A 17-Year-Old Male With Hypoxemia After Long-Bone Fracture.

CASE PRESENTATION: An otherwise healthy 17-year-old male patient presented to a periphery hospital with a compound fracture of the right distal tibia and fibula after a traumatic accident on a ski trip. He was treated empirically with IV cefazolin before undergoing open reduction with internal fixation with intramedullary nail for surgical fixation. Postoperatively, he became febrile, tachypneic, and hypoxemic, requiring up to 6 L/min supplemental oxygen by nasal prongs. He reported mild chest discomfort but denied productive cough, hemoptysis, or calf tenderness. Because of nonresolving oxygen demands, on postoperative day (POD) 4, he was transferred to a tertiary care center for further management.

A systematic review and meta-analysis of computed tomography in the diagnosis of pediatric foreign body aspiration.

INTRODUCTION: Rigid bronchoscopy remains the gold standard for the diagnosis of foreign body aspiration (FBA) despite high rates of negative bronchoscopies. The use of computed tomography (CT) imaging in the assessment of FBA has recently emerged and could help obviate unnecessary bronchoscopy in these patients. The aim of this study is to assess the diagnostic accuracy of CT in the diagnosis of pediatric FBA. METHODS: A systematic literature review was conducted to identify studies reporting the use of CT imaging in suspected pediatric FBA. The search included published articles in Ovid MEDLINE, Ovid EMBASE, PubMed MEDLINE and Web of Science. The search strategy included all articles from inception of the database to January 2021. Manuscripts were reviewed and graded for quality using the QUADAS-2 tool. Subgroup analyses based on the use of virtual bronchoscopy (VB) and sedation was conducted. A meta-analysis evaluating the use of VB in the diagnosis of FBA was also conducted. RESULTS: Sixteen manuscripts met all inclusion criteria. In total, 2056 pediatric patients ranging from 0.3 to 15 years underwent CT for suspected FBA. The sensitivity and specificity of CT were 98.8% and 96.6%, respectively. VB was used in 71.4% (1391/1948) of patients while sedation during CT was required in 70.2% (1263/1800) of patients. Radiation dosing ranged from 0.04 to 2 mSv, 0.99-59.1 mGy-cm and 0.03-16.99 mGy. CONCLUSION: CT can accurately diagnose pediatric FBA and can help decrease the rate of unnecessary bronchoscopies with an acceptable dose of radiation.

Predictors of Sentinel Lymph Node Metastasis in Patients with Thin Melanoma: An International Multi-institutional Collaboration.

BACKGROUND: Consideration of sentinel lymph node biopsy (SLNB) is recommended for patients with T1b melanomas and T1a melanomas with high-risk features; however, the proportion of patients with actionable results is low. We aimed to identify factors predicting SLNB positivity in T1 melanomas by examining a multi-institutional international population. METHODS: Data were extracted on patients with T1 cutaneous melanoma who underwent SLNB between 2005 and 2018 at five tertiary centers in Europe and Canada. Univariable and multivariable logistic regression analyses were performed to identify predictors of SLNB positivity. RESULTS: Overall, 676 patients were analyzed. Most patients had one or more high-risk features: Breslow thickness 0.8-1 mm in 78.1% of patients, ulceration in 8.3%, mitotic rate > 1/mm2 in 42.5%, Clark's level ≥ 4 in 34.3%, lymphovascular invasion in 1.4%, nodular histology in 2.9%, and absence of tumor-infiltrating lymphocytes in 14.4%. Fifty-three patients (7.8%) had a positive SLNB. Breslow thickness and mitotic rate independently predicted SLNB positivity. The odds of positive SLNB increased by 50% for each 0.1 mm increase in thickness past 0.7 mm (95% confidence interval [CI] 1.05-2.13) and by 22% for each mitosis per mm2 (95% CI 1.06-1.41). Patients who had one excised node (vs. two or more) were three times less likely to have a positive SLNB (3.6% vs. 9.6%; odds ratio 2.9 [1.3-7.7]). CONCLUSIONS: Our international multi-institutional data confirm that Breslow thickness and mitotic rate independently predict SLNB positivity in patients with T1 melanoma. Even within this highly selected population, the number needed to diagnose is 13:1 (7.8%), indicating that more work is required to identify additional predictors of sentinel node positivity.

Risk factors for suicidal ideation and suicide attempt among medical students: A meta-analysis.

BACKGROUND: Medical training poses significant challenge to medical student wellbeing. With the alarming trend of trainee burnout, mental illness, and suicide, previous studies have reported potential risk factors associated with suicidal behaviours among medical students. The objective of this study is to provide a systematic overview of risk factors for suicidal ideation (SI) and suicide attempt (SA) among medical students and summarize the overall risk associated with each risk factor using a meta-analytic approach. METHODS: Systemic search of six electronic databases including MEDLINE, Embase, Education Source, Scopus, PsycInfo, and CINAHL was performed from database inception to March 19, 2021. Studies reporting original quantitative or epidemiological data on risk factors associated with SI and SA among undergraduate medical students were included. When two or more studies reported outcome on the same risk factor, a random-effects inverse variance meta-analysis was performed to estimate the overall effect size. RESULTS: Of 4,053 articles identified, 25 studies were included. Twenty-two studies reported outcomes on SI risk factors only, and three studies on both SI and SA risk factors. Meta-analysis was performed on 25 SI risk factors and 4 SA risk factors. Poor mental health outcomes including depression (OR 6.87; 95% CI [4.80-9.82] for SI; OR 9.34 [4.18-20.90] for SA), burnout (OR 6.29 [2.05-19.30] for SI), comorbid mental illness (OR 5.08 [2.81-9.18] for SI), and stress (OR 3.72 [1.39-9.94] for SI) presented the strongest risk for SI and SA among medical students. Conversely, smoking cigarette (OR 1.92 [0.94-3.92]), family history of mental illness (OR 1.79 [0.86-3.74]) and suicidal behaviour (OR 1.38 [0.80-2.39]) were not significant risk factors for SI, while stress (OR 3.25 [0.59-17.90]), female (OR 3.20 [0.95-10.81]), and alcohol use (OR 1.41 [0.64-3.09]) were not significant risk factors for SA among medical students. CONCLUSIONS: Medical students face a number of personal, environmental, and academic challenges that may put them at risk for SI and SA. Additional research on individual risk factors is needed to construct effective suicide prevention programs in medical school.

From cellular function to global impact: the vascular perspective on COVID-19.

Since COVID-19 was declared a pandemic a year ago, our understanding of its effects on the vascular system has slowly evolved. At the cellular level, SARS-CoV-2 - the virus that causes COVID-19 - accesses the vascular endothelium through the angiotensin-converting enzyme 2 (ACE-2) receptor and induces proinflammatory and prothrombotic responses. At the clinical level, these pathways lead to thromboembolic events that affect the pulmonary, extracranial, mesenteric, and lower extremity vessels. At the population level, the presence of vascular risk factors predisposes individuals to more severe forms of COVID-19, whereas the absence of vascular risk factors does not spare patients with COVID-19 from unprecedented rates of stroke, pulmonary embolism and acute limb ischemia. Finally, at the community and global level, the fear of COVID-19, measures taken to limit the spread of SARS-CoV-2 and reallocation of limited hospital resources have led to delayed presentations of severe forms of ischemia, surgery cancellations and missed opportunities for limb salvage. The purpose of this narrative review is to present some of the data on COVID-19, from cellular mechanisms to clinical manifestations, and discuss its impact on the local and global surgical communities from a vascular perspective.

Depuis que la COVID-19 s'est vu donner le statut de pandémie il y a 1 an, notre connaissance des effets de cette maladie sur le système vasculaire a évolué. À l'échelle cellulaire, le SRAS-CoV-2 ­ le virus qui cause la COVID-19 ­ accède à l'endothélium vasculaire par le récepteur de l'enzyme de conversion de l'angiotensine-2 (ACE-2) et provoque des réponses proinflammatoires et prothrombotiques. À l'échelle clinique, ces réponses peuvent mener à une activité thromboembolique touchant les vaisseaux pulmonaires, extracrâniens, mésentériques et des membres inférieurs. À l'échelle populationnelle, la présence chez certaines personnes de facteurs de risque vasculaires les prédispose à une forme plus grave de la COVID-19, mais l'absence de ces facteurs n'empêche pas les patients atteints de la COVID-19 de présenter des taux sans précédent d'AVC, d'embolie pulmonaire et d'ischémie aiguë aux membres. Enfin, à l'échelle locale et mondiale, la peur entourant la COVID-19, les mesures prises pour en endiguer la propagation et le redéploiement des ressources limitées des hôpitaux ont mené au report de visites à l'hôpital pour des formes graves d'ischémie, à l'annulation de chirurgies et à des occasions manquées de préserver des membres. La présente revue non systématique a pour objectif de présenter une partie des données sur la COVID-19, de ses mécanismes cellulaires à ses manifestations cliniques, et de discuter des répercussions de la crise sur les communautés chirurgicales locales et mondiales, dans une optique vasculaire.

Addressing the physician burnout epidemic with resilience curricula in medical education: a systematic review.

BACKGROUND: A variety of stressors throughout medical education have contributed to a burnout epidemic at both the undergraduate medical education (UGME) and postgraduate medical education (PGME) levels. In response, UGME and PGME programs have recently begun to explore resilience-based interventions. As these interventions are in their infancy, little is known about their efficacy in promoting trainee resilience. This systematic review aims to synthesize the available research evidence on the efficacy of resilience curricula in UGME and PGME. METHODS: We performed a comprehensive search of the literature using MEDLINE, EMBASE, PsycINFO, Educational Resources Information Centre (ERIC), and Education Source from their inception to June 2020. Studies reporting the effect of resilience curricula in UGME and PGME settings were included. A qualitative analysis of the available studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using the ROBINS-I Tool. RESULTS: Twenty-one studies met the inclusion criteria. Thirteen were single-arm studies, 6 quasi-experiments, and 2 RCTs. Thirty-eight percent (8/21; n = 598) were implemented in UGME, while 62 % (13/21, n = 778) were in PGME. There was significant heterogeneity in the duration, delivery, and curricular topics and only two studies implemented the same training model. Similarly, there was considerable variation in curricula outcome measures, with the majority reporting modest improvement in resilience, while three studies reported worsening of resilience upon completion of training. Overall assessment of risk of bias was moderate and only few curricula were previously validated by other research groups. CONCLUSIONS: Findings suggest that resilience curricula may be of benefit to medical trainees. Resilience training is an emerging area of medical education that merits further investigation. Additional research is needed to construct optimal methods to foster resilience in medical education.

Systematic review of pre-clinical therapies for post-operative atrial fibrillation.

BACKGROUND: Post-operative atrial fibrillation (POAF) is a frequent cardiothoracic surgery complication that increases hospital stay, mortality and costs. Despite decades of research, there has been no systematic overview and meta-analysis of preclinical therapies for POAF in animal models. METHODS: We performed a systematic search of MEDLINE and EMBASE from their inception through September 2020 to determine the effect of preclinical POAF therapies on primary efficacy outcomes using a prospectively registered protocol (CRD42019155649). Bias was assessed using the SYRCLE tool and CAMARADES checklist. RESULTS: Within the 26 studies that fulfilled our inclusion criteria, we identified 4 prevention strategies including biological (n = 5), dietary (n = 2), substrate modification (n = 2), and pharmacological (n = 17) interventions targeting atrial substrate, cellular electrophysiology or inflammation. Only one study altered more than 1 pathophysiological mechanism. 73% comprised multiple doses of systemic therapies. Large animal models were used in 81% of the studies. Preclinical therapies altogether attenuated atrial fibrosis (SMD -2.09; 95% confidence interval [CI] -2.95 to -1.22; p < 0.00001; I2 = 47%), AF inducibility (RR 0.40; 95% CI 0.21 to 0.79; p = 0.008; I2 = 39%), and AF duration (SMD -2.19; 95% CI -3.05 to -1.32; p < 0.00001; I2 = 50%). However, all the criteria needed to evaluate the risk of bias was unclear for many outcomes and only few interventions were independently validated by more than 1 research group. CONCLUSION: Treatments with therapies targeting atrial substrate, cellular electrophysiology or inflammation reduced POAF in preclinical animal models compared to controls. Improving the quality of outcome reporting, independently validating promising approaches and targeting complimentary drivers of POAF are promising means to improve the clinical translation of novel therapies for this highly prevalent and clinically meaningful disease.