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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.

Objectives\ud We aimed to examine differences in fear conditioning between anxious and nonanxious participants in a single large sample.\ud \ud Materials and methods\ud We employed a remote fear conditioning task (FLARe) to collect data from participants from the Twins Early Development Study (n = 1,146; 41% anxious vs. 59% nonanxious). Differences between groups were estimated for their expectancy of an aversive outcome towards a reinforced conditional stimulus (CS+) and an unreinforced conditional stimulus (CS−) during acquisition and extinction phases.\ud \ud Results\ud During acquisition, the anxious group (vs. nonanxious group) showed greater expectancy towards the CS−. During extinction, the anxious group (vs. nonanxious group) showed greater expectancy to both CSs. These comparisons yielded effect size estimates (d = 0.26–0.34) similar to those identified in previous meta‐analyses.\ud \ud Conclusion\ud The current study demonstrates that remote fear conditioning can be used to detect differences between groups of anxious and nonanxious individuals, which appear to be consistent with previous meta‐analyses including in‐person studies.

Over the last two decades, minimally invasive surgery (MIS) has emerged as an attractive alternative to traditional open surgical procedures. MIS has been shown to provide excellent surgical outcomes with the added benefit of decreased procedure-related morbidity. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery times are all proven advantages for laparoscopic procedures. [1-3] However, many MIS procedures are more technically challenging than the traditional open counterpart, and the learning curve to proficiency is markedly steeper than standard open procedures. Several factors including establishing adequate access, two dimensional vision, decreased depth perception, restricted instrument maneuverability, decreased dexterity and dampened tactile feedback are all unique limitations that make laparoscopic surgery challenging for surgeons trained in traditional open approaches. To the laparoscopically naive surgeon, this translates into a loss of confidence in performing a procedure in which they were previously skilled. Appropriate training and education are therefore essential for a surgeon to develop the necessary skills required in order to comfortably perform a surgery adequately and safely. Unfortunately, resources are limited. Time, monetary and geographical constraints often limit the ubiquitous dissemination of new surgical knowledge, skills and techniques. The inability to provide adequate training opportunities and support for surgeons in the community continues to be the limiting factors determining the success and widespread availability of laparoscopic surgeries. Thankfully, with the ever-increasing push to incorporate technological advances into the medical field, we are now able to overcome these barriers. In this chapter we outline how the recent progress in technology and telecommunication has led to the advent of telemedicine – an ingenious solution to our current problem, which will allow for the widespread availability of MIS and improve patient care.

Introduction This study aims to explore gender-related differences in persistent opioid use following an acute pain episode and evaluate potential explanatory variables. Methods This retrospective population-based study using administrative databases included all opioid-naïve patients in Ontario with renal colic between 2013 and 2017. The primary outcome was to assess any association between persistent opioid use at 3–6 months by gender. Key confounding covariates and explanatory variables examined included both care- and patient-related factors, specifically past evidence of mental health diagnoses. Results The dataset of 64,240 males and 37,656 females demonstrated that 8.7% of males and 9.6% of females had evidence of persistent opioid use 3–6 months after presentation (OR 1.11, 95% CI 1.05, 1.17). Females had a higher incidence of mental health services utilization [44.5% vs 29.6% (p Interpretation After controlling for key covariates, females are at slightly higher risk of demonstrating long term opioid use following an episode of renal colic. Evidence of prior mental health service utilization and acute colic care did not appear to significantly explain these observations.

Fear conditioning models key processes related to the development, maintenance and treatment of anxiety disorders and is associated with group differences in anxiety. However, laboratory administration of tasks is time and cost intensive, precluding assessment in large samplesnecessary for the analysis of individual differences. This study introduces a newly developed smartphone app that delivers a fear conditioning paradigm remotely using a loud human scream as an aversive stimulus. Three groups of participants (total n = 152) took part in three studies involving a differential fear conditioning experiment to assess the reliability and validity of a smartphone administered fear conditioning paradigm. This comprised of fear acquisition, generalisation, extinction, and renewal phases during which online US-expectancy ratings were collected during every trial with evaluative ratings of negative affect at three time points. We show that smartphone app delivery of a fear conditioning paradigm results in a pattern of fear learning comparable to traditional laboratory delivery and is able to detect individual differences in performance that show comparable associations with anxiety to the prior group differences literature., Highlights • A smartphone app reliably delivers a differential fear conditioning paradigm using an aversive human scream. • Within-person associations of fear conditioning between laboratory and app delivery do not differ from those across time. • App-based administration is able to detect individual differences in anxiety related processes. • Fear conditioning data can be collected with minimal financial and time cost.

We present an unusual complication secondary to indwelling urethral catheter placement. Routine catheter placement by the obstetrics team in a postpartum female leads to retention of the catheter and inability of its removal by both the obstetrics and urology teams. Although a retained urinary catheter is relatively common, inability to remove a catheter secondary to placement inadvertently into a ureter is extremely rare. In this paper we will discuss the options in removing a retained catheter and present our case of a retained catheter secondary to placement within the right proximal ureter.

In the contemporary era of minimally invasive surgery, very few T1/T2 renal lesions are not amenable to nephron-sparing surgery. However, centrally located lesions continue to pose a clinical dilemma. We sought to describe our local experience with three cases of laparoscopic nephrectomy,ex vivopartial nephrectomy, and autotransplantation. Laparoscopic donor nephrectomy was performed followed by immediate renal cooling and perfusion with isotonic solution. Back-table partial nephrectomy, renorrhaphy, and autotransplantation were then performed. Mean warm ischemia (WIT) and cold ischemic times (CIT) were 2 and 39 minutes, respectively. Average blood loss was 267 mL. All patients preserved their renal function postoperatively. Final pathology confirmed pT1, clear cell renal cell carcinoma with negative margins in all. All are disease free at up to 39 months follow-up with stable renal function. In conclusion, the described approach remains a viable option for the treatment of complex renal masses preserving oncological control and renal function.

Left ventricular assist device (LVAD) therapy is an established treatment option for select patients with advanced heart failure. Advances in technology and patient management have resulted in improved post-implant outcomes. Consequently, more patients with LVADs are presenting for evaluation and care of non-cardiac surgical disease. However, there is a paucity of literature regarding the optimal perioperative and surgical management of such patients. We present the case of a 71-year-old male with a HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD, who underwent a laparoscopic left nephroureterectomy for an upper urinary tract transitional cell carcinoma. His perioperative course was uneventful due to the multidisciplinary efforts of cardiac surgery, cardiac anesthesia, nephrology and urology. To our knowledge, this is the first reported case of a laparoscopic nephroureterectomy in a patient with a HeartMate II LVAD.

The acceptance of closed-loop blood glucose (BG) control using continuous glucose monitoring systems (CGMS) is likely to improve with enhanced performance of their integral hypoglycemia alarms. This article presents an in silico analysis (based on clinical data) of a modeled CGMS alarm system with trained thresholds on type 1 diabetes mellitus (T1DM) patients that is augmented by sensor fusion from a prototype hypoglycemia alarm system (HypoMon). This prototype alarm system is based on largely independent autonomic nervous system (ANS) response features.Alarm performance was modeled using overnight BG profiles recorded previously on 98 T1DM volunteers. These data included the corresponding ANS response features detected by HypoMon (AiMedics Pty. Ltd.) systems. CGMS data and alarms were simulated by applying a probabilistic model to these overnight BG profiles. The probabilistic model developed used a mean response delay of 7.1 minutes, measurement error offsets on each sample of +/- standard deviation (SD) = 4.5 mg/dl (0.25 mmol/liter), and vertical shifts (calibration offsets) of +/- SD = 19.8 mg/dl (1.1 mmol/liter). Modeling produced 90 to 100 simulated measurements per patient. Alarm systems for all analyses were optimized on a training set of 46 patients and evaluated on the test set of 56 patients. The split between the sets was based on enrollment dates. Optimization was based on detection accuracy but not time to detection for these analyses. The contribution of this form of data fusion to hypoglycemia alarm performance was evaluated by comparing the performance of the trained CGMS and fused data algorithms on the test set under the same evaluation conditions.The simulated addition of HypoMon data produced an improvement in CGMS hypoglycemia alarm performance of 10% at equal specificity. Sensitivity improved from 87% (CGMS as stand-alone measurement) to 97% for the enhanced alarm system. Specificity was maintained constant at 85%. Positive predictive values on the test set improved from 61 to 66% with negative predictive values improving from 96 to 99%. These enhancements were stable within sensitivity analyses. Sensitivity analyses also suggested larger performance increases at lower CGMS alarm performance levels.Autonomic nervous system response features provide complementary information suitable for fusion with CGMS data to enhance nocturnal hypoglycemia alarms.

We report the first case of totally tubeless outpatient percutaneous nephrolithotomy (PCNL). Our patient was discharged home safely less than 4 hours following uncomplicated PCNL with no nephrostomy tube, ureteral stent, or urethral catheter. Follow-up the next day in clinic confirmed that the procedure was successful, as the patient was clinically well and stone free. To our knowledge, this is the first case report of totally tubeless (no nephrostomy, no ureteral stent) PCNL performed on a truly outpatient basis.