Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations.

BACKGROUND: Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. METHODS: This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. RESULTS: A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). CONCLUSIONS: Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.

Navigating the uncertainty of health advocacy teaching and evaluation from the trainee's perspective.

BACKGROUND: There may be no competency more shrouded in uncertainty than health advocacy (HA), raising questions about the robustness of advocacy training in postgraduate medical education. By understanding how programs currently train HA, we can identify whether trainees' learning needs are being met. METHODS: From 2017 to 2019, we reviewed curricular documents across nine direct-entry specialties at all Ontario medical schools, comparing content for the HA and communicator roles to delineate role-specific challenges. We then conducted semi-structured interviews with trainees (n = 9) and faculty (n = 6) to review findings and discuss their impact. Data were analyzed using thematic content analysis. RESULTS: Curricular documents revealed vague objectives and ill-defined modes of assessment for both intrinsic roles. This uncertainty was perceived as more problematic for HA, in part because HA seemed both undervalued in, and disconnected from, clinical learning. Trainees felt that the onus was on them to figure out how to develop and demonstrate HA competence, causing many to turn their learning attention elsewhere. DISCUSSION: Lack of curricular focus seems to create the perception that advocacy isn't valuable, deterring trainees-even those keen to become competent advocates-from developing HA skills. Such ambivalence may have troubling downstream effects for both patient care and trainees' professional development.

Gender disparity in dermatologic society leadership: A global perspective.

BACKGROUND: In the last half-century, there has been increased representation of women in medicine. Despite this increase, there continues to be underrepresentation of women in medical leadership positions. The objective of this study was to investigate the phenomenon of gender disparity in the leadership of professional societies of dermatology worldwide. METHODS: Online databases were used to extract the names of global dermatologic societies. Individual society websites were accessed to obtain information on executive members. Data not available on society websites were obtained through internet searches. Scopus was used to obtain H-indexes and other bibliometric outcomes. RESULTS: Our data collection spanned 92 countries, with 1733 society leaders identified and information available for 1710. In North America, Europe, Asia, Australia, and the Middle East, women were in a minority in dermatology professional society leadership. In South America, Central America, and Africa, women were in a slight majority. Across all professional societies, the role of president was more frequently held by men (n = 95) as opposed to women (n = 75). Female leaders were less likely to hold concurrent academic positions as deans/chairpersons/directors (83.33%) than their male counterparts (92.06%). The median H-index of female leaders (9) was lower than that of men (14). CONCLUSION: Gender disparity exists in leadership positions in professional dermatology societies. Cultural/continental specific factors should be explored further. Enhancement of institutional support, mentorship, and sponsorship for female dermatologists should be encouraged.

The Impact of Foundation Medicine Testing on Cancer Patients: A Single Academic Centre Experience.

BACKGROUND: The use of Next-Generation Sequencing (NGS) has recently allowed significant improvements in cancer treatment. Foundation Medicine® (FM) provides a genomic profiling test based on NGS for a variety of cancers. However, it is unclear if the Foundation Medicine test would result in a better outcome than the standard on-site molecular testing. In this retrospective chart review, we identified the FM cases from an academic Canadian hospital and determined whether these test results improved treatment options for those patients. MATERIALS AND METHODS: A retrospective analysis was performed on patients with solid tumors who had FM testing between May 1, 2014 and May 1, 2018. Clinical factors and outcomes were measured using descriptive statistics using Microsoft Excel® Software. RESULTS: Out of 66 FM tests, eight patients (= 12%) had a direct change in therapy based on the FM tests. Identified were 285 oncogenic mutations (median 1, range 0-31); where TP53 (n = 31, 10.9%), CDKN2A (n = 19, 6.7%), KRAS (n = 16, 5.6%) and APC (n = 9, 3.2%) were the most common FM mutations identified. CONCLUSION: A small proportion of FM reports identified actionable mutations and led to direct treatment change. FM testing is expensive and a few of the identified mutations are now part of routine on-site testing. NGS testing is likely to become more widespread, but this research suggests that its true clinical impact may be restricted to a minority of patients.

Program Website Evaluation of Canadian Obstetrics and Gynaecology Residency and Fellowship Programs.

OBJECTIVE: The purpose of our study was to assess the comprehensiveness of Canadian obstetrics and gynaecology residency and fellowship program websites to understand the quality of information available to prospective students and make recommendations, if needed. METHODS: All active residency and fellowship program websites (as of May 2020) were evaluated and compared using 72-point criteria in the following domains: Recruitment, Faculty, Current Residents/Fellows, Research and Education, Surgical Procedures, Clinical Work, Benefits and Incentives, Wellness, and Environment. Programs without websites were excluded from the study. Program website information availability was compared by geographic region. RESULTS: Out of the identified 80 residency and fellowship programs, 68.75% (55) were from central Canada, 6.25% (5) from Atlantic Canada, and 25% (20) from western Canada. The mean score for residency websites was 25.4 ± 7.59 (35.6% of criteria complete). The domains with the highest and lowest inclusion rates were Research and Education (46.3% criteria complete) and Current Residents (16.2% criteria complete). The mean score of fellowship websites was 27.9 ± 8.89 (38.8% criteria complete). For fellowship websites, Wellness had the highest inclusion rate (66.0% criteria complete), while Current Fellows had the lowest (13.2% criteria complete). Overall, fellowship websites scored higher than residency websites (27.9 ± 8.89 and 25.4 ± 7.59 out of 72 criteria, respectively). CONCLUSION: Overall, Canadian postgraduate obstetrics and gynaecology program websites include information on many topics relevant to prospective students, such as research, education, and wellness. Programs should provide more information about work hours, call schedules, and current trainees. Lastly, there is an opportunity for programs in western and Atlantic Canada to increase the comprehensiveness of their websites.

North American urogynecology fellowship programs: value of program website content.

INTRODUCTION AND HYPOTHESIS: Urogynecology fellowship program websites are an important source of information to potential applicants, especially given the ongoing COVID-19 pandemic and resulting travel restrictions. Our study evaluated the publicly available information on American and Canadian urogynecology fellowship websites and present recommendations for website content development to promote the subspecialty of urogynecology. METHODS: Data were collected from all active American and Canadian urogynecology fellowship program websites between May and June 2020 against 72 criteria developed from previously published studies. The criteria included the following sections: Recruitment, Faculty Information, Current Fellows, Research and Education, Surgical Program, Clinical Work, Benefits and Career Planning, Wellness, and Environment. RESULTS: 54 American urogynecology program websites and 11 Canadian urogynecology program websites were analyzed. The mean score of American and Canadian websites was 46.46% (n = 33.45 ± 7.20 out of 72) and 27.40% (n = 19.73 ± 3.77 out of 72), respectively. American program websites scored significantly higher on available information than Canadian websites. The highest prevalence section across American websites was Wellness (64%, n = 1.92 ± 0.85 out of 3 criteria) while the lowest prevalence section was Clinical Work (15.17%, n = 0.91 ± 1.02 out of 6 criteria). Comparatively, Canadian websites scored highest in the Faculty Information section (43.12%, 3.45 ± 2.02) and lowest in the Clinical Work section (6%, n = 0.36 ± 0.67 out of 6 criteria). CONCLUSIONS: American and Canadian websites thoroughly covered the Wellness and Faculty Information sections, respectively. Program websites should consider adding details about Benefits and Career Planning and Clinical Work.

Factors associated with early phosphate levels in preterm infants.

To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32 weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72 h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.

Potential of feedback during objective structured clinical examination to evoke an emotional response in medical students in Canada.

Feedback has been shown to be an important driver for learning. However, many factors, such as the emotional reactions feedback evokes, may impact its effect. This study aimed to explore medical students' perspectives on the verbal feedback they receive during an objective structured clinical examination (OSCE); their emotional reaction to this; and its impact on their subsequent performance. To do this, medical students enrolled at 4 Canadian medical schools were invited to complete a web-based survey regarding their experiences. One hundred and fifty-eight participants completed the survey. Twenty-nine percent of respondents asserted that they had experienced emotional reactions to verbal feedback received in an OSCE setting. The most common emotional responses reported were embarrassment and anxiousness. Some students (n=20) reported that the feedback they received negatively impacted subsequent OSCE performance. This study demonstrates that feedback provided during an OSCE has the ability to evoke an emotional response in students and to potentially impact subsequent performance.

Very Prolonged Anti-D: Confusion Surrounding Alloimmunization After Extra Rh Immunoglobulin: A Case Report.

BACKGROUND: Rh immunoglobulin (RhIg) is usually detectable a maximum of 12 to 14 weeks after administration. Positive antibodies beyond this time frame suggests alloimmunization. CASE: A woman had three pregnancies over a 6-month period, with two first-trimester losses. She received RhIg in the first pregnancy but not in the second. Two months after the second loss, in her third pregnancy, she received RhIg at week 6 due to first-trimester bleeding. She was subsequently anti-D antibody positive up to week 28 with antibodies too low to titre, leading to confusion about whether alloimmunization had occurred. CONCLUSION: Rh Ig administration led to positive anti-D antibodies lasting 22 weeks, suggesting keeping this differential diagnosis in mind when suspecting alloimmunization with positive antibodies at levels too low to titre.

Exploring Tobacco Use and Smoking Cessation Best Practices From the Perspectives of Individuals With Lung Cancer and Health Care Professionals.

BACKGROUND: Lung cancer patients who continue to smoke after diagnosis are at increased risk of treatment toxicity, residual/recurrent disease, future malignancies, and all-cause mortality. Guidelines including those from National Comprehensive Cancer Network and Cancer Care Ontario advocate for screening, counseling, and access to smoking cessation services for all cancer patients; however, barriers from both patient and health care professional (HCP) perspectives contribute to lack of implementation. OBJECTIVE: The objective of this study was to identify the different perspectives among patients and HCPs in how the promotion of person-centred approaches may be used when offering smoking cessation services to patients who are receiving care within a regional cancer centre. METHODS: Qualitative data were generated using various methods, including focus groups with HCPs and interviews with patients. In total, 16 HCPs participated in three focus groups: including nine radiation therapists, five registered nurses, one registered dietitian, and one physiotherapist. Of 55 patients accrued, 19 were interviewed. Both focus groups and interviews were audio recorded, and the recordings were transcribed verbatim. Transcripts were then analyzed using narrative thematic analysis to define and identify themes. RESULTS: The identified themes were categorized into three topic areas: knowledge (eg, impact of smoking on illness and why they should not smoke); individual decision to quit (eg, motivators), and the social unacceptability of smoking (eg, the public perception of smoking over the last 40 years). HCP-identified themes included identification of smokers, triggers to start a conversation, approach, gaps and barriers to cessation, rationale for cessation, and judgment. Patient-identified themes included knowledge, individual decision to quit, and the social unacceptability of smoking. CONCLUSION: Understanding patient and HCP perspectives on smoking cessation will help influence practice to ensure that patients are not judged, assumptions are not made, and individualized and person-centred care is provided. HCP awareness of these themes and the patient perspective may challenge assumptions and values.

A Quality Improvement Intervention to Reduce Necrotizing Enterocolitis in premature infants with Probiotic Supplementation.

Necrotizing Enterocolitis (NEC) is a severe intestinal inflammatory disease due to multifactorial causes that present in preterm infants. Compared with similar neonatal intensive care units, our NEC rate was increasing and prompted reduction by a quality improvement (QI) intervention. METHODS: We aimed to reduce NEC rate by 30% by the end of 2016. We used the Institute of Healthcare Improvement model and typical QI tools, including teamwork, process organizing tools, and evidence-based review, to assist in our selection of supplementation of Lactobacillus reuteri probiotic. We used education, process mapping, process control statistics, and forcing mechanism to implement the changes. In addition to reducing NEC rates, our additional outcome measures were sepsis, mortality, sepsis evaluations, feeding intolerance, growth, days of both antimicrobials, and parenteral nutrition use. Process measures were compliance with probiotics supplementation policy and balancing measures were sepsis rates and feeding intolerance. RESULTS: NEC rates decreased from 4.4% to the current 1.7%, and in a pre/post-intervention analysis, the results were significant in all patient subcategories. We did not demonstrate a reduction in mortality. No adverse events occurred. Feeding intolerance episodes and days nil-per-os decreased with no differences in growth at discharge. These results continued over 2 years, and this practice has already spread to several neonatal intensive care units in Ontario, Canada. CONCLUSIONS: We utilized QI methods and tools to implement a successful practice change of routine probiotic supplementation to reduce NEC rates in preterm infants. We suggest considering this intervention as a successful means to prevent this serious illness.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding.

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F (9, 65) = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

MEDTalks: a student-driven program to enhance undergraduate student understanding and interest in medical schools in Canada.

Given the lack of programs geared towards educating undergraduate students regarding medical school, the purpose of this study was to evaluate whether medical student-driven initiative program, MEDTalks, enhanced undergraduate student understanding of medical school in Canada and stimulated interest in pursuing medicine. The MEDTalks program that ran between January and April 2018 in the University of Ottawa consisted of 5 teaching sessions, each including large-group lectures, small group case-based learning, physical skills tutorials, and anatomy lab demonstrations, to mimic the typical Medical School curriculum. At the end of the program, undergraduate student learners were invited to complete a feedback questionnaire. Twenty-nine participants provided feedback. Twenty-five reported that MEDTalks allowed them to gain exposure to the University of Ottawa Medical Program; 27 said that it gave them a greater understanding of the teaching structure; and 25 responded that it increased their interest in attending medical school. The MEDTalks program successfully developed greater understanding of medical school and helped stimulate interest in pursuing medical studies in undergraduate students.