The exploration of remote simulation strategies for the acquisition of psychomotor skills in medicine: a pilot randomized controlled trial.

Background: Progress in remote educational strategies was fueled by the advent of the COVID-19 pandemic. This pilot RCT explored the efficacy of a decentralized model of simulation based on principles of observational and peer-to-peer learning for the acquisition of surgical skills. Methods: Sixty medical students from the University of Montreal learned the running subcuticular suture in four different conditions: (1) Control group (2) Self-learning (3) Peer-learning (4) Peer-learning with expert feedback. The control group learned with error-free videos, while the others, through videos illustrating strategic sub-optimal performances to be identified and discussed by students. Performance on a simulator at the end of the learning period, was assessed by an expert using a global rating scale (GRS) and checklist (CL). Results: Students engaging in peer-to-peer learning strategies outperformed students who learned alone. The presence of an expert, and passive vs active observational learning strategies did not impact performance. Conclusion: This study supports the efficacy of a remote learning strategy and demonstrates how collaborative discourse optimizes the students' acquisition of surgical skills. These remote simulation strategies create the potential for implantation in future medical curriculum design.Trial Registration: NCT04425499 2020-05-06.

Sequential targeting of PARP with carboplatin inhibits primary tumour growth and distant metastasis in triple-negative breast cancer.

BACKGROUND: Patients with triple-negative breast cancer (TNBC) develop early recurrence. While PARP inhibitors (PARPi) have demonstrated potential in BRCA1/2-mutant (BRCAMUT) TNBC, durable responses will likely be achieved if PARPi are used in combination. It is plausible that sequential administration of a potent PARPi like talazoparib in combination with carboplatin can enhance primary tumour and metastasis inhibition in BRCAMUT and BRCA1/2 wild-type (BRCAWT) TNBCs, and decrease toxicity. METHODS: We evaluated the impact of the concurrent combination of talazoparib and carboplatin on cell survival in 13 TNBC cell lines. We compared the concurrent and sequential combination upon fork replication, migration and invasion. We also used three orthotopic xenograft models to evaluate primary tumour growth, distant metastasis, and toxicity. RESULTS: Concurrent talazoparib and carboplatin was synergistic in 92.3% of TNBC cell lines, independent of BRCA1/2-mutation status. The sequential combination decreased fork speed in normal cells, but not in TNBC cells. The talazoparib-first sequential combination resulted in a strong reduction in migration (70.4%, P < 0.0001), invasion (56.9%, P < 0.0001), lung micrometastasis (56.4%, P < 0.0001), and less toxicity in a BRCAWT model. CONCLUSION: The sequential combination of talazoparib and carboplatin is an effective approach to inhibit micrometastatic disease, providing rationale for the use of this combination in early TNBC patients.

Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis.

Introduction Targeted axillary dissection (TAD) is a novel technique in the field of surgical oncology. During TAD, patients with node-positive breast cancer who clinically responded to neoadjuvant chemotherapy undergo resection of a previously proven metastatic node together with sentinel lymph node dissection (SLND). We aimed to assess the success rates of seed insertion and seed retrieval in the Canadian setting, as well as hospital costs of the procedure. Methods Patients converted to clinically node-negative status post-neoadjuvant chemotherapy underwent TAD. Before surgery, an iodine-125 radioactive seed was inserted in the previously proven metastatic node. The seed node was resected together with an SLND. Axillary lymph node dissection (ALND) was performed in all patients with residual metastases. Results Radioactive seeds were successfully inserted in 34/35 patients. In 34 patients, the targeted node was successfully resected with the radioactive probe during TAD. In one patient, the seed was retrieved inferiorly in the axilla during surgery. There was no adverse event. In total, 50% (17/34) of patients had no residual metastases and were able to avoid ALND. Eight out of 17 patients who underwent ALND did not have any residual disease in their specimen. The mean cost of TAD was 25% superior to the mean cost of ALND (p = 0.02). However, the mean total cost of the hospital stay for TAD was 20% superior to the mean cost of ALND (p = 0.11). The mean cost of TAD was 4,322 Can$ (Canadian dollars), similar to the mean cost of both ALND and SLND performed during the same procedure (4,479 Can$). Conclusions TAD was successful in 97% of patients. Despite increased procedural costs, with a lesser impact on total hospital stay costs, TAD was beneficial in 50% of patients. These patients avoided the unnecessary morbidity associated with ALND.

Mapping sentinel lymph nodes in cutaneous melanoma: a vast array of perioperative imaging modalities.

Sentinel lymph node biopsy (SLNB) is a decisive step in the staging process of melanoma, critically impacting patients' oncological outcome and driving the decision-making process. SLNB limits the extent of the dissection in cases where no metastases are found. Conversely, when metastases are detected, SLNB has the potential to improve regional control of the disease when complete lymphadenectomy or early administration of adjuvant treatment are indicated. Thus, accurately identifying sentinel lymph nodes represents an important prognostic factor. Several strategies have been studied, including novel procedures that are not commonly used in the clinical setting. This review highlights the different tracers, preoperative and intraoperative imaging modalities studied to perform SLNB in cutaneous melanoma. The development of innovative modalities has been fueled by a need to optimize current approaches, offering new alternatives that can overcome some of the limitations of the standard method.

An Educational Network for Surgical Education Supported by Gamification Elements: Protocol for a Randomized Controlled Trial.

BACKGROUND: Traditionally, medical students have learned surgical skills by observing a resident physician or surgeon who is performing the technique. Due to inconsistent practice opportunities in the clinical setting, a disparity of skill levels among students has been observed. In addition, the poor availability of faculty professors is a limiting factor in teaching and adequately preparing medical students for their clerkship years. With the ongoing COVID-19 pandemic, medical students do not have access to traditional suturing learning opportunities. Didactic courses are available on videoconferencing platforms; however, these courses do not include technical training. OBJECTIVE: Our overarching goal is to evaluate the efficacy and usability of web-based peer-learning for advanced suturing techniques (ie, running subcuticular sutures). We will use the Gamified Educational Network (GEN), a newly developed web-based learning tool. We will assess students' ability to identify and perform the correct technique. We will also assess the students' satisfaction with regard to GEN. METHODS: We will conduct a prospective randomized controlled trial with blinding of expert examiners. First-year medical students in the Faculty of Medicine of Université de Montréal will be randomized into four groups: (1) control, (2) self-learning, (3) peer-learning, and (4) peer-learning with expert feedback. Each arm will have 15 participants who will learn how to perform running subcuticular sutures through videos on GEN. For our primary outcome, the students' ability to identify the correct technique will be evaluated before and after the intervention on GEN. The students will view eight videos and rate the surgical techniques using the Objective Structured Assessment of Technical Skills Global Rating Scale and the Subcuticular Suture Checklist as evaluation criteria. For our secondary outcomes, students will anonymously record themselves performing a running subcuticular suture and will be evaluated using the same scales. Then, a survey will be sent to assess the students' acceptance of the intervention. RESULTS: The study will be conducted in accordance with the Declaration of Helsinki and has been approved by our institutional review board (CERSES 20-068-D). No participants have been recruited yet. CONCLUSIONS: Peer learning through GEN has the potential to overcome significant limitations related to the COVID-19 pandemic and the lack of availability of faculty professors. Further, a decrease of the anxiety related to traditional suturing classes can be expected. We aim to create an innovative and sustainable method of teaching surgical skills to improve the efficiency and quality of surgical training in medical faculties. In the context of the COVID-19 pandemic, the need for such tools is imperative. TRIAL REGISTRATION: ClinicalTrials.gov NCT04425499; https://clinicaltrials.gov/ct2/show/NCT04425499. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/21273.

Repercussions of the COVID-19 pandemic on the well-being and training of medical clerks: a pan-Canadian survey.

BACKGROUND: The COVID-19 pandemic has been an unprecedented and potentially stressful event that inserted itself into the 2019-2020 Canadian medical curriculum. However, its impact on stress and subsequent professional pathways is not well understood. This study aims to assess the impact of the COVID-19 pandemic on the mental well-being, training, and career choices of Canadian medical clerks within the first three months of the pandemic. It also aims to assess their use of university support systems and their appreciation of potential solutions to common academic stressors. METHODS: An electronic survey composed of four sections: demographics, stressors experienced during the pandemic, World Health Organization (WHO) well-being index, and stress management and resources was distributed to Canadian clerks. RESULTS: Clerks from 10 of the 17 Canadian medical faculties participated in this study (n = 627). Forty-five percent of clerks reported higher levels of stress than usual; 22% reconsidered their residency choice; and 19% reconsidered medicine as a career. The factors that were most stressful among clerks were: the means of return to rotations; decreased opportunities to be productive in view of residency match; and taking the national licensing exam after the beginning of residency. The mean WHO well-being index was 14.8/25 ± 4.5, indicating a poor level of well-being among a considerable proportion of students. Clerks who reconsidered their residency choice or medicine as a career had lower mean WHO well-being indices. Most clerks agreed with the following suggested solutions: training sessions on the clinical management of COVID-19 cases; being allowed to submit fewer reference letters when applying to residency; and having protected time to study for their licensing exam during residency. Overall, clerks were less concerned with being infected during their rotations than with the impact of the pandemic on their future career and residency match. CONCLUSION: The COVID-19 pandemic had a considerable impact on the medical curriculum and well-being of clerks. A number of student-identified solutions were proposed to reduce stress. The implementation of these solutions throughout the Canadian medical training system should be considered.

Use of Intraoperative Radioguidance in Recurrent Merkel Carcinoma.

Merkel cell carcinoma is a rapidly progressive nonmelanoma skin cancer with a high risk of recurrence. When recurrence occurs, it is associated with poor prognosis and there is a lack of guidelines for the management of such cases. This article describes a challenging case in which the innovative use of iodine-125 radioactive seeds permitted us to precisely identify and resect two nonpalpable recurrent nodules. The safety and accuracy of the surgical procedure were compromised by the presence of scar tissue following two past resections and two courses of radiotherapy. Radioactive seed localization is a well-known procedure in breast cancer, demonstrating potential for an extended application in other cancer types and in complex clinical situations.

Novel Uses of Radioactive Seeds in Surgical Oncology: A Case Series.

The localization of nonpalpable axillary metastatic lymph nodes has been achieved using several techniques in the past. Amongst these techniques, the use of radioactive iodine seeds is increasingly spread, and was initially reserved to breast-conserving surgery. Many studies have assessed the use of radioactive seed localization for the surgical management of breast cancer patients diagnosed with lymph node metastases. However, few articles have reported their utilization in other cancer subtypes and in complex clinical situations. This case series describes the innovative use of radioactive seeds in the axilla in five patients, including one case of squamous cell carcinoma skin cancer, one case of malignant melanoma, and three cases of invasive breast cancer.

Peritoneal Metastases from Breast Cancer: A Scoping Review.

Breast cancer is the leading cause of cancer deaths amongst American women aged 20 to 59. While the incidence of breast cancer has been increasing, its mortality rates have significantly declined from 1989 to 2016. As a result, the number of survivors considerably increased. This impacts the detection and management of recurrences. Peritoneal metastases from breast cancer is a rare and challenging clinical presentation. There is a lack of knowledge syntheses and specific recommendations for the management of breast cancer peritoneal metastases. This review aims to determine the pattern of spread, prognosis, diagnosis, and role of surgery in this subset of patients. Relevant studies were searched in PubMed and Web of Science between April and June 2019. Included studies were written in English and reported data on breast cancer peritoneal or gastrointestinal metastases. Articles published before 1990, case reports, editorials, and articles with no full text available were excluded. Data abstraction was performed for citation information, population, sample, methods, relevant results, mentioned limitations, and study design. The search identified 505 unique reports. A total of 21 articles were included in the synthesis. Sixteen articles were observational studies, four were experimental, and one article was a proof-of-concept study. Amongst all observational studies, the diagnostic methods and criteria for breast cancer carcinomatosis were particularly heterogeneous, including ascites cytology, biopsy, surgical exploration, and various computed tomography (CT) findings. The majority of pathology and imaging reports demonstrated that breast cancer peritoneal metastases are mainly associated with invasive lobular carcinoma (ILC) and the following intrinsic subtypes: HER2-enriched, luminal B and basal-like. Experimental studies demonstrated that peritoneal metastases can be studied using breast cancer xenograft models. Somatic loss of both p53 and E-cadherin was associated with ILC peritoneal spread. Studies on prognosis and treatment highlighted that peritoneal metastases were associated with a poorer prognosis than other metastatic sites. In terms of surgical management, there is a paucity of data on the outcomes of hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. However, included studies suggested a role for cytoreductive surgery in selected patients when there is no residual disease after the procedure. This review summarizes data on the development, diagnosis, prognosis, and treatment of breast cancer peritoneal and gastrointestinal metastases. Patients' survival is significantly reduced in comparison with other distant metastatic sites. A deeper understanding of the invasion mechanisms and the role of surgery will be important.