Canadian medical student knowledge and attitudes toward female genital mutilation.

Background: Despite female genital mutilation/cutting (FGM/C) practices being an illegal form of gender-based violence in Canada, this practice impacts many Canadians. Lack of education and training among Canadian health-care providers has resulted in systematic barriers to care. Awareness and FGM/C-related education among Canadian health-care providers must be urgently assessed. Methods: Canadian medical students were recruited to complete an anonymous survey via E-mails distributed through their schools' student organization between January and March 2021. We evaluated student understanding of FGM/C, attitudes toward medicalization and legislation, and prior clinical experience using multiple choice, Likert scale, and open-response questions. Results: Respondents (n = 135) performed poorly on knowledge assessment questions (mean percent correct <50%). Only 10.4% of respondents indicated knowing how to involve appropriate authorities when necessary, and most never evaluate FGM/C in patient history (86.7%) or clinical examination (57.1%). Subgroup analysis revealed that prior education significantly improved knowledge scores and influenced students' behaviors and attitudes. About 92.2% of respondents supported the integration of FGM/C curricula in undergraduate medical education. Discussion: This study reveals that Canadian medical students have a poor understanding of FGM/C and are not prepared to identify affected patients or intervene when necessary. These results provide rationale for the implementation of FGM/C-learning modules in undergraduate medicine.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review.

BACKGROUND: There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives. METHODS: English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS: We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria. CONCLUSIONS: Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

Assessing the Quality of Reporting on Quality Improvement Initiatives in Breast Reconstruction: A Systematic Review.

BACKGROUND: There has been a recent increase in the number and complexity of quality improvement (QI) studies in breast reconstruction. To assist with the development of thorough QI reporting practices, with the goal of improving the transferability of these initiatives, the authors conducted a systematic review of studies describing the implementation of QI initiatives in breast reconstruction. The authors used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guideline to appraise the quality of reporting of these initiatives. METHODS: English language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of QI initiatives in breast reconstruction were included. The primary endpoint of interest in this review was the distribution of studies according to SQUIRE 2.0 criteria scores in proportions. Abstracts and full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS: The authors screened 1107 studies, of which 53 full texts were assessed and 35 met inclusion criteria. In our assessment, only three studies (9%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and analysis. The lowest SQUIRE 2.0 scores appeared in the interpretation criteria. CONCLUSIONS: Significant opportunity exists to improve QI reporting in breast reconstruction, especially in the realm of costs, strategic tradeoffs, ethical considerations, project sustainability, and potential for spread to other contexts. Improvements in these areas will help to further advance the transferability of QI initiatives in breast reconstruction.

Preventing Surgery-Induced NK Cell Dysfunction Using Anti-TGF-ß Immunotherapeutics.

Natural Killer (NK) cell cytotoxicity and interferon-gamma (IFNγ) production are profoundly suppressed postoperatively. This dysfunction is associated with increased morbidity and cancer recurrence. NK activity depends on the integration of activating and inhibitory signals, which may be modulated by transforming growth factor-beta (TGF-ß). We hypothesized that impaired postoperative NK cell IFNγ production is due to altered signaling pathways caused by postoperative TGF-ß. NK cell receptor expression, downstream phosphorylated targets, and IFNγ production were assessed using peripheral blood mononuclear cells (PBMCs) from patients undergoing cancer surgery. Healthy NK cells were incubated in the presence of healthy/baseline/postoperative day (POD) 1 plasma and in the presence/absence of a TGF-ß-blocking monoclonal antibody (mAb) or the small molecule inhibitor (smi) SB525334. Single-cell RNA sequencing (scRNA-seq) was performed on PBMCs from six patients with colorectal cancer having surgery at baseline/on POD1. Intracellular IFNγ, activating receptors (CD132, CD212, NKG2D, DNAM-1), and downstream target (STAT5, STAT4, p38 MAPK, S6) phosphorylation were significantly reduced on POD1. Furthermore, this dysfunction was phenocopied in healthy NK cells through incubation with rTGF-ß1 or POD1 plasma and was prevented by the addition of anti-TGF-ß immunotherapeutics (anti-TGF-ß mAb or TGF-ßR smi). Targeted gene analysis revealed significant decreases in S6 and FKBP12, an increase in Shp-2, and a reduction in NK metabolism-associated transcripts on POD1. pSmad2/3 was increased and pS6 was reduced in response to rTGF-ß1 on POD1, changes that were prevented by anti-TGF-ß immunotherapeutics. Together, these results suggest that both canonical and mTOR pathways downstream of TGF-ß mediate phenotypic changes that result in postoperative NK cell dysfunction.

Perioperative arginine prevents metastases by accelerating natural killer cell recovery after surgery.

Profound natural killer (NK) cell suppression after cancer surgery is a main driver of metastases and recurrence, for which there is no clinically approved intervention available. Surgical stress is known to cause systemic postoperative changes that negatively modulate NK cell function including the expansion of surgery-induced myeloid-derived suppressor cells (Sx-MDSCs) and a marked reduction in arginine bioavailability. In this study, we determine that Sx-MDSCs regulate systemic arginine levels in the postoperative period and that restoring arginine imbalance after surgery by dietary intake alone was sufficient to significantly reduce surgery-induced metastases in our preclinical murine models. Importantly, the effects of perioperative arginine were dependent upon NK cells. Although perioperative arginine did not prevent immediate NK cell immunoparalysis after surgery, it did accelerate their return to preoperative cytotoxicity, interferon gamma secretion, and activating receptor expression. Finally, in a cohort of patients with colorectal cancer, postoperative arginine levels were shown to correlate with their Sx-MDSC levels. Therefore, this study lends further support for the use of perioperative arginine supplementation by improving NK cell recovery after surgery.

Multifaceted quality improvement initiatives improve rate of pediatric hand injury reduction.

BACKGROUND: Hand fractures account for a significant proportion of all fractures seen in pediatric emergency departments (ED). It is essential for initial interventions to be successful to avoid unnecessary repeat interventions/complications. We sought to assess whether quality improvement interventions could decrease the rate of repeat reductions by plastic surgeons in our tertiary centre. METHODS: We included patients ≤ 18 years of age who presented to ED with a hand injury from January 2014 to May 2019. Data were collected and presented over two plan-do-study-act cycles. The interventions comprised the dissemination of previous research identifying hand injuries requiring repeat reduction at our centre and commencement of a quality improvement initiative that coincided with hiring of a fellowship-trained pediatric hand surgeon and the implementation of an electronic medical record. In the second plan-do-study-act cycle, we implemented formal educational workshops for ED physicians and a standardized flowsheet in our electronic medical record to track patients with hand injuries. RESULTS: We identified 272 hand injuries (136 in cycle 1, 136 in cycle 2) from January 2014 to May 2019. As a result of the implemented quality improvement initiatives, the proportion of hand injuries requiring repeat reduction decreased from 8.7% (n = 8) to 3.0% (n = 2) during cycle 1. This improvement was sustained during the 17-month-long (November 2017-May 2019) second cycle (3.0%, n = 6). CONCLUSION: This study highlights the importance of multifaceted interventions to achieve improved patient care, specifically the potential impact of specialized physicians, informal feedback and education, formal teaching workshops, and electronic medical records.

RéSUMé: CONTEXTE: Les fractures de la main représentent une proportion importante de toutes les fractures vues dans les services d'urgence pédiatriques. Il est essentiel que les interventions initiales réussissent afin d'éviter des interventions/complications répétées inutiles. Nous avons cherché à évaluer si les interventions d'amélioration de la qualité pouvaient réduire le taux de réductions répétées par les chirurgiens plasticiens dans notre centre tertiaire. MéTHODES: Nous avons inclus les patients ≤ 18 ans qui se sont présentés aux urgences avec une blessure à la main entre janvier 2014 et mai 2019. Les données ont été recueillies et présentées au cours de deux cycles planifier-faire-étudier-agir. Les interventions comprenaient la diffusion de recherches antérieures identifiant les blessures à la main nécessitant une réduction répétée dans notre centre et le lancement d'une initiative d'amélioration de la qualité qui a coïncidé avec l'embauche d'un chirurgien de la main pédiatrique formé en bourse et la mise en œuvre d'un dossier médical électronique. Au cours du deuxième cycle planifier-faire-étudier-agir, nous avons mis en place des ateliers éducatifs formels pour les médecins des urgences et une feuille de route standardisée dans notre dossier médical électronique pour suivre les patients souffrant de blessures aux mains. RéSULTATS: Nous avons identifié 272 blessures à la main (136 au cycle 1, 136 au cycle 2) entre janvier 2014 et mai 2019. Grâce aux initiatives d'amélioration de la qualité mises en œuvre, la proportion de blessures à la main nécessitant une réduction répétée a diminué de 8,7% (n = 8) à 3,0% (n = 2) au cours du cycle 1. Cette amélioration s'est maintenue tout au long du deuxième cycle de 17 mois (novembre 2017-mai 2019) (3,0%, n = 6). CONCLUSION: Cette étude souligne l'importance d'interventions multiformes pour parvenir à améliorer les soins aux patients, en particulier l'impact potentiel des médecins spécialisés, de la rétroaction et de l'éducation informels, des ateliers d'enseignement formels et des dossiers médicaux électroniques.

Hands-On Workshops Improve Emergency Department Physicians' Self-Reported Understanding of Pediatric Hand Injuries.

OBJECTIVES: The aims of this study were to assess emergency department (ED) physician perception of hand injuries and improve their understanding and confidence in treating these injuries. METHODS: Combined didactic and hands-on workshops for ED physicians were developed and run by a team of medical students, plastic surgeons, and ED physicians. The workshops consisted of a short review by a hand surgeon followed by hands-on sessions involving radiograph assessment, administration of local anesthetic, closed reduction, and splinting. Two sessions, 6 months apart, were provided. The workshops were evaluated using preworkshop and postworkshop questionnaires to assess the following domains: confidence and competence in treating hand injuries, knowledge of basic hand injury care, and feedback on the intervention itself. RESULTS: Fifty physicians participated in the workshops. After the workshops, physician recognition of hand fracture reduction as a critical skill increased. Self-efficacy ratings of fracture assessment, administration of local anesthetic, performing a reduction, and applying postreduction immobilization increased. Median scores on knowledge-testing questions also increased postintervention from 73.3% (95% confidence interval, 70.2-78.5) to 86.7% (95% confidence interval, 79.3-86.2) (P < 0.05). Finally, physicians reported that they found the intervention educational, useful, and important, and approximately 90% of participants indicated they intended to change their practice based on this intervention. CONCLUSIONS: Knowledge sharing between specialists and generalists through combined didactic and hands-on workshops is an effective and well-received method of refining physician knowledge and increasing confidence in treating subspecialty-specific clinical presentations.

Postoperative Natural Killer Cell Dysfunction: The Prime Suspect in the Case of Metastasis Following Curative Cancer Surgery.

Surgical resection is the foundation for the curative treatment of solid tumors. However, metastatic recurrence due to the difficulty in eradicating micrometastases remain a feared outcome. Paradoxically, despite the beneficial effects of surgical removal of the primary tumor, the physiological stress resulting from surgical trauma serves to promote cancer recurrence and metastasis. The postoperative environment suppresses critical anti-tumor immune effector cells, including Natural Killer (NK) cells. The literature suggests that NK cells are critical mediators in the formation of metastases immediately following surgery. The following review will highlight the mechanisms that promote the formation of micrometastases by directly or indirectly inducing NK cell suppression following surgery. These include tissue hypoxia, neuroendocrine activation, hypercoagulation, the pro-inflammatory phase, and the anti-inflammatory phase. Perioperative therapeutic strategies designed to prevent or reverse NK cell dysfunction will also be examined for their potential to improve cancer outcomes by preventing surgery-induced metastases.

Pediatric Hand Injuries Requiring Closed Reduction at a Tertiary Pediatric Care Center.

Background: Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts. Methods: A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included. Results: Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified. Conclusions: Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.

Flattening the COVID-19 Curve With Natural Killer Cell Based Immunotherapies.

Natural Killer (NK) cells are innate immune responders critical for viral clearance and immunomodulation. Despite their vital role in viral infection, the contribution of NK cells in fighting SARS-CoV-2 has not yet been directly investigated. Insights into pathophysiology and therapeutic opportunities can therefore be inferred from studies assessing NK cell phenotype and function during SARS, MERS, and COVID-19. These studies suggest a reduction in circulating NK cell numbers and/or an exhausted phenotype following infection and hint toward the dampening of NK cell responses by coronaviruses. Reduced circulating NK cell levels and exhaustion may be directly responsible for the progression and severity of COVID-19. Conversely, in light of data linking inflammation with coronavirus disease severity, it is necessary to examine NK cell potential in mediating immunopathology. A common feature of coronavirus infections is that significant morbidity and mortality is associated with lung injury and acute respiratory distress syndrome resulting from an exaggerated immune response, of which NK cells are an important component. In this review, we summarize the current understanding of how NK cells respond in both early and late coronavirus infections, and the implication for ongoing COVID-19 clinical trials. Using this immunological lens, we outline recommendations for therapeutic strategies against COVID-19 in clearing the virus while preventing the harm of immunopathological responses.

A Method of Assessment of Human Natural Killer Cell Phenotype and Function in Whole Blood.

The majority of data on human Natural Killer (NK) cell phenotype and function has been generated using cryopreserved peripheral blood mononuclear cells (PBMCs). However, cryopreservation can have adverse effects on PBMCs. In contrast, investigating immune cells in whole blood can reduce the time, volume of blood required, and potential artefacts associated with manipulation of the cells. Whole blood collected from healthy donors and cancer patients was processed by three separate protocols that can be used independently or in parallel to assess extracellular receptors, intracellular signaling protein phosphorylation, and intracellular and extracellular cytokine production in human NK cells. To assess extracellular receptor expression, 200 µL of whole blood was incubated with an extracellular staining (ECS) mix and cells were subsequently fixed and RBCs lysed prior to analysis. The phosphorylation status of signaling proteins was assessed in 500 µL of whole blood following co-incubation with interleukin (IL)-2/12 and an ECS mix for 20 min prior to cell fixation, RBC lysis, and subsequent permeabilization for staining with an intracellular staining (ICS) mix. Cytokine production (IFNγ) was similarly assessed by incubating 1 mL of whole blood with PMA-ionomycin or IL-2/12 prior to incubation with ECS and subsequent ICS antibodies. In addition, plasma was collected from stimulated samples prior to ECS for quantification of secreted IFNγ by ELISA. Results were consistent, despite inherent inter-patient variability. Although we did not investigate an exhaustive list of targets, this approach enabled quantification of representative ECS surface markers including activating (NKG2D and DNAM-1) and inhibitory (NKG2A, PD-1, TIGIT, and TIM-3) receptors, cytokine receptors (CD25, CD122, CD132, and CD212) and ICS markers associated with NK cell activation following stimulation, including signaling protein phosphorylation (p-STAT4, p-STAT5, p-p38 MAPK, p-S6) and IFNγ in both healthy donors and cancer patients. In addition, we compared extracellular receptor expression using whole blood vs. cryopreserved PBMCs and observed a significant difference in the expression of almost all receptors. The methods presented permit a relatively rapid parallel assessment of immune cell receptor expression, signaling protein activity, and cytokine production in a minimal volume of whole blood from both healthy donors and cancer patients.

Using Self-Reported Measures of Confidence and Anxiety to Determine the Efficacy of the Surgical Exploration And Discovery (SEAD) Program in Reducing Anxiety and Increasing Confidence in Performing Procedural Skills.

OBJECTIVE: Clerkship students feel increased anxiety and lack of confidence when it comes to surgery. This study assessed whether participation in Surgical Exploration And Discovery (SEAD), a 2-week intensive surgical program that includes career information, simulation workshops, and operating room observerships, would help decrease anxiety, increase confidence, and foster interest in a surgical career. SETTING: This study took place at The Ottawa Hospital in Ottawa, Ontario, Canada. DESIGN: Thirty first year medical students were randomly selected for the SEAD program and 32 were only given the program's instruction manual during the duration of the program serving as the control. At baseline and after the completion of SEAD, both groups were given a survey containing the State Trait Anxiety Inventory that measures self-reported anxiety levels with an adjunct that gauges confidence and interest in a surgical career. RESULTS: Students who participated in the program showed significant improvements in self-perceived knowledge and confidence for each surgical skill: scrubbing (p-value < 0.001, p-value < 0.001), maintaining sterility (p-value < 0.001, p-value < 0.001), and surgical assisting (p-value < 0.001, p-value < 0.001). However, there was no difference in the average state anxiety with procedural skills (p-value = 0.190) between students who participated in SEAD and those who did not. Students who completed SEAD had a notable increase in their interest in pursuing a career in surgery compared with their pretest (p-value = 0.020) and compared with the control group (p-value = 0.600). CONCLUSIONS: The SEAD program may increase medical students' confidence and interest in pursuing a surgical career. These results encourage offering medical students with similar opportunities that provide exposure to surgery in preclerkship.

The Potential for Cancer Immunotherapy in Targeting Surgery-Induced Natural Killer Cell Dysfunction.

Natural Killer (NK) cells are granular lymphocytes of the innate immune system that are able to recognize and kill tumor cells without undergoing clonal selection. Discovered over 40 years ago, they have since been recognized to possess both cytotoxic and cytokine-producing effector functions. Following trauma, NK cells are suppressed and their effector functions are impaired. This is especially important for cancer patients undergoing the removal of solid tumors, as surgery has shown to contribute to the development of metastasis and cancer recurrence postoperatively. We have recently shown that NK cells are critical mediators in the formation of metastasis after surgery. While research into the mechanism(s) responsible for NK cell dysfunction is ongoing, knowledge of these mechanisms will pave the way for perioperative therapeutics with the potential to improve cancer outcomes by reversing NK cell dysfunction. This review will discuss mechanisms of suppression in the postoperative environment, including hypercoagulability, suppressive soluble factors, the expansion of suppressive cell populations, and how this affects NK cell biology, including modulation of cell surface receptors, the potential for anergy, and immunosuppressive NK cell functions. This review will also outline potential immunotherapies to reverse postoperative NK dysfunction, with the goal of preventing surgery-induced metastasis.