Characterizing Canadian rural general surgeons: trends over time and 10-year replacement needs.

BACKGROUND: Recruiting residents to practise rurally begins with an accurate characterization of rural surgeons. We sought to identify and analyze demographic trends among rural surgeons in Canada and to predict the rural workforce requirements for the next decade. METHODS: In this retrospective observational study, we assessed the demographic and practice characteristics of rural general surgeons in Canada, defined as surgeons working in cities with a population of 100 000 or less. Surgeons were identified using the websites of provincial colleges of physicians and surgeons. Demographic characteristics included year and country of medical degree achievement, fellowship status and primary practice location. We developed a model predicting future rural workforce requirements based on the following assumptions: that the current ratio of rural surgeons to rural patients is adequate, that the rural population will increase by 1.1% annually, that a rural surgeon's career length is 36 years, and that 85 graduates will enter the workforce annually. RESULTS: Our study sample included 760 rural general surgeons. The majority graduated after 1989 (75%), were Canadian medical graduates (73%) and did not complete a fellowship (82%). There was a significant shift toward rural surgeons being trained in Canada, from 37% of surgeons graduating before 1969 to 91% of those graduating after 2009 (p < 0.001). Modelling predicts 282 rural general surgeons will retire by 2031, with 88 new surgeons needed to account for the population growth. Therefore, we predict a demand for 370 rural surgeons over the next decade, meaning 43% of general surgery graduates will need to enter rural practice. CONCLUSION: Rural general surgeons in Canada vary widely in their background demographic characteristics. Future opportunities in rural general surgery are projected to increase. Recruitment and training of general surgery graduates to serve Canada's rural communities remains essential.

Medical Tourism for CCSVI Procedures in People with Multiple Sclerosis: An Observational Study.

BACKGROUND: Many Canadians with multiple sclerosis (MS) have recently travelled internationally to have procedures for a putative condition called chronic cerebrospinal venous insufficiency (CCSVI). Here, we describe where and when they went and describe the baseline characteristics of persons with MS who participated in this non-evidence-based medical tourism for CCSVI procedures. METHODS: We conducted a longitudinal observational study that used online questionnaires to collect patient-reported information about the safety, experiences, and outcomes following procedures for CCSVI. A convenience sample of all Albertans with MS was recruited between July 2011 and March 2013. RESULTS: In total, 868 individuals enrolled; 704 were included in this cross-sectional, baseline analysis. Of these, 128 (18.2%) participants retrospectively reported having procedures for CCSVI between April 2010 and September 2012. The proportion of participants reporting CCSVI procedures declined from 80 (62.5%) in 2010, to 40 (31.1%) in 2011, and 8 (6.3%) in 2012. In multivariable logistic regression analysis, CCSVI procedures were independently associated with longer disease duration, secondary progressive clinical course, and greater disability status. CONCLUSIONS: Although all types of people with MS pursued procedures for CCSVI, a major driver of participation was greater disability. This highlights that those with the greatest disability are the most vulnerable to unproven experimental procedures. Participation in CCSVI procedures waned over time possibly reflecting unmet expectations of treated patients, decreased media attention, or that individuals who wanted procedures had them soon after the CCSVI hypothesis was widely publicized.

Canadian Pediatric Surgeon Workforce: Characterization of Training, Trends Over Time, and 10-year Model for Pediatric Surgery Need.

BACKGROUND: Graduate and fellowship training trends for Canadian pediatric surgeons remain uncharacterized. Similarly, updated workforce planning for pediatric surgeons is required. We aimed to characterize graduate degree and fellowship trends for Canadian pediatric surgeons, with modelling to inform workforce planning. METHODS: We performed a cross sectional observational study evaluating Canadian pediatric surgeons in January 2022. Surgeon demographics collected included year of medical degree (MD) conferment, MD location, fellowship location, and graduate degree achievement. Our primary outcome was to evaluate training characteristics over time. Secondary outcomes evaluated surgeon supply and demand from 2021 to 2031. Supply was extrapolated from current Canadian pediatric surgery fellows assuming static fellowship matriculation, while retirement was estimated using a 31-, 36-, or 41-year career following MD conferral. RESULTS: Of included surgeons (n = 77), 64 (83%) completed fellowship training in Canada and 46 (60%) have graduate degrees. No surgeons graduating ≤1980 hold graduate degrees, compared to 8 (100%) surgeons with MD ≥ 2011 (p < 0.001). Similarly, more surgeons with MD ≥ 2011 appear to have a Canadian MD (n = 7, 87.5%) and Canadian fellowship (n = 8, 100%). Modelling predicts that 19-49 (25%-64%) surgeons will retire between 2021 and 2031, while 37 fellows will graduate with intention to work in Canada, creating between a 12 surgeon deficit up to an 18 surgeon surplus depending on career length. CONCLUSIONS: Trends in graduate degree achievement and fellowship location suggest increasing competition for Canadian pediatric surgery positions. Additionally, a substantial number of Canadian-trained fellows will need positions outside of Canada in the next decade. Overall, results support previous work demonstrating saturation of the Canadian pediatric workforce. LEVEL OF EVIDENCE: Level IV. ACGME COMPETENCY ADDRESSED: Medical Knowledge.

Patient-centered approaches to targeting incomplete bowel preparations for inpatient colonoscopies.

BACKGROUND: A high-quality colonoscopy bowel prep is vital to completing the procedure. Adequate inpatient bowel preparation has been consistently difficult to achieve because of multiple factors. Incomplete bowel prep can lead to repeated colonoscopies, poor patient experience, increased costs, and prolonged hospitalization. This study aimed to develop patient-centered interventions to optimize bowel prep for inpatients undergoing colonoscopy. METHODS: The Model for Improvement and Donabedian frameworks guided this project. An interdisciplinary team compiled quality improvement tools that identified areas for improvement. Interventions development included a nursing tip sheet for troubleshooting symptoms, a standardized order label and a patient educational placemat. Plan-Do-Study-Act (PDSA) cycles were carried out to test and analyze the effects of the interventions. The project aim was a 30% reduction in incomplete inpatient colonoscopies from poor bowel prep. Process measures included the number of colonoscopy split prep order labels, and placemats used. The balancing measure was the number of repeat colonoscopies. RESULTS: Prior to the intervention, 44% (44/99) of inpatient colonoscopies had poor bowel prep resulting in 10 repeat procedures (10%). Post intervention, 60% (28/47) of the colonoscopies used the standardized label, 66% of physician orders used 2-L split prep, and 80% of patients were provided with the educational placemat. Of the 47 colonoscopies audited post intervention, there was a significant decrease in poor prep (27.7% [13/47], P=0.038) for colonoscopies. The percentage of repeated colonoscopies decreased to 4% (2/47). CONCLUSION: Developing simple and easy-to-use patient-centered interventions can effectively improve colonoscopy preparation for hospitalized patients.

Spectral Characterization of Stem Cell-Derived Myelination within the Injured Adult PNS Using the Solvatochromic Dye Nile Red.

BACKGROUND: Myelin is an essential component of the peripheral and central nervous system, enabling fast axonal conduction and supporting axonal integrity; limited tools exist for analysis of myelin composition in-vivo. OBJECTIVE: To demonstrate that the photophysical properties of myelin-incorporated solvatochromic dyes can be exploited to probe the biochemical composition of living peripheral nerve myelin at high spatial resolution. METHODS: Using the myelin-incorporated fluorescent dye Nile Red we sequentially analyzed the spectral characteristics of remyelinating myelin membranes both in-vitro and in-vivo, including in living rats. RESULTS: We demonstrated a consistent bi-phasic evolution of emission spectra during early remyelination, and visually report the reliable biochemical flux of myelin membrane composition in-vitro and in-vivo. CONCLUSIONS: Solvatochromic spectroscopy enables the analysis of myelin membrane maturity during remyelination, and can be performed in-vivo. As the formation of myelin during early-to-late remyelination likely incorporates fluctuating fractions of lipophilic components and changes in lateral membrane mobility, we propose that our spectrochemical data reflects the observation of these biochemical processes.

National Survey of Bladder and Gastrointestinal Dysfunction in People with Spinal Cord Injury.

Small-scale studies indicate that spinal cord injury (SCI) may lead to significant gastrointestinal and bladder dysfunction. However, how the prevalence of chronic disease related to these dysfunctions compares with non-SCI individuals and whether there are robust relationships to level and severity of injury are still unclear. Here, our goal was to provide high-level evidence on the association between bladder and gastrointestinal dysfunction and SCI using population-level data from the Canadian Community Health Survey (CCHS) and the SCI Community Survey. Data from more than 60,000 individuals in the 2010 CCHS and 1500 individuals with SCI from the SCI Community Survey were analyzed. We used bi-variable and multi-variable logistic regression to examine relationships between explanatory and outcome variables. We found that SCI was associated with increased odds of urinary incontinence (adjusted odds ratio [aOR] = 5.0, 95% confidence interval [CI]: 3.4-7.1), bowel disorders (aOR = 2.3, CI: 1.5-3.4), as well as gastric ulcers (aOR: 3.3, CI: 2.1-4.8), even after adjusting for key confounding variables. Additionally, we found that complete SCI was associated with increased odds of urinary tract infections (aOR = 2.0, CI: 1.6-2.5) and bowel incontinence (aOR = 2.1, CI: 1.7-2.6). Individuals with SCI are at increased odds for having bladder and gastrointestinal dysfunction, certain aspects of which are dependent on the level and severity of injury. Targeted intervention and prevention strategies to manage bladder and bowel problems after SCI should be a priority for both caregivers and policy makers.

A novel approach to 32-channel peripheral nervous system myelin imaging in vivo, with single axon resolution.

OBJECTIVE Intravital spectral imaging of the large, deeply situated nerves in the rat peripheral nervous system (PNS) has not been well described. Here, the authors have developed a highly stable platform for performing imaging of the tibial nerve in live rodents, thus allowing the capture of high-resolution, high-magnification spectral images requiring long acquisition times. By further exploiting the qualities of the topically applied myelin dye Nile red, this technique is capable of visualizing the detailed microenvironment of peripheral nerve demyelination injury and recovery, while allowing us to obtain images of exogenous Schwann cell myelination in a living animal. METHODS The authors caused doxorubicin-induced focal demyelination in the tibial nerves of 25 Thy-1 GFP rats, of which 2 subsets (n = 10 each) received either BFP-labeled SKP-SCs or SCs to the zone of injury. Prior to acquiring images of myelin recovery in these nerves, a tibial nerve window was constructed using a silicone hemitube, a fast drying silicone polymer, and a small coverslip. This construct was then affixed to a 3D-printed nerve stage, which in turn was affixed to an external fixation/microscope stage device. Myelin visualization was facilitated by the topical application of Nile red. RESULTS The authors reliably demonstrated intravital peripheral nerve myelin imaging with micron-level resolution and magnification, and minimal movement artifact. The detailed microenvironment of nerve remyelination can be vividly observed, while exogenously applied Schwann cells and skin-derived precursor Schwann cells can be seen myelinating axons. CONCLUSIONS Topically applied Nile red enables intravital study of myelin in the living rat PNS. Furthermore, the use of a tibial nerve window facilitates stable intravital peripheral nerve imaging, making possible high-definition spectral imaging with long acquisition times.