Does exposure to anatomy education in medical school affect surgical residency applications? An analysis of Canadian residency match data

Background: The time dedicated to teaching gross anatomy, including cadaveric dissection, has been decreasing in North American medical schools. The impact of this trend on surgical residency applications is unknown. We sought to identify trends in surgical residency applications in Canada and to determine if medical schools with more gross anatomy instruction and mandatory cadaveric dissection produced more applicants ranking surgical residency programs as their first choice. Methods: Canadian Resident Matching Service (CaRMS) data from 1997 to 2016 were analyzed. A questionnaire was distributed to Canadian medical schools requesting current and historic information on their anatomy curricula and the number of hours of anatomy instruction. Results: The survey response rate was 35% (6 of the 17 Canadian medical schools responded); partial data were available for 16 (94%) of the 17 Canadian medical schools. A total of 4.3% of graduating students ranked general surgery as their first choice in the CaRMS match and 17.2% ranked any surgical program first. Over time, the percentage of graduating students who ranked surgical programs as their first choice decreased (p < 0.001). Three schools were significantly more likely than the others to produce graduates ranking general surgery as their first choice. Between 2012 and 2016 the percentage of graduating students ranking surgical programs first was significantly higher (2.2%, p = 0.024) in schools with mandatory cadaver dissection. There was no correlation between the number of hours of gross anatomy instruction and the percentage of graduates ranking any surgical program or a general surgical program first. Conclusion: The number of applications to surgical programs has decreased in Canada over the past 20 years. Certain schools are more likely than others to produce graduates ranking general surgery as their first choice. Programs with mandatory cadaver dissection produced more graduates favouring surgical programs.

Contexte: Le temps alloué à l'enseignement de l'anatomie macroscopique, y compris la dissection cadavérique, est en baisse dans les facultés de médecine nord-américaines. Les répercussions de cette tendance sur le nombre de demandes dans les programmes de résidence en chirurgie sont encore inconnues. Nous avons cherché à dégager des tendances concernant les demandes aux programmes de résidence en chirurgie au Canada et à déterminer si les facultés de médecine intégrant une plus grande proportion d'enseignement de l'anatomie macroscopique et de dissection cadavérique obligatoires produisaient plus de candidats indiquant la résidence en chirurgie comme premier choix. Méthodes: Nous avons analysé les données du Service canadien de jumelage des résidents (CaRMS) de 1997 à 2016. Un questionnaire recueillant les données actuelles et historiques sur la matière enseignée en anatomie et le nombre d'heures d'enseignement consacrées à la discipline a été distribué aux facultés de médecine canadiennes Résultats: Le taux de réponse au sondage était de 35 % (6 des 17 facultés de médecine canadiennes ont répondu), et des données partielles ont été recueillies pour 16 (94 %) des 17 facultés. Au total, 4,3 % des finissants ont mis la chirurgie générale comme premier choix au jumelage du CaRMS, et 17,2 % ont mis un programme de chirurgie comme premier choix. Le pourcentage de finissants ayant mis les programmes chirurgicaux comme premier choix a diminué avec le temps (p < 0,001). Trois écoles étaient toutefois significativement plus susceptibles que les autres de produire des étudiants indiquant la chirurgie générale comme premier choix. Entre 2012 et 2016, le pourcentage d'étudiants inscrivant un programme chirurgical comme premier choix était significativement plus élevé (2,2 %, p = 0,024) dans les facultés ayant des dissections cadavériques obligatoires. Aucune corrélation n'a été observée entre le nombre d'heures d'enseignement de l'anatomie macroscopique et le pourcentage d'étudiants mettant un programme chirurgical comme premier choix. Conclusion: Le nombre de demandes pour les programmes chirurgicaux est en baisse au Canada depuis les 20 dernières années. Certaines écoles sont toutefois plus susceptibles que les autres de produire des finissants indiquant la chirurgie générale comme premier choix de programme de résidence. Les programmes intégrant la dissection cadavérique obligatoire produisent plus d'étudiants choisissant les programmes chirurgicaux pour la résidence.

Inhaled birch pollen extract induces airway hyperresponsiveness via oxidative stress but independently of pollen-intrinsic NADPH oxidase activity, or the TLR4-TRIF pathway.

Oxidative stress in allergic asthma may result from oxidase activity or proinflammatory molecules in pollens. Signaling via TLR4 and its adaptor Toll-IL-1R domain-containing adapter inducing IFN-ß (TRIF) has been implicated in reactive oxygen species-mediated acute lung injury and in Th2 immune responses. We investigated the contributions of oxidative stress and TLR4/TRIF signaling to experimental asthma induced by birch pollen exposure exclusively via the airways. Mice were exposed to native or heat-inactivated white birch pollen extract (BPEx) intratracheally and injected with the antioxidants, N-acetyl-L-cysteine or dimethylthiourea, prior to sensitization, challenge, or all allergen exposures, to assess the role of oxidative stress and pollen-intrinsic NADPH oxidase activity in allergic sensitization, inflammation, and airway hyperresponsiveness (AHR). Additionally, TLR4 signaling was antagonized concomitantly with allergen exposure, or the development of allergic airway disease was evaluated in TLR4 or TRIF knockout mice. N-acetyl-L-cysteine inhibited BPEx-induced eosinophilic airway inflammation and AHR except when given exclusively during sensitization, whereas dimethylthiourea was inhibitory even when administered with the sensitization alone. Heat inactivation of BPEx had no effect on the development of allergic airway disease. Oxidative stress-mediated AHR was also TLR4 and TRIF independent; however, TLR4 deficiency decreased, whereas TRIF deficiency increased BPEx-induced airway inflammation. In conclusion, oxidative stress plays a significant role in allergic sensitization to pollen via the airway mucosa, but the pollen-intrinsic NADPH oxidase activity and TLR4 or TRIF signaling are unnecessary for the induction of allergic airway disease and AHR. Pollen extract does, however, activate TLR4, thereby enhancing airway inflammation, which is restrained by the TRIF-dependent pathway.

ICOS-expressing CD4 T cells induced via TLR4 in the nasal mucosa are capable of inhibiting experimental allergic asthma.

Modulation of adaptive immune responses via the innate immune pattern recognition receptors, such as the TLRs, is an emerging strategy for vaccine development. We investigated whether nasal rather than intrapulmonary application of Protollin, a mucosal adjuvant composed of TLR2 and TLR4 ligands, is sufficient to elicit protection against murine allergic lower airway disease. Wild-type, Tlr2(-/-), or Tlr4(-/-) BALB/c mice were sensitized to a birch pollen allergen extract (BPEx), then received either intranasal or intrapulmonary administrations of Protollin or Protollin admixed with BPEx, followed by consecutive daily BPEx challenges. Nasal application of Protollin or Protollin admixed with BPEx was sufficient to inhibit allergic lower airway disease with minimal collateral lung inflammation. Inhibition was dependent on TLR4 and was associated with the induction of ICOS in cells of the nasal mucosa and on both CD4+Foxp3+ and CD4+Foxp3- T cells of the draining lymph nodes (LNs), as well as their recruitment to the lungs. Adoptive transfer of cervical LN CD4+ICOS+, but not CD4+ICOS-, cells inhibited BPEx-induced airway hyperresponsiveness and bronchoalveolar lavage eosinophilia. Thus, our data indicate that expansion of resident ICOS-expressing CD4+ T cells of the cervical LNs by nasal mucosal TLR4 stimulation may inhibit the development of allergic lower airway disease in mice.

The Evolution of the Sentinel Node Biopsy in Melanoma.

The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.

Capturing the True Cost of Breast Cancer Treatment: Molecular Subtype and Stage-Specific per-Case Activity-Based Costing.

BACKGROUND: Breast cancer (BC) treatment is rapidly evolving with new and costly therapeutics. Existing costing models have a limited ability to capture current treatment costs. We used an Activity-Based Costing (ABC) method to determine a per-case cost for BC treatment by stage and molecular subtype. METHODS: ABC was used to proportionally integrate multidisciplinary evidence-based patient and provider treatment options for BC, yielding a per-case cost for the total duration of treatment by stage and molecular subtype. Diagnostic imaging, pathology, surgery, radiation therapy, systemic therapy, inpatient, emergency, home care and palliative care costs were included. RESULTS: BC treatment costs were higher than noted in previous studies and varied widely by molecular subtype. Cost increased exponentially with the stage of disease. The per-case cost for treatment (2023C$) for DCIS was C$ 14,505, and the mean costs for all subtypes were C$ 39,263, C$ 76,446, C$ 97,668 and C$ 370,398 for stage I, II, III and IV BC, respectively. Stage IV costs were as high as C$ 516,415 per case. When weighted by the proportion of molecular subtype in the population, case costs were C$ 31,749, C$ 66,758, C$ 111,368 and C$ 289,598 for stage I, II, III and IV BC, respectively. The magnitude of cost differential was up to 10.9 times for stage IV compared to stage I, 4.4 times for stage III compared to stage I and 35.6 times for stage IV compared to DCIS. CONCLUSION: The cost of BC treatment is rapidly escalating with novel therapies and increasing survival, resulting in an exponential increase in treatment costs for later-stage disease. We provide real-time, case-based costing for BC treatment which will allow for the assessment of health system economic impacts and an accurate understanding of the cost-effectiveness of screening.

Surgical Management of Lymph Nodes in Melanoma.

This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.

Independent Heath Facility Meets Cancer Care Ontario and Canadian Association of Gastroenterology Guidelines for Endoscopic Procedure Wait Times While Meeting Quality Indicators: A Retrospective Review.

Background: Canadian independent health facilities (IHFs) have been implemented to reduce hospital endoscopy volume and expedite endoscopic evaluations for patients suspected to have underlying colorectal cancer. Methods: We conducted a retrospective review of a prospective database at a large-volume urban IHF. The primary outcomes were wait times, and the secondary outcomes were colonoscopy quality indicators and complication rates. Results: Median wait times from referral to colonoscopy met the recommendations set out by the Canadian Association of Gastroenterology and Cancer Care Ontario for all indications: chronic abdominal pain: 43 days; new onset change in bowel habits: 36 days; bright red rectal bleeding: 42 days; documented iron-deficiency anemia: 43 days; fecal occult blood test positive: 38 days; cancer likely based on imaging or physical exam: 23 days; chronic diarrhea and chronic constipation: 42 days; and screening colonoscopies: 55 days. Secondary outcomes of quality indicators and complication rates all met or exceeded the CCO and CAG recommendations. Conclusions: This IHF met the recommended wait times for all indications for colonoscopy while maintaining high procedural quality and safety. IHFs are one solution to help meet the increasing demand for colonoscopy in Ontario.

Fibroepithelial breast lesions diagnosed by core needle biopsy demonstrate a moderate rate of upstaging to phyllodes tumors.

BACKGROUND: Fibroepithelial lesions of the breast (FEL) are atypical lesions diagnosed on core-needle biopsy. The purpose of this study was to determine the rate at which FELs are upstaged to phyllodes tumor on excision, and to examine the clinical and radiological factors that may be predictive of upstaging. METHODS: A retrospective review from the medical records of patients diagnosed with FEL on CNB at a single institution between 2010 and 2015 was performed. Patients diagnosed with benign or borderline phyllodes tumors were compared to those diagnosed with fibroadenoma. RESULTS: Of 74 patients diagnosed with FEL, 48 underwent excision (64.9%). Of the 48 lesions excised, pathology revealed 30 fibroadenomas (62.5%), 14 benign phyllodes tumors (29.2%), and 4 borderline phyllodes tumor (8.3%). No malignant phyllodes tumors were identified. On preoperative ultrasound, heterogeneous echotexture (p = 0.03) and lack of internal vascularity (p = 0.03) were significantly associated with upstaging to phyllodes tumor. CONCLUSIONS: Surgical excision of FELs yield a pathological diagnosis of benign and borderline phyllodes tumor in 37.5% of cases. A high BIRADs score (≥4b), heterogeneous echotexture and lack of internal vascularity on ultrasound may help predict upstaging to phyllodes tumor.

Airway hyperreactivity is frequent in non-asthmatic children with sickle cell disease.

BACKGROUND: Asthma is associated with poorer outcomes in sickle cell disease (SCD). Whether AHR can exist in SCD as a distinct entity, separate and independent of asthma, is unknown. AIMS: Our goal was to elucidate the prevalence of AHR, as measured by a methacholine challenge test (MCT), in children with SCD who did not have concomitant asthma or any recent history of acute chest syndrome (ACS). To determine if AHR was associated with asthma-like symptoms, we compared the results of the MCT to a validated asthma questionnaire. We also examined if a correlation between AHR and inflammatory markers exists. METHODS: AHR was identified with a positive MCT defined as a provocation concentration (PC20 ) < 4 mg/ml. The children and/or their parents completed the ISAAC (International Study of Asthma and Allergies in Children) questionnaire. We obtained blood, urine, and exhaled breath condensate samples. We measured cysteinyl leukotriene levels in urine and exhaled breath condensate via enzyme immunoassay. RESULTS: Twenty-nine of forty children (72.5%) had a positive MCT. Nine (31.0%) also reported asthma-like symptoms on questionnaire. Inflammatory markers did not correlate with AHR. Among MCT positive subjects, those on hydroxyurea had significantly less severe AHR as quantified by PC20 (P = 0.014). CONCLUSIONS: In children with SCD, there is a high prevalence of AHR that is not associated with asthma-like symptoms. AHR may be a distinct entity in children with SCD, existing in the absence of concomitant asthma. Hydroxyurea therapy might lessen the severity of AHR in affected individuals. Pediatr Pulmonol. 2016; 51:950-957. © 2015 Wiley Periodicals, Inc.

Influence of preoperative magnetic resonance imaging on the surgical management of breast cancer patients.

BACKGROUND: Magnetic resonance imaging (MRI) is gaining popularity in the preoperative management of breast cancer patients. However, the role of this modality remains controversial. We aimed to study the impact of preoperative MRI (pMRI) on the surgical management of breast cancer patients. METHODS: This retrospective study included 766 subjects with breast cancer treated operatively at the specialized academic center. RESULTS: Between those who underwent pMRI (MRI group, n = 307) and those who did not (no-MRI group, n = 458), there were no significant differences (P = .254) in the proportions of either total mastectomies (20.5% vs 17.2%, respectively) or segmental mastectomies (79.5% vs 82.8%). Patients in the MRI group were significantly more likely (P = .002) to undergo contralateral surgery (11.7% vs 5.5%). Similar results were obtained in multivariate analysis adjusting for age, with the proportions of contralateral breast operations significantly higher in the MRI group (Odds Ratio = 2.25, P = .007). pMRI had no significant effect (P = .54) on the proportion of total re-excisions (7.5% vs 8.7%) or the type of re-excision (total vs segmental mastectomy) between the groups. CONCLUSIONS: pMRI does not have a significant impact on the type of operative intervention on the ipsilateral breast but is associated with an increase in contralateral operations. Similarly, pMRI does not change the proportion of re-excisions or the type of the re-excision performed. This study demonstrates that pMRI has little impact on the surgical management of breast cancer, and its value as a routine adjunct in the preoperative work-up of recently diagnosed breast cancer patients needs to be re-examined.