NOSM University

<p class="AbstractBody">The authors report the case of an 80-year-old Canadian male with a giant bladder stone who declined treatment. A bladder stone is defined as a giant bladder stone when it has a diameter greater than 4 cm or a weight greater than 100 g; they are rare, with less than 100 cases reported in the literature. These stones are even rarer in developed countries like Canada. This pathology usually requires open cystolithotomy for definitive management. To the authors’ knowledge, this is the only reported case of a patient declining treatment, which helps urologists understand the natural history of this condition through a novel growth analysis of the patient’s bladder stone.

Background: Lemierre’s syndrome (LS), previously termed the “forgotten disease” after the introduction of modern antibiotics, is a rare and potentially fatal infection of the neck resulting in septic thrombophlebitis of the internal jugular and other neck veins. In recent years, there has been an increased resurgence of this disease, or at least in its detection, and it remains an important diagnosis with life-threatening potential to consider when presenting with multifocal cavitary pneumonia. Fusobacterium necrophorum, an obligate anaerobic Gram-negative bacterium, is the most isolated culprit organism involved in this condition; however, it is often fastidious and difficult to culture. The use of 16s rRNA gene sequencing can aid in this diagnosis when uncertainty exists. Methods: This case report describes an otherwise healthy 17-year-old male with a history of regular vaping presenting with upper respiratory infectious symptoms who was ultimately diagnosed with multifocal necrotizing pneumonia. In this case, there was initial diagnostic uncertainty as traditional microbiologic culture mechanisms failed to identify a causative organism for tailored antimicrobial treatment. This was despite direct empyema fluid analysis and pulmonary-bronchial biopsy. Novel gene sequencing was performed using 16s rRNA typing, a promising new way to identify a catalog of host organisms, detecting F. necrophorum. This diagnosis prompted further diagnostic imaging of the neck, confirming a small internal jugular clot and diagnosis of LS. Results: This case highlights the need for suspicion of LS in patients presenting with multifocal pneumonia. Furthermore, it re-iterates the idea of culture-negative infections, whereby fastidious organisms or tissue samples do not readily provide a diagnosis. Lastly, it further introduces hypotheses regarding the use of vaping as a possible associated factor for significant infection and lung injury. Conclusions: The use of 16s rRNA sequencing for the detection of fastidious, opportunistic organisms is another tool for physicians to ensure additional diagnostic clarity and appropriate treatment.

To evaluate the effect of intraoperative administration of 1g of tranexamic acid (TXA) on perioperative and postoperative outcomes in patients receiving antithrombotic therapy undergoing endoscopic enucleation of the prostate (EEP). This multicenter, prospective, observational study included 932 patients across 30 centers (December 2024-June 2025). Patients were divided into four groups based on TXA use and continuation or discontinuation of blood thinners during EEP. The primary endpoint was bleeding complications within 30 days, defined as a composite of transfusion, clot retention, bleeding requiring restart of continuous bladder washout (CBWO), or surgical reintervention to control hemostasis. Multivariable Logistic regression analysis identified independent predictors of bleeding complications. There were 534 patients in Group 1 (stopped blood thinners, no TXA given), 316 in Group 2 (on blood thinners, no TXA given), 69 in Group 3 (stopped blood thinners, TXA given), and 13 in Group 4 (on blood thinners, TXA given). Median total operative time was longest in Group 2 (88min [IQR 70-127]) and shortest in Group 3 (55min [IQR 39-69]). Hemostasis time was shortest in TXA groups (p < 0.001). Transfusions occurred in 0.6-7.7% and surgical reinterventions in 0.6-7.7% across groups (p < 0.001). At 3 months, urinary symptoms and continence were comparable. On multivariable analysis, TXA reduced the odds of bleeding complications (OR 0.17, p < 0.001), while ongoing anticoagulant therapy (OR 2.93, p = 0.01), dual therapy (OR 4.31, p < 0.001), and longer operative time (OR 1.01, p < 0.001) increased the odds. Intraoperative TXA might mitigate perioperative bleeding and potentially protect patients at higher hemorrhagic risk.

Background: Acute coronary syndrome (ACS) is a "can't miss" diagnosis. The gold-standard workup for this requires serial troponin biomarker evaluation over a period of hours. Traditionally, many of these patients required telemetry while being evaluated in this fashion; however, the high-quality literature suggests that low-risk patients do not require ongoing continuous cardiac monitoring. Locally, it was found that over 70% of patients presenting with low-risk chest pain to our high-volume urgent care were transferred to the main hospital for an ACS rule-out work-up via emergency medical services (EMS). We felt this intersection of patient care and medical services could be streamlined to reduce critical resource utilization. Objective: The aim of this study is to reduce the usage of EMS utilization for transport of low-risk chest-pain patients from the urgent care to the main hospital by 25% over a 3-month period. Methods: This study was conducted as an uncontrolled before-after interrupted time series design. A comprehensive data drilldown was performed through a chart review and structured clinical-practice evaluation. This led to a multi-factorial quality improvement initiative centered around the creation of an evidence-based safe-for-self-transport tool and physician education. The primary outcome measure was the proportion of patients transported via EMS with the main balancing measures being the proportion of self-transported patients admitted to the hospital and the time to troponin blood-draw in self-transported patients. Results: The education and the newly developed transport tool resulted in a sustained shift below the previous baseline system mean control limit, indicating a significant reduction in EMS usage for patient transport. The overall reduction in usage was 30%. No change in balancing (safety) measures was identified post-implementation. Conclusions: EMS remains a finite resource within many Canadian health regions. The results of this study show that by focusing on a cardinal emergency-department presentation like chest pain, adapting evidence-based practice through quality-improvement methodologies can result in a significant sustained reduction in EMS utilization.

Most clinical cancer therapy trials do not specifically consider the effect of patient age on treatment outcomes, and many even exclude older individuals. This is despite the fact that solid cancers are age-associated diseases and that there are many shared hallmarks between biological ageing and cancer. Thus, there is an increasing awareness of the serious gaps remaining in our knowledge of how older adults respond to cancer treatments, particularly immunotherapies. Emerging evidence suggests that it is not only the physiological and immunological changes associated with chronological ageing that impacts cancer treatment, but also those heterogeneous differences that impact treatment outcomes, such as frailty, comorbidities, and more generally, biological ageing. Importantly, it remains unclear which of these factors are negative or positive contributors, as has been illuminated by recent evidence pertaining to the incidence and severity of immune-related adverse events and survival. Much of our information on older patients in this context is essentially anecdotal, mostly deriving from the treatment of older adults in real-world practice or clinical trials that happened to include some older patients. Given the lack of comprehensive articles on the heterogeneity of ageing as a core determinant of cancer treatment outcomes, we briefly consider the state of the art of cancer research and treatment in the older patient, with an emphasis on immunotherapy and geriatric oncology.

Bilateral complex nephrolithiasis presents a significant surgical challenge. The standard treatment, percutaneous nephrolithotomy (PCNL), can be performed in a traditional staged approach (staged bilateral PCNL [sPCNL]) or as a bilateral same-session procedure (same-session bilateral PCNL [ssPCNL]). Although the staged method has been favored for safety, ssPCNL has emerged as a viable alternative. This meta-analysis aims to systematically compare the efficacy, safety, and efficiency of ssPCNL vs sPCNL to provide comprehensive, evidence-based insights for clinical decision-making. A systematic review and meta-analysis was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Scopus, and Cochrane databases for comparative studies. Primary outcomes analyzed were stone-free rate (SFR), minor complications (Clavien-Dindo I-II), and hospital stay. Secondary outcomes included operative time, hemoglobin decrease, and transfusion need. Data from studies were pooled using a random-effects model for all analyses. Risk of bias was assessed with risk of bias in randomized trials and Risk of Bias in Nonrandomized Studies of Interventions. Five studies met the inclusion criterion, comprising a total of 749 patients (308 ssPCNL, 441 sPCNL). The pooled analysis revealed no statistically significant difference between the groups in SFRs (odds ratio [OR]: 0.80 [0.47; 1.36]) or minor complications (OR: 0.88 [0.44; 1.73]). However, the ssPCNL group demonstrated a significantly shorter hospital stay (mean difference [MD] = -2.92 days; [-3.60; -2.24]; I2 = 84.7%). After sensitivity analysis, ssPCNL was also associated with a reduced operative time (MD: -45.18 minutes). Transfusion needs were comparable. ssPCNL is a safe, effective, and efficient alternative to the staged approach for managing bilateral renal stones. It offers comparable clinical outcomes while reducing patient morbidity and health care burdens associated with multiple procedures and longer hospitalizations. Thus, ssPCNL should be considered a valuable treatment option for appropriately selected patients in experienced centers.

PurposeMedical schools and healthcare institutions are increasingly committing to social accountability, the reorientation and prioritization of addressing local community health needs. Now, as part of this commitment, schools and institutions are called upon to demonstrate evidence of their progress towards social accountability to governments, accreditors, funders, and communities. This study aimed to understand what social accountability means to diverse interest holders, particularly with regard to demonstrating local evidence, to provide contextual insight for the development of an “impact framework” for one Canadian medical school.MethodsOne-on-one semi-structured key informant interviews were conducted with three diverse groups: academic, health services, and community interest holders to understand multiple perspectives on social accountability in health professional education. Respondents were asked how they perceive, actualize, and measure social accountability at different levels (societal, school, individual). Interviews were transcribed and thematically analyzed.ResultsEighteen interviews were conducted, with eight academic representatives, six health care professionals, and four community leaders. The researchers identified three high-level themes in their analysis: the definition of social accountability, enacting and embodying social accountability, and measuring social accountability. There were distinct differences in terms of defining, executing, and evaluating being socially accountable and doing social accountability.ConclusionRespondents emphasized that defining what social accountability means for a specific context is critical to advancing the movement. Acknowledging that there are similarities and differences between being socially accountable and doing social accountability is important for evaluating an individual’s or a group’s accountability to society in health care, health professional education, and research. While the actual indicators and outcomes used to assess the progress toward social accountability are likely geographically bound; meaningful engagement, shared governance and power structures, and integrated data and analytic capacities are important enablers to move social accountability measurement forward.

Mandibular osteoradionecrosis (ORN) is a severe late complication affecting patients with head and neck cancer (HNC) treated with radiation therapy (RT) that significantly impacts patients' quality of life and can require costly interventions. Although radiation dose is a key factor, other clinical and demographic risk factors also influence ORN development. Previous predictive models have primarily been single-institutional, limiting their generalizability. In this first analysis from the PREDMORN Consortium, we have aimed to reproduce existing statistical association and modeling analyses on the largest and most diverse mandibular ORN cohort worldwide to allow comparison with previous studies. This retrospective multi-institutional study included 3928 patients with HNC (622 ORN cases) from 8 institutions. Clinical, demographic, and dosimetric variables were analyzed to develop a prediction model (any grade ORN vs no ORN) using forward stepwise logistic regression with correlation-based variable preselection. The ORN normal tissue complication probability (NTCP) model was developed on 80% of data from 6 institutions, tested on the remaining unseen 20%, and externally validated on a matched cohort (58 patients, 19 ORN cases) and a large population-based cohort (2687 patients, 215 ORN cases). Key predictors of ORN were D30%, V70Gy, pre-RT dental extractions, and smoking status. The ORN NTCP model demonstrated very good calibration on the population-based external cohort (Brier score, 0.077; Log Loss, 0.281). Model discrimination improved on a subcohort including oropharyngeal and locally advanced larynx/hypopharynx cancer cases only (AUC from 0.69 to 0.75 and from 0.65 to 0.67 on the matched and the population-based external cohorts, respectively). The PREDMORN NTCP model is the largest multi-institutional effort to date aimed at predicting ORN risk in patients with HNC using real-world data. The model demonstrated good generalizability when externally validated to a large population-based cohort. Our observations align with current guidelines and corroborate findings from smaller single-institution studies.