Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey.

INTRODUCTION: Frostbite in the pediatric population, where skeletal maturity has not been achieved, can have important repercussions on subsequent growth. Yet, the optimal management of frostbite injuries in children remains vague. This review aims to summarize the current evidence for frostbite management in children and understand Canadian practice trends on this topic. METHODS: A review using Medline, Scopus, Web of Science, and gray literature was performed to identify relevant literature on the clinical manifestations, diagnostic methods, and treatment options in pediatric frostbite. An online survey was sent to plastic surgeons through the Canadian Society of Plastic Surgeons (CSPS) mailing list to further identify national practices and trends for pediatric frostbite management. RESULTS: A total of 109 articles were reviewed. No article provided a specific algorithm for pediatric frostbite, with existing recommendations suggesting the use of adult guidelines for treating children. Our survey yielded 9 responses and highlighted the rarity of pediatric frostbite cases, with no responder treating more than 10 cases per year. Most (55.6%) do not use a pediatric-specific treatment algorithm, whereas 30% apply adult guidelines. A conservative approach focusing on rewarming (55.6%), limb elevation (50%), and tetanus status verification (66.7%) was predominant. Imaging and surgical interventions seem to be reserved for severe cases. CONCLUSIONS: The current literature for pediatric frostbite management lacks specificity. Canadian practices vary, with a trend toward a conservative approach. The limited evidence and rarity of experience highlight the need for further research, ideally in a collaborative multicentric manner, to create a consensus for pediatric frostbite care.

The Montréal Classification of urethral lengthening for phalloplasty in transmasculine patients-surgical techniques and urethral complications.

Introduction: Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes. Materials and methods: All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student's T-test, Chi-squared test, Fisher's exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction. Results: Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively. Conclusions: We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results.

Financial Barriers to Surgical Conferences: A Cross-Sectional Analysis of Registration Fees.

BACKGROUND: Scientific meetings provide much educational value to participants of all career stages. There is a paucity of literature surrounding the costs of attending scientific meetings and how this may affect participation, especially among trainees. The objective of this study is to assess the accessibility of surgical conferences for attendees by analyzing costs related to surgical society membership and conference registration. METHODS: Societal membership and conference registration fee data were collected according to career stage (i.e., student, resident, fellow, and staff) for the fourteen surgical specialties recognized by the American College of Surgeons (ACS). Fees for participants from low- and middle-income countries (LMICs) and for virtual-only attendance options were also collected when available. RESULTS: Overall, we included data from 46 surgical societies (32 North American, 14 European or global). The median conference fees for students in the member and non-member categories were 191.55 USD (IQR 42.22-320.99) and 452.40 USD (IQR 294.06-555.00), respectively, representing a 136.2% price increase if not a member. Median conference fees for residents, fellows, and staff in the member category were 65.5%, 66.9%, and 230.9% greater than that for students, respectively. Median prices for residents, fellows, and staff in the non-member category were 49.9%, 54.9%, and 49.9% greater than that for member trainees of the same category, respectively. CONCLUSIONS: Our results highlight the substantial costs associated with attending surgical conferences, especially for trainees, representing a significant barrier to already financially burdened trainees, especially those from LMICs, smaller institutions, or less well-off backgrounds.

Dynamic monitoring of circulating tumor DNA to analyze genetic characteristics and resistance profile of lorlatinib in ALK positive previously treated NSCLC.

BACKGROUND: To dynamically monitor the changes of genomic characteristics during lorlatinib treatment and analyze the resistance profile of lorlatinib in ALK-positive advanced Chinese patients with non-small cell lung cancer (NSCLC) with first- and second-generation ALK inhibitor resistance. METHODS: Ten eligible patients who were from a phase 2 study in China and admitted to the Fifth Medical Center of PLA General Hospital were analyzed. Blood samples were collected for next-generation sequencing (NGS) to characterize genetic variation at baseline, during treatment, and after disease progression. RESULTS: Among the 10 patients treated with lorlatinib, objective response rate (ORR) was 50%. The median progression-free survival (PFS) was 13.3 months, and median overall survival (OS) was 15.6 months. At baseline, the mutation frequency of ALK in circulating tumor DNA (ctDNA) was higher in the group who received two lines of previous anaplastic lymphoma kinase-tyrosine kinase inhibitors (ALK-TKIs), and a similar trend was observed for TP53. After one follow-up cycle, the decreased variant allele frequency (VAF) had a trend to be predictive for responses. In six patients in which blood samples had been taken after lorlatinib resistance, ALK compound mutations were found in three patients (50%), which were G1202R/L1196M, L1196M/D1203N, and G1202R/F1174C. The DNMT3A N403Tfs*4, ERCC3 E259D, and GNAS p.A436_P459del variants were only detected after progression in two of the other three patients without ALK compound mutations. CONCLUSIONS: The dynamic changes of genomic characteristics during lorlatinib treatment revealed the mutation landscape of Chinese patients with NSCLC after ALK-TKI resistance, indicated that the resistance profile of lorlatinib were heterogeneous, which laid the foundation for subsequent treatment to overcome lorlatinib resistance.

Incorporating surgical and anesthesia care into universal health care: a national plan for the development of surgery in Madagascar.

Efforts have been made to strengthen national health systems for safe, affordable, and timely surgical, obstetric, trauma, and anesthesia (SOTA) care since 2015 when the Lancet Commission on Global Surgery (LCoGS) identified critical needs in improving access to essential surgical care for five billion people worldwide. Several governments have developed National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) as a commitment to ensuring safe and accessible surgical care for all of their population. The Ministry of Public Health (MoPH) of Madagascar launched its NSOAP in May 2019, named Le Plan National de Développement de la Chirurgie a Madagascar (PNDCHM). This policy established Madagascar as the first African francophone country to define concrete objectives for the Malagasy health system to meet the targets set by the LCoGS by 2030. The PNDCHM outlined the following priorities and specific action points to be implemented from 2019 to 2023: improving technical capacity, training human resources, developing a health information system, ensuring adequate governance and leadership, offering quality care, creating specific surgical services, and financing and mobilizing resources for implementation. Challenges encountered in the process included complex coordination between different stakeholders, allocating a sufficient budget for its implementation, frequent turnover within the MoPH, and the COVID-19 pandemic. The PNDCHM is a first of its kind in francophone Africa and the many lessons learned can serve as guidance for countries aspiring to build NSOAPs of their own.

RéSUMé: Des efforts ont été déployés pour renforcer les systèmes de santé nationaux pour des soins chirurgicaux, obstétricaux, traumatologiques et anesthésiques sécuritaires, abordables et lorsque nécessaires depuis 2015, lorsque la Commission Lancet sur la chirurgie mondiale (LCoGS) a identifié des besoins critiques pour améliorer l'accès aux soins chirurgicaux essentiels pour cinq milliards de personnes dans le monde. Plusieurs gouvernements ont élaboré des Plans nationaux pour des soins en chirurgie, d'obstétrique et anesthésie (PNCOA) dans le but d'assurer des soins chirurgicaux sécuritaires et accessibles à l'ensemble de leur population. En mai 2019, le ministère de la Santé publique de Madagascar a lancé son propre PNCOA, baptisé Le Plan National de Développement de la Chirurgie à Madagascar (PNDChM). Cette politique a fait de Madagascar le premier pays africain francophone à définir des objectifs concrets pour que le système de santé malgache atteigne les cibles fixées par la Commission Lancet d'ici 2030. Le PNDChM a défini les priorités et points d'action spécifiques suivants à mettre en œuvre de 2019 à 2023 : amélioration des plateaux techniques, formation des ressources humaines, développement d'un système d'information sanitaire, bonne gouvernance et leadership, offre de soins de qualité, création de services chirurgicaux spécialisés, et financement et mobilisation des ressources pour la mise en œuvre. Les défis rencontrés dans le processus comprenaient une coordination complexe entre les différentes parties prenantes, l'allocation d'un budget suffisant pour sa mise en œuvre, un roulement fréquent au sein du ministère de la Santé publique et la pandémie de COVID-19. Le PNDChM est une première en son genre en Afrique francophone et les nombreuses leçons apprises pourront être utiles aux pays qui aspirent à élaborer leurs propres PNCOA.

Transcutaneous and Direct Electrical Stimulation of Mouse Sciatic Nerve Accelerates Functional Recovery After Nerve Transection and Immediate Repair.

BACKGROUND: Electrical stimulation can accelerate peripheral nerve regeneration after injury and repair. Clinically, direct electrical stimulation (DES) may involve longer operating times, increasing risks of perioperative complications. Transcutaneous electrical stimulation (TCES) is a noninvasive alternative. In this study, we investigate how transcutaneous and DES compare for accelerating functional nerve recovery in a mouse sciatic nerve model. METHODS: Twenty-eight mice were divided into sham (n = 4), axotomy (n = 8), DES (n = 8), and TCES (n = 8) groups. After sciatic nerve transection and repair, the proximal nerve was subjected to DES or TCES at 20 Hz for 1 hour. Sciatic functional index was measured before the injury, and at weeks 1, 2, 4, 6, 8, 10, and 12 by walking-track analysis. Electrophysiological measures were taken at week 12. RESULTS: Kinematic studies showed significant improvement from the 8th week to the 12th week for both electrical stimulation groups compared with the axotomy group (P < 0.05), with no difference between the electrical stimulation groups. At the 12th week, both DES and TCES groups had significantly faster average conduction velocity than the axotomy group. CONCLUSIONS: Functional recovery was significantly better from 8 weeks onward in mice receiving either DES or TCES stimulation when compared with axotomy and repair alone. Transcutaneous electrical stimulation is a minimally invasive alternative treatment for accelerating functional recovery after peripheral nerve injury.

Screening methods for congenital anomalies in low and lower-middle income countries: A systematic review.

INTRODUCTION: Surgically correctable congenital anomalies are responsible for a significant burden of morbidity and mortality in children from low-and lower-middle-income countries (LMICs). Early identification through fetal and neonatal screening is critical to reducing death and disability. This study aims to identify feasible screening methods for surgically correctable congenital anomalies in LMICs. METHODS: A systematic search looking at screening for congenital anomalies in LMIC was conducted in seven databases from 2000 until May 25, 2020, with no language restriction. All articles discussing screening methods for surgically correctable congenital anomalies in LMICs were included. Articles were screened by two independent contributors using Rayyan software, with a third contributor resolving conflicts. Feasibility of the screening method and its risk of bias were assessed using the MINORS scale. RESULTS: Of 3473 articles, 24 were included in the full-text review. Nine screening methods (three prenatal and six postnatal) were identified - the most frequently utilized being physician clinical examination (45.8%), pulse oximetry (33.3%) and fetal ultrasound (20.8%). The use of a birth defect picture toolkit was the most feasible screening method. The risk of bias scale yielded an average of 11.9 points, which corresponds to a moderate level of bias. CONCLUSION: Despite clear benefits, prenatal and neonatal screening methods are infrequently used in LMICs to identify surgically correctable congenital anomalies in neonates, likely due to financial, material, and human resource constraints. Further research into the development of low-cost feasible methods is needed within these settings. PROSPERO REGISTRATION NUMBER: CRD42020192051. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: IV.

Vascular Surgery Research in the Coronavirus Disease 2019 Pandemic: A Sex-Based Bibliometric Analysis.

INTRODUCTION: The COVID-19 pandemic has disrupted vascular surgery services globally and its impact on researchers has illustrated disproportionate barriers for female researchers. We assessed the pandemic's consequences on bibliometric trends in vascular surgery and vascular medicine throughout the pandemic. METHODS: A scoping review was performed using the PubMed/MEDLINE, Scopus, and EMBASE databases from January to December 2020 to identify articles related to COVID-19 and vascular surgery or vascular medicine. Articles only describing cardiac or neurovascular care were excluded. The scoping review was performed according to the PRISMA-ScR guidelines. Bibliometric data were extracted and analyzed. RESULTS: Four hundred and fourteen articles were identified, including 125 (30.2%) original articles, 42 (10.1%) review papers, 105 (25.4%) case reports, 27 (6.5%) editorials and commentaries, 94 (22.7%) letters and correspondences, and 21 (5.1%) conference abstracts. The 5 most common countries of study or discussion were all high-income countries. English was the predominant (n = 393, 94.9%) language. Funding was reported for 5.1% (n = 21) of articles. In the first 6 months, 17.6% (n = 30) of first authors and 10.6% (n = 18) of last authors were female, while the last 6 months saw an increase in representation to 30.6% (n = 74) and 15.6% (n = 38) for first and last author, respectively. CONCLUSION: The pandemic caused a rapid surge in vascular publications related to COVID-19. Female authors remain underrepresented in vascular research and the share in female authorship has dropped early in the pandemic, but rose after the end of the first wave. High-income countries remain overrepresented in research productivity, alluding to important disparities in COVID-19-related literature.

Investigation on maternal and infant health literacy among lying-in women / 预防医学

Objective@#To investigate the level of maternal and infant health literacy and its influencing factors among lying-in women, so as to provide insights into formulating maternal and infant health education and promotion strategies. @*Methods@# Lying-in women were sampled from Children's Hospital of Shanxi using a cluster sampling method from March to September 2022. Demographic characteristics, maternal and infant health literacy, and health education demands were collected through a questionnaire survey. Factors affecting maternal and infant health literacy among lying-in women were identified using a multivariable logistic regression model. @*Results@#A total of 1 099 questionnaires were allocated, and 1 059 valid questionnaires were recovered, with an effective rate of 96.36%. Participants had a mean age of (30.93±4.01) years, 930 urban residents (87.82%), and 706 pluripara (66.67%). The overall prevalence of maternal and infant health literacy was 35.51% among lying-in women, and the prevalence rates of basic knowledge and concept, healthy lifestyles and behaviors and basic skills were 47.69%, 83.10% and 38.81%, respectively. Multivariable logistic regression analysis showed that educational level (diploma or undergraduate degree, OR=3.916, 95%CI: 1.250-9.031; master degree and above, OR=4.557, 95%CI: 1.498-11.460), occupation (company employees, OR=2.701, 95%CI: 1.385-5.268; medical staff, OR=2.981, 95%CI: 1.289-6.893), pluripara (OR=5.649, 95%CI: 3.919-8.142), participating in health education activities (OR=2.332, 95%CI: 1.524-3.570), and participating in schools for pregnant women (OR=2.252, 95%CI: 1.541-3.291) were promoting factors for maternal and infant health literacy; while gestational hypertension (OR=0.255, 95%CI: 0.133-0.488) and gestational diabetes (OR=0.318, 95%CI: 0.211-0.478) were inhibiting factors for maternal and infant health literacy. Most participants acquired health knowledge through online media (62.42%), and hoped to participate in health education activities through online media publicity (68.18%).@* Conclusions @#The maternal and infant health literacy level of lying-in women in this survey is associated with education, occupation, parturition frequency, participation in health education activities, participation in schools for pregnant women, gestational hypertension and gestational diabetes.

Peer mentorship to build research capacity among members of the International Student Surgical Network (InciSioN): a proof of concept study.

BACKGROUND: International Student Surgical Network (InciSioN) is the largest student and trainee global surgery interest group worldwide and its members have contributed significantly to global surgery research. The InciSioN Research Capacity-Building (IReCaB) program aimed to enhance the research skills and confidence of participants via a peer mentorship model. METHODS: After an open call to members of InciSioN to enroll, participants' knowledge of research methods and the process was evaluated through a test to assign mentor and mentee roles, with mentors being those who scored ≥ 20/25. Mentors then delivered a series of four webinars to help disseminate research methodology to mentees. Finally, mentees were tested on their knowledge of research and their satisfaction with the program was also evaluated. RESULTS: Fifty-two participants, mostly from LMICs (n = 23/52, 44.2%) were enrolled, and 36 completed the program. There was a significant improvement in the proportion of questions answered correctly on the post-program test (R = 0.755, p < 0.001). Post-IReCaB test scores were greater than pre-IReCaB scores (p < 0.001). The difference in confidence after the course was also significant (p < 0.001). IReCaB participants successfully designed, implemented, and published an international cross-sectional study. CONCLUSION: This study showed improvements in participants' understanding of theoretical components of scientific research. We offer a model for research capacity building that can be implemented, modeled, and further refined by similar organizations with academic research goals.

Management Strategies for Descending Thoracic Aortic Thrombus: A Review of the Literature.

Descending thoracic aortic thrombus (DTAT) is an under-recognized source of systemic emboli with potential catastrophic consequences. Imaging modalities such as echocardiography, computed tomography, magnetic resonance imaging, and angiography can help identify and characterize the extent of embolic events. Established guidelines regarding the management of DTAT are currently lacking. Multiple treatment modalities are available; however, the effectiveness of each approach remains to be determined. In this study, we performed a review to examine the clinical presentation, diagnostic methods and findings, and outcomes of various treatment options for patients with DTAT. Medical management is the least invasive and most frequently chosen initial approach, offering a high reported success rate, whereas endovascular therapy can have a role in thrombus exclusion should conservative management fail.

Efficacy of different sequential patterns after crizotinib progression in advanced anaplastic lymphoma kinase-positive non-small cell lung cancer.

BACKGROUND: The efficacy difference between the second- and third-generation of anaplastic lymphoma kinase-tyrosine kinase inhibitors (ALK-TKIs) after crizotinib failure in advanced ALK-positive non-small cell lung cancer (NSCLC) has not been clarified. This study evaluates the efficacy of different sequential patterns after crizotinib progression. METHODS: Data of patients who met the study criteria were retrospectively analyzed. The Kaplan-Meier method was used to draw survival curves, log-rank method was used to compare the differences between groups, and Cox multivariate analysis was used to evaluate the significance of influencing factors. RESULTS: A total of 128 patients developed disease progression after crizotinib. The overall survival (OS) of 57 patients in the sequential second-generation ALK-TKIs group was significantly longer than that of 65 patients with other systemic treatment (58.5 months vs. 33.0 months, p < 0.001); The OS of the direct sequential lorlatinib group was significantly longer than the second-generation ALK-TKIs group (114.0 months vs. 58.5 months, p = 0.020). Similarly, of the 48 patients who developed disease progression after first- and second-generation ALK-TKIs treatment, 16 patients with sequential lorlatinib had significantly longer OS than the others (62.0 months vs. 43.0 months, p = 0.014). The progression-free survival (PFS) of second-line and third- or later-line lorlatinib were statistically different (20.0 months vs. 5.5 months, p = 0.011). CONCLUSIONS: The application of next-generation ALK-TKIs after crizotinib progression significantly prolonged survival, whereas direct sequencing lorlatinib seemed advantageous. Similarly, lorlatinib also prolonged survival in patients with first- and second-generation ALK-TKIs failure.

Growing academic global surgery: opportunities for Canadian trainees.

SummaryGlobal surgery has seen exponential growth over the past few years, and Canadian trainees' interest in the field has followed. Global surgery is defined by a commitment to health equity and community partnership. Engagement with its core principles is relevant for all Canadian surgical trainees and offers a perspective into inequities in surgical access and outcomes for patients and communities, both locally and globally. Several opportunities in academic global surgery for trainees have emerged in Canada, but appear to be underutilized. This article highlights existing Canadian global surgery initiatives, including formal postgraduate curricula, research and policy collaborations, trainee networks, advocacy projects, dedicated fellowships, and conferences. We identify areas in which institutions and departments of surgery can better support trainees in exploring each of these categories during training. Canadian trainees' exposure to global surgery can nurture their roles as future health advocates, communicators, and leaders locally and beyond.

The international treaty for pandemic preparedness and response: same story, different times?

In November, dozens of nations and the WHO will draft the international treaty for pandemic preparedness and response. Will the treaty be the needed change in global health equity or are we doomed to repeat history?

The impact of the COVID-19 pandemic on wellness among vascular surgeons.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant strain on the health and welfare of all health care professionals, including vascular surgeons. This review summarizes the implications of the pandemic on the health and wellness of surgeons and trainees, with a particular focus on those in vascular surgery (VS). A literature review was completed using common resource databases. We provide a brief history of burnout in VS and explore burnout and wellness in VS during this unprecedented pandemic. We then offer recommendations to address mental health needs by the VS workforce and highlight opportunities to address the gaps in the literature. The impact of COVID-19 on the professional and personal lives of surgeons and trainees in VS is notable. More than half of vascular surgeons reported some degree of anxiety. Factors associated with anxiety and burnout include COVID-19 exposure, moral injury, practice changes, and financial impacts. Trainees appeared to have more active coping strategies with dampened rates of anxiety compared to those in practice. Women appear to be disproportionately affected by the pandemic, with higher rates of anxiety and burnout. Groups underrepresented in medicine seemed to have more resilience when it came to burnout, but struggled with other inequities in the health care environment, such as structural racism and isolation. Strategies for addressing burnout include mindfulness practices, exercise, and peer and institutional support. The COVID-19 pandemic has had a substantial mental health impact on the VS workforce globally, as shifts were made in patient care, surgical practice, and work-home life concerns.