LN –ve and 30% in LN positive patients.

 

 

Firstly, it has certainly been suggested that the overall survival and cancer free survival outcomes are not as good in broader population based studies (Ontario Cancer Registry). Why?

 

 

 

 

Analysis of the SEER database has shown that cancer specific survival and overall mortality has not improved for any clinical stage of bladder cancer and in fact suggests that the incidence is increasing in the United States.

 

 

And of course, we must always look at the study design and determine whether the outcomes are reflective of the patient populations that we see in practice.

 


 

The roles of neo- and adjuvant chemotherapy were discussed at length. Only 6% of patients received neoadjuvant chemotherapy, with worse OS and RFS in multivariate analysis. The use of adjuvant chemotherapy actually almost doubled from the 80’s to 90’s, stable in the 00’s at 29%.

 

  

 

 

 

 

 

If neoadjuvant chemotherapy is so widely recommended, why has its use failed to take off?

 

 

 

 

 

 

 

Jim Catto suggested an excellent clinical pathway for the implementation of neoadjuvant chemotherapy.

If indeed bladder cancer is the poor cousin of prostate cancer, why has progress stagnated and what can we change?

 

 

 

 

 

 

 

 

 

 

So what are my humble take home messages from the discussion surrounding this month’s #urojc paper?

  1. Current data suggests that we have made no significant progress in bladder cancer outcomes over the past 30 years
  2. Early referral and diagnosis coupled with timely intervention key; be wary of progression in context of high grade NMIBC
  3. Both surgeon volume and hospital volume are thought to be independent predictors of overall survival. Patie nts do best at a high volume facility under the care of a high-volume Uro-oncologist in a multidisciplinary context
  4. Neoadjuvant chemotherapy, despite randomized controlled trial evidence in favour of its use, has poor uptake in a real world setting. Advances in dense dose regimens (MVAC and Phase III GC underway) with resultant improvement in progression free survival, lower toxicity profile and fewer dose delays make for an attractive partner to radical cystectomy and extended pelvic lymph node dissection.

To finish with the words of the self-proclaimed Urology King of Twitter, Dr Ben Davies:

 

 

 

Winner of the best tweet prize for July’s #urojc was Mike Leveridge from Queens University, Canada – he was certainly a little frustrated with the apparent lack of progress we have made. The July #urojc Best Tweet Prize was kindly supported by the Nature Journal “Prostate Cancer Prostatic Diseases” which is edited by Dr Stephen Freedland and will be a complimentary 12 month online access to the journal.

 

 

 

 

 

 

Do join us for the August #urojc which commences on Sunday 4th/Monday 5th depending on your time zone.

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

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A beer a day keeps stones away

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This month the Twitter-based International Urology Journal Club #urojc made a bold move away from cancer to discuss kidney stones. The paper entitled ‘Soda and other beverages and the Risk of Kidney Stones’ by Ferraro et al. was published online on 15th March 2013. Open access to the article was generously provided by the Clinical Journal of the American Society of Nephrology. The lead author, Pietro Manuel Ferraro, was kind enough to actively participate within the Twitter discussion.

This particular study looked at a total of 194 095 participants amalgamated from the Harvard-based Health Professionals Follow-Up Study and The Nurses Health Studies I and II. These individuals all filled in biennial questionnaires regarding their diet, general health and kidney stone pain for a median follow up period of 8 years. It is interesting that the event rate was relatively low with only 4462 cases identified, however it is important to note that the study looked only for new stone formers and persons who had previously had a kidney stone were excluded from the trial. At the outset this begs the question as to whether these results are in any way applicable to the recurrent stone former population.

 

So what did they find? The referent is the consumption of less than one drink per month, so with respect to daily consumption of one or more sugar sweetened colas there was a 23% increased risk in the incidence of renal calculi. Other beverages to show a statistically significant increased risk of stones included:

Sweetened non-cola soft drinks 33% increased risk
Artificially sweetened non-cola soft drinks 17% increased risk (p=0.05)
Punch (sugar sweetened fruit drink) 18% increased risk

 

And what decreases your risk?   % risk reduction        
Coffee 26%                 
Decaffeinated coffee 16%
Tea 11%
Red Wine 31%
White Wine 33%
Beer 41%
Orange Juice 12%          

 

Missing my poison of choice, diet cola? While there was a trend towards a decreased risk, this was not found to be statistically significant. But not an increased risk….so I may just keep drinking it for the time being. I am not alone.


There were certainly more than one of the so called Urological ‘Twitterati’ who seemed delighted that the study findings justified their habits:

   

There are undoubtedly limitations with any cohort questionnaire analysis. The authors have acknowledged that while they tried to control and adjust for variables including age, BMI, diabetes, race, BP and dietary intake, there are variables that simply cannot be accounted for on the basis of a simple questionnaire. Fructose, for example, is purported to be a potential contributor to the increased risk of stones by increasing calcium, oxalate and uric acid excretion. There are many other dietary sources of fructose, including fruits, cereals and processed foods and sauces that are not accounted for and are potential confounders. Along the same lines, coffee is a relatively broad category of beverage. When one compares an espresso with a teaspoon of sugar to a Starbucks Frappuccino the difference in sucrose, and thus fructose, content is extraordinary. The caffeine content of these beverages, while purported to decrease the risk of stones through diuresis, is variable and thus also a potential confounder.

Manuel Ferraro importantly acknowledged that the study observed ‘associations, not causal effects’. Harder evidence such as 24 hour urines, stone analysis and imaging data would be useful to draw more significant conclusions as to causality.
 

The population studied was also somewhat limited. As mentioned by Jason Lee, Henry Woo and Matt Bultitude the study included male health professionals and female nurses, who were generally white, an older population with a relatively low BMI and potentially prone to dehydration. There was also limited control of comorbidities.

As suggested by Christopher Bayne, the only evidence as yet in randomized controlled trials is that water consumption as reflective of hydration status and urinary volume is the only substance known to reduce the risk of stone formation.
 

An astute observation by one of my fellow Australian trainees Janice Cheng noted the relatively dehydrated status of the study subjects.


This won the best Tweet prize, kindly donated by European Urology @EUplatinum.

Increased water intake has been reviewed on the Cochrane Database in 2012, however the consensus drawn was that there is currently insufficient evidence that increased water intake specifically, as opposed to other fluids, prevents the formation of urinary calculi.

So what conclusions should we draw? A patient with his first presentation kidney stone actually asked me yesterday whether he could keep drinking his favourite drink….beer. I simply replied that there was no current evidence that this would increase his risk of stones, however that moderation was key. We must remember that many of these calorific drinks have significant impact on comorbidities outside of the world of kidney stones. #a(lotof)wateradaykeepstheurologistaway

The overall participation in #urojc continues at a solid rate, with 39 participants and 178 total tweets over the 48 hour period. The next #urojc will be on the first Sunday or Monday of July (depending on your time zone).

   

Dr Helen Nicholson is an Australian Urology Trainee, currently based at The Sydney Adventist Hospital, NSW. Tweeted initially under duress, now a voluntary convert @DrHLN

 

Comments on this blog are now closed.

 

International Urology Journal Club on Twitter

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International Urology Journal Club on Twitter: The Beginnings of a New Application of Social Media in Urology CME

The International Urology Journal Club on Twitter almost came about by accident, although the formation of such was an inevitability. Over the course of 2012, a number of research papers have been the subjects of discussion amongst urologists on Twitter.

The standout paper as example for discussion in 2012 was the PIVOT study. This generated comments that were difficult to follow unless you were following all of the many participants. Although one could find the majority of the tweets in chronological order by doing a search under the tab “Discover”, it was still dependent upon whether the term PIVOT was used in the tweet or not – it was quite often the case that a comment was made without the term PIVOT being used and these would be missed by a search for PIVOT. In essence, a form of journal club was already happening although there was no organized manner by which all comments could be filed or arranged to provide context. When limited to 140 characters, a tweet can easily lose context if it cannot be connected to other tweets it may refer to or be in reply to. The use of a hashtag provides a filing system for related tweets and had all participants in the PIVOT study discussion used the hashtag #PIVOT, a search under that term would have enabled easy following and review of the discussion pertaining to that topic. The use of a hashtag does require general agreement by contributors that this will be the agreed filing (this is what I call it even though it is not a universal way of describing it) system for the tweets. It also meant that inclusion of long twitter handle names such as @cooperberg_ucsf would not eat into the precious 140 character limit to which we wish to make comment – as we are a tolerant, respectful and good humoured community, we of course continue to tolerate this blight on our character count. (I have incidentally shortened my Twitter name from @DrHenryWoo to @DrHWoo as a donation of 4 precious characters to those who wish to engage me on Twitter).

So how did the International Urology Journal Club on Twitter come about? It all started with Canadian urologist Michael Leveridge sending a few live tweets from his local journal club and nominally used the hastag #quroljc, which stood for Queens Urology Journal Club. A number of urology colleagues around the world, including myself, were intrigued by this.

Following an exchange of tweets, we came to realization that we were effectively engaging in a Twitter urology journal club. We soon realized that in order to do this effectively, we needed a hashtag to which we could all tweet our journal club responses and the hastag #urojc was born.

According to the exchange of tweets above, we can credit Michael Leveridge for coining the hashtag #urojc. On Twitter, it does not take long for the message to spread.

To administer Journal Club, an administrative account @iurojc and specific blog account was established. You will note that the administrative account is @iurojc and not @urojc since the latter had already been taken by another urologist. The #urojc blog carries information about the journal club as well as the tweet logs from the discussions.

In short, a recently published manuscript is selected for each month’s discussion. Such manuscripts are usually those that have been published online ahead of print in order to offer the most cutting edge research discussion. Discussions occur on the first Sunday or Monday of each month depending on which time zone you are in. Tweet discussion is carried out in an asynchronous manner over the course of 48 hours. Since commencing in November 2012, there has been a truly global engagement and with the amplification effect of Social Media, we have seen in excess of 50,000 impressions (a Twitter metric of reach). A novel approach to this format of journal club is the invitation and participation of the lead author and/or corresponding author associated with the paper for discussion – there is no question that this significantly enhances the value of the discussion.

Prior to the commencement of the first #urojc discussion, it was suggested that there should be a prize for the best tweet. This has now been instituted and a #urojc Hall of Fame is now in the making. With the Best Tweet prize for November 2012 being awarded to Ben Davies, it has only fueled his belief that he is indeed the urological King of Twitter. He is, however, the inaugural prize winner and at the top of the list of the #urojc Twitter Hall of Fame. The winner of the December Best Tweet Prize was another Ben, namely Ben Jackson. We thank Urology Match and Nature Reviews in Urology for donating the prizes for November and December respectively. Whilst there were suggestions of a Ben conspiracy, we cannot promise that the January Best Tweet Prize, which has been donated by the Urological Society of Australia and New Zealand (USANZ) will be awarded to a non-Ben participant.

It is our belief that the #urojc is the first truly international clinical journal club discussion taking place on Twitter in an organized manner. Whilst there are local real time Twitter journal club chats and similar discussions in non-clinical areas of health care, this is again a demonstration of how urologists lead the way with the embracement of technology to advance health care. For now, the discussions are on a monthly basis with a focus on uro-oncology. As interest grows, the plan is to expand to twice monthly with the mid-month discussion being on topics such as endourology or voiding dysfunction or female urology or any other area of interest. Do follow @iurojc and put forward your suggestions for papers to discuss. Again remember that the Twitter user name is slightly different to the hashtag, which is #urojc.

We look forward to having you join us for the next #urojc. 

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

 

January #urojc paper will be on PHI by @LoebStacy jurology.com/article/S0022-… ncbi.nlm.nih.gov/pubmed/23206426

 

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