Introduction: Computed tomography (CT) scans are associated with increased cost and exposure to radiation when compared to ultrasound (US) in patients presenting with renal colic. Consequently, a Choosing Wisely recommendation from 2014 states that US should be used over CT in uncomplicated presentations of renal colic in patients under the age of 50. The objective of this study was to describe imaging practice patterns in Ontario among patients presenting with renal colic and the relationship between initial imaging modality, subsequent imaging, and burden of care indicators. Methods: This is a population-based study of patients who presented with renal colic in Ontario between 2003 and 2019 using administrative data. Patients were assessed according to the first imaging modality they had during their index visit. Descriptive statistics and the Chi-squared test were used to examine differences between these groups. The primary outcome was the need for subsequent imaging. Secondary outcomes included length of renal colic episode, days to surgery, number of emergency department visits, and number of primary care visits during the renal colic episode. To identify the factors associated with outcomes, both univariate and multivariable logistic regression models were used. Results: A total of 429 060 patients were included in the final analysis. Of those, 50.5% (216 747) had a CT scan as their initial imaging modality, 20% (84 672) had an US, and 3% (13 643) had both a CT and an US on the same day. Subsequent imaging was obtained in 40.7% of those who had a CT scan as the initial imaging, compared to 43% in those who had an US and 43% who had both an US at CT on the same day. Of those who initially had an US, 38% went on to have at least one CT scan during their renal colic episode, including those who had a CT on the same day as the initial US, while 62% were able to avoid a CT scan altogether. In contrast, 17% had a repeat CT after an initial CT at the time of presentation. The overall use of US increased from 15% to 31% during the study period. The length of the renal colic episode was slightly longer in those who had a CT first compared to US in multivariable models (ARR 1.005, 95% confidence interval [CI] 1.000–1.009); however, the time to surgery was less in those who had a CT first (ARR 0.831, 95% CI 0.807–0.856). Fewer emergency department and family physician visits were seen in those who had an initial CT. Conclusions: In patients presenting with renal colic in Ontario, approximately half are having a CT done as the initial imaging modality despite US being the recommended imaging modality in uncomplicated renal colic presentations. While US use remains low, its use doubled during this study period, demonstrating an encouraging trend. Those who have an US done first are often able to avoid subsequent CT scans. Efforts should be made to further promote the use of US in those presenting with renal colic rather than CT when clinically indicated.
Intravesical bacillus Calmette-Guerin (BCG) G immunotherapy is the gold standard treatment for patients with non-muscle invasive bladder cancer (NMIBC). Unfortunately, more than 50% patients experience early recurrence or progression. Increased intra-tumoral immune infiltration in pre-treatment tumors has been shown to associate with poor outcomes post BCG therapy. Specifically, we recently showed that high intra-tumoral B cell density was associated with early recurrence and progression of NMIBC. Here, we address a major knowledge gap in the role of BCG induced expansion of a B cell population, called atypical B cells (ABCs), in the context of age and sex, the two major variables in the pathophysiology of NMIBC. We first investigated whether pre-BCG TLSs associate with response to BCG. Using multiplex immunofluorescence and NanoString GeoMx digital spatial profiling-based characterization, we found higher density of tumor adjacent (TA) TLSs in patients categorized as BCG non-responders. Spatial proteomic profiling of 49 immune function and phenotype associated proteins revealed increased expression of immune exhaustion associated proteins in pre-BCG TLSs in tumors from both BCG responders and non-responders. It is established that patient age is a risk factor associated with poor outcomes in NMIBC and that biological aging associates with exhausted populations of immune cells. The expansion of ABCs is known to accompany biological aging and repetitive immunizations. We hypothesized that ABCs are recruited to the bladder mucosa due to repeated BCG instillations in the induction phase and dampen local anti-tumor immunity in patients deemed as BCG non-responders. Using the N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) carcinogen induced murine model, we investigated the role of B cells in BCG response in aging mice. Bladder local and systemic immune alterations were characterized at post BCG therapy with or without B cell depletion. Since B cells exhibit significant shifts with biological aging in a sex associated manner, we used the four-core genotype mouse model to determine such differences following repeated treatment with BCG. BCG treatment in combination with B-cell depletion led to distinct bladder immune microenvironment states and systemic immune profiles. Overall, this study demonstrates the significant role of ABCs in disease progression and that the B cell infiltrated pre-BCG therapy TA-TLSs reflect a systemically exhausted B cell functional state in patients deemed as BCG non-responders. Findings from this study provide the first evidence suggesting the role of B cells/ABCs in BCG response and will inform future translation to development of therapies targeting the B cell exhaustion axis.
Introduction: We sought to determine the satisfaction rates of examiners and candidates in a Virtual Objective Structured Clinical Exam (OSCE) of graduating Canadian urology residents. Methods: An annual mock exam, aimed at simulating the licencing urology exam for Canadian graduates, was moved to an online format for the 2020 cohort. This exam consists of an Objective Structured Clinical Exam (OSCE), and a written multiple-choice exam. The Telemedicine Satisfaction Questionnaire (TSQ), a previously validated tool for clinical encounters with three sub-domains (quality of care provided, similarity to face-to-face encounter, and perception of the interaction) was modified for the purposes of evaluating the OSCE encounter. The TSQ was sent electronically to all examiners and candidates after the exam. Results: There were 14/16 responses from examiners (87.5%) and 24/39 responses from candidates (61.5%). Overall, the format was judged to be a good experience by 13/14 (92.9%) of examiners and 21/24 (87.5%) of candidates; however, when asked specifically if the virtual OSCE was an acceptable way to determine a candidate’s competency to practice urology independently, only 8/14 (57.1%) of examiners and 15/24 (62.5%) of candidates agreed. Conclusions: This study demonstrates an overall good satisfaction rate among both examiners and candidates when using a teleconference format for a mock OSCE.
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