Female surgical trainee recruitment and attrition - A 10-year national retrospective review.

BACKGROUND: Female trainees continue to be underrepresented in surgical specialties. Studies have shown lower enrollment and higher attrition of female trainees in surgery. However, there is no comprehensive data examining trends to determine if positive strides have been made towards greater equity. METHODS: Retrospective cohort study examining Canadian surgical residents who began training between 2000 and 2010. Enrollment data was compared to how many of those individuals registered for their final surgical certifying examinations by 2018, which indicated completion of residency. RESULTS: In the 10-year period, overall attrition rates of surgical trainees was 8%. Female residents were twice as likely to leave training compared to their male counterparts (12.4 vs 6.1% p < 0.001). Attrition rates for female residents appeared to trend downwards. Enrollment of female surgical trainees across all surgical specialties increased from 27.3% to 39.2% during this time. CONCLUSION: Equity in Canadian surgical training enrollment and retention improved for those who began training from 2000 to 2010, but there continued to be differences in female trainee recruitment and attrition rates compared to their male counterparts.

A fresh look at the concept of Genus Epidemicus: findings from the Clificol Project

The Clificol® COVID-19 Support Project is an innovative international data collection project aimed at tackling some of the core questions in homeopathy, including the notion of Genus Epidemicus. Aims:To shed some light on the notion of Genus Epidemicus in the context of this infection. Going beyond that, the project aims to use these data to tackle more fundamental questions, such as the role of symptoms and rubrics in treatment individualisation. Methodology:This online multi-national data-collection project is supported by the ECH, ECCH, ICH, HRI, LMHI, and other professional associations. The collected data includes demographic information, severity, conventional diagnosis and treatment, presenting symptoms as well as the remedies prescribed. The outcome of treatment was tracked using the ORIDL scale. The concept of Genus Epidemicus, including the role of treatment individualisation, was investigated by analysing whether presenting symptoms cluster into distinct groups (K-Means clustering approach). The symptom data originating from China was obtained using a questionnaire. Results and discussion: 20 Chinese practioners collected 359 cases, primarily in the first half of 2020 (766 consultations, 363 prescriptions). The cluster analysis found two to be the optimum number of clusters. These two symptomatic clusters had a high overlap with the two most commonly prescribed remedies in that population: In cluster 1 there were 297 prescriptions, 95.6% of which were Gelsemium sempervirens, incluster 2, there were 61 prescriptions, 95.1% of which were Bryonia alba. Under the assumption of a single genus epidemicuswe would expect to see a single cluster of symptoms. The data from the Chinese population were not compatible with this assumption. Conclusion:This was the first study that investigated the notion of Genus Epidemicus by using modern statistical techniques. These analyses identified at least two distinct symptom pictures. The notion of a single COVID-19 Genus Epidemicus did not apply to this population.

Update from the Clificol Project: Omicron in Hong-Kongand worldwide overview of the pandemic

The Clificol® COVID-19 Support Project is an innovative international data collection project aimed at documenting the presenting symptoms, use of homeopathy through the pandemic and tackling some of the core questions in homeopathy. The Covid-19 pandemic raised many questions and mobilised many resources. In order to make good use of resources, sound knowledge of the presenting complaints and demographics are required. In particular, we aimed to characterise the recent Omicron wave in Hong-Kong and to get an overall picture of the global pandemic as experienced by the homeopathic community. This online multi-national data-collection project is supported by the ECH, ECCH, ICH, HRI, LMHI, and other professional associations. The collected data includes demographic information, severity, conventional diagnosis and treatment, presenting symptoms as well as the remedies prescribed. The outcome of treatment was tracked using the ORIDL scale. More recently a 23-items prospective questionnaire was added to the input in order to gather targeted data about the presenting complaints. The recent wave of the Omicron variant in Hong-Kong, was analysed (N=372 cases) in terms of the symptomatology of this variant. The data from the 23-items questionnaire is compared to the longer questionnaire (150 items) used by the Hong-Kong team (21 practitioners). The most frequently reported common Clinical symptoms were extreme tiredness (60%), sore throat (46%), headache during fever (45%), dryness of mouth (37%), poor appetite (37%), runny nose (34%) and unusual muscle pains (31%).Also, the cases collected from around the world over the course of the pandemic (N=1300) were analysed, providing an overall picture of the pandemic and its specificities per country and over time. Clificol has shown and continues to show the value of data collection for the homeopathy community, providing important information for the management of future pandemics and opening new avenues for research in homeopathy.

Twelve tips to center social accountability in undergraduate medical education.

As the intersections of social identities and health become increasingly evident, the need for medical schools to center their education on social accountability becomes critical. Medical schools have a responsibility to direct their curriculum to ensure graduates become competent physicians in identifying and intervening for their community's needs. These topics have historically been taught in a didactic fashion, but there lacks adequate translation of this teaching style to clinical and community health advocacy. Active learning strategies must be used to engage students to critically think and act on the inter-relationships of social issues and health. We provide 12 recommendations to optimize medical education to effectively immerse students in social accountability through the use of experiential learning within a spiral curriculum. These recommendations are based on reviews of the literature and an environmental scan of curricular activities across Canadian medical schools.

Intrinsic peripheral nerve and root tumor and pseudotumoral lesions at a tertiary care pediatric hospital.

PURPOSE: Tumors affecting peripheral nerves in children are rare. Accurate diagnosis ensures that management is appropriate and timely. A review of intrinsic nerve tumors was completed to differentiate common peripheral nerve lesions based on clinical characteristics and investigations. METHODS: A retrospective review was conducted for children (< 18 years old) diagnosed with an intrinsic tumor affecting peripheral nerve(s) or roots at the Children's Hospital of Eastern Ontario (CHEO) from 2009 to 2019. RESULTS: We report 14 children with perineurioma (N = 6), neurofibroma (N = 4), intraneural ganglion cyst (N = 2), or lipomatosis (N = 2). Mean age of symptom onset was 8.2 years (range 0.3 to 17.3 years). Presenting symptoms included muscle weakness (7/14), painless muscle wasting (2/14), contracture (1/14), pain (1/14), or the identification of a painless mass (3/14). Nerve conduction studies (NCS) or electromyography (EMG) were performed in 11/14 patients. MRI was useful at differentiating between these pediatric nerve tumors. Biopsies were performed in nine patients with additional surgical management pursued in four patients. CONCLUSION: The rare nature of peripheral nerve tumors in children can pose diagnostic challenges. NCS/EMG are important to assist with localization, and MRI is useful to distinguish more benign tumors. Key MRI, clinical, and NCS features can in some cases guide management, potentially avoiding the need for invasive procedures.

Homeopathic Clinical Features of 18 Patients in COVID-19 Outbreaks in Hong Kong.

BACKGROUND: Hong Kong is geographically located in the province of Guangdong which, after Hubei, has been the region of China second-most affected by the COVID-19 pandemic. Compared to the pathognomonic symptoms of the named disease, homeopathic symptoms are always more helpful for homeopathic prescriptions. AIM: This study reports and summarizes the homeopathic symptoms observed in 18 confirmed/suspected epidemiologically related cases in cluster outbreaks of COVID-19 in Hong Kong in early 2020. METHODS: Homeopathic symptoms from this case series were collected from 18 consecutive patients who, in addition to their concurrent conventional treatment or traditional Chinese medicine, actively sought help from homeopathy as an adjunctive measure for symptomatic relief from COVID-19. Cases were categorized according to outbreak clusters, focusing mainly on the homeopathic symptoms. In the analysis, frequency of all homeopathic medicines, common rubrics in all the cases, common rubrics in each of the top-ranked remedies, and differentiating symptoms for each top-ranked remedy were determined. RESULTS: Homeopathic symptoms of 18 cases, each identified as mild and belonging to one of six separate clusters, are reported. Eighteen common symptoms screened out of 79 selected rubrics constituted two sets of homeopathic symptom pictures: Bryonia alba (n = 4) and Gelsemium sempervirens (n = 12). Eight and seven differentiating features, respectively, were identified for Bryonia alba and Gelsemium sempervirens. CONCLUSION: The common symptoms of 18 mild COVID-19 cases constituted two sets of homeopathic symptom pictures, indicating Bryonia alba or Gelsemium sempervirens; they were indicated in 4 and 12 cases, respectively, out of the 18 in total.

Does being in the hot seat matter? Effect of passive vs active learning in surgical simulation.

BACKGROUND: Participation in simulation can improve future performance, but it is unclear if observation of simulation scenarios can produce an equivalent benefit. METHODS: First-year surgical residents were exposed to various simulation scenarios in groups of 4 or 5, either through active participation or passive observation. Residents were individually assessed on 3 of the scenarios. Scores were categorized based on resident level of exposure to the scenario and analyzed using a multivariate analysis. RESULTS: 32 residents were enrolled and 28 underwent testing. Previous exposure to the scenario as a participant or observer led to improved performance on medical management and overall performance compared to those who had not been exposed (p < 0.02). However, active participation did not improve performance relative to passive observation (p > 0.1). Previous exposure did not improve communication aspects of the scenarios. CONCLUSION: Analyses confirmed the advantage of simulation-based training, but additionally suggest that the benefits for similar in both active participants and passive observers. This supports the idea of group based simulation training which can be more cost and time efficient.

Health Advocacy Competency: Integrating Social Outreach into Surgical Education.

OBJECTIVE: Being a strong health advocate is recognized as being an important part of being a good surgeon. Residency training programs have struggled with teaching health advocacy beyond didactic sessions, and in a way that encourages trainees to incorporate changes into their practice. This curriculum development aimed to incorporate reflective practice to encourage patient compassion and advocacy. DESIGN: Community service was incorporated as a mandatory component of a postgraduate surgical training program. Residents participated in a community service activity, and reflected upon their learning with a presentation to their peers. PARTICIPANTS: Mandatory advocacy curriculum for all 67 first and second year surgical residents. Sixty-four residents chose to participate in a community service activity. Forty-six residents completed year end evaluations on the curriculum. RESULTS: Seventy percent of outreach activities were medically related, and 30% nonmedical. Most residents felt that the amount of work required to complete this project was reasonable (90%), and learned from their experiences (76%). Residents who participated in medically related projects self-described greater learning from their activity (93%), and from watching their peer presentations (79%). These trainees were also more likely to alter their patient management based on their experiences (68%). Trainees who participated in nonmedically related outreach projects were less likely to self-reflect learning from their experiences. Despite mandatory teaching in health advocacy, trainees are often unaware of this teaching within their curriculum. CONCLUSIONS: A mandatory outreach project in residency can encourage trainees to reflect on their volunteer activities as a physician and how it impacts their patient's health. Academic departments should try to encourage volunteerism within their trainees by providing opportunities for residents to participate in outreach activities related to their specialty.

International surgery: How to be involved while maintaining a surgical practice.

BACKGROUND: Surgeons can find it challenging to sustain their global involvement while maintaining a clinical practice. This study gathered advice from surgeons with global surgical experience on how to do so successfully. METHODS: Using a qualitative approach with thematic analysis, 14 semi-structured interviews were conducted with surgeons from different specialties involved in varying international projects. RESULTS: Early involvement is important to set up expectations for one's practice, and makes anticipated costs more manageable. The type of practice does not limit amount of participation, but maintaining a broader skill set can be beneficial. Hiring locums can help defray costs for community surgeons, and good collegial support is important for academic surgeons. Family support is important to maintain involvement. CONCLUSIONS: Surgeons from diverse clinical practices are able to participate in international surgery. Early involvement sets up expectations and allows one to build their practice and lives around their international work instead of the other way around.

Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital

Background: The use of outpatient health care services by homeless people is low compared to their high level of need; however, it is unclear whether this applies to surgical care. We sought to describe surgical care access among homeless patients in a Canadian tertiary care setting. Methods: We reviewed the medical records of adult (age > 18 yr) patients with no fixed address or a shelter address who presented to The Ottawa Hospital Emergency Department from Jan. 1, 2013, to Dec. 31, 2014, and required surgical referral. We analyzed the data using descriptive statistics. Results: A surgical referral was initiated in 129 emergency department visits for 97 patients (77 men [79%], mean age 46.7 yr). Most patients lived in shelters (77 [79%]) and had provincial health insurance (82 [84%]), but only 35 (36%) had a primary care physician. The mean number visits for any reason was 7.9 (standard deviation 13.7) (range 1­106). The majority of surgical referrals (83 [64.3%]) were for traumatic injuries, and the most frequently consulted service (52 [40.3%]) was orthopedic surgery. Just under half (48 [49%]) of referred patients attended at least 1 outpatient appointment, and only a third (33 [34%]) completed full follow-up. Conclusion: Homeless patients presenting to an emergency department and requiring surgical care were predominantly men living in shelters, most frequently seeking care for traumatic injuries. Current outpatient services may not meet the surgical care needs of these patients, as many do not access them. Alternative approaches to outpatient care must be considered, particularly among high-need services such as orthopedics, to support surgical care access among this population.

Contexte: L'utilisation des services de santé ambulatoires par les sans-abri est faible si on la compare à leurs besoins qui sont élevés; on ignore par contre s'il en va de même pour les soins chirurgicaux. Nous avons voulu décrire l'accès aux soins chirurgicaux chez les patients sans domicile fixe dans un hôpital de soins tertiaires au Canada. Méthodes: Nous avons passé en revue les dossiers médicaux de patients adultes (âge > 18 ans) sans domicile fixe ayant consulté aux urgences de l'Hôpital d'Ottawa entre le 1er janvier 2013 et le 31 décembre 2014, et pour qui une consultation en chirurgie avait été demandée. Nous avons analysé les données au moyen de statistiques descriptives. Résultats: Une consultation en chirurgie a été demandée lors de 129 visites aux urgences, pour 97 patients (77 hommes [79 %], âge moyen 46,7 ans). La plupart de ces patients vivaient dans des refuges (77 [79 %]) et bénéficiaient d'un régime d'assurance maladie provincial (82 [84 %]), mais seulement 35 (36 %) avaient un médecin de famille. Le nombre moyen de visites, toutes raisons confondues, a été de 7,9 (écart-type 13,7) (entre 1 et 106). La majorité des demandes de consultations en chirurgie (83 [64,3 %]) concernaient des lésions traumatiques et le service le plus souvent appelé en consultation (52 [40,3 %]) était la chirurgie orthopédique. Un peu moins de la moitié (48 [49 %]) des patients envoyés en consultation se sont présentés à au moins un rendez-vous en clinique externe, et seulement le tiers d'entre eux (33 [34 %]) se sont soumis au suivi complet. Conclusion: Les patients sans domicile fixe qui consultent aux urgences et ont besoin de soins chirurgicaux étaient principalement des hommes hébergés dans des refuges ayant le plus souvent consulté pour des blessures traumatiques. Les services ambulatoires actuels ne répondent peut-être pas aux besoins chirurgicaux de ces patients, car plusieurs n'y accèdent pas. Il faudrait envisager d'autres approches, particulièrement en ce qui concerne les services très en demande, comme l'orthopédie, pour faciliter l'accès aux soins chez cette population.

Individualized homeopathic treatment in addition to conventional treatment in type II diabetic patients in Hong Kong - a retrospective cohort study.

OBJECTIVE: Glycaemic goals are not achieved in most patients with type II diabetes mellitus (T2DM), especially in those with long disease duration and taking multiple oral antidiabetic drugs (OAD). We aimed to investigate the effectiveness of individualized homeopathic treatment in glycaemic control. DESIGN: Retrospective cohort study. SETTING: At least 6 months of individualized homeopathic treatment at a private homeopathic centre in Hong Kong. PARTICIPANTS: Twenty-seven adults aged 37-84 years were treated with individualized homeopathic remedies between 2012 and 2015. Published data on 40 T2DM patients under standard conventional treatment in Hong Kong were used as a control. MAIN OUTCOME MEASURE: Change in fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) at 12-month or the last follow-up, whichever is earlier. RESULTS: Compared with the conventional treatment only group, the homeopathy group had higher baseline FPG (p = 0.044), and more patients had a long (>20 years) duration of diabetes (p = 0.006), and a history of cardiac events (p = 0.022). The mean difference in FPG in the homeopathy group was significantly greater than in the control after 12 months: -2.24 mmol/L (95% confidence interval [CI]: -3.47 to -1.01) vs 0.16 mmol/L (95% CI: -1.72 to 2.04), p = 0.001. The mean difference in glycated haemoglobin (HbA1c) was also significantly greater, -1.11% (95% CI: -2.17 to -0.05) vs 0.08% (95% CI: -1.37 to 1.53), p = 0.046. Poorer baseline glycaemic control was associated with better outcome (r = -0.750, p < 0.001), but not the duration of diabetes (r = 0.058, p = 0.772). The improvement was robust to sensitivity analyses. CONCLUSION: Individualized homeopathic treatment was associated with better glycaemic control compared with standard conventional treatment alone.

Plasticity of mammary cell boundaries governed by EGF and actin remodeling.

Defined signals that dictate the architecture of cellular boundaries in confluent cultures are poorly characterized. Here, we report dramatic remodeling, invoked by long-term epidermal growth factor (EGF) withdrawal from mammary-derived MCF10A cells. Such intervention generates an interdigitated, desmosome-rich monolayer, wherein cells project actin-containing protrusions deep into neighboring cells. These changes protect cellular sheets from mechanical disruption and dramatically restrict the freedom of cells to roam within the monolayer. Ectopic expression of activated Rac counteracts interdigitation and induces membrane ruffling, but cells remain confined by their interdigitated neighbors. Interdigitations are rapidly dissolved by acute EGF application in a process that is sensitive to actin depolymerization and myosin II inhibition. These assays for formation and dissolution of interdigitations provide a platform for the dissection of novel signaling pathways that are highly specific to EGF receptor (EGFR) activation.

Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial.

BACKGROUND: Some children feel pain during wound closures using tissue adhesives. We sought to determine whether a topically applied analgesic solution of lidocaine-epinephrine-tetracaine would decrease pain during tissue adhesive repair. METHODS: We conducted a randomized, placebo-controlled, blinded trial involving 221 children between the ages of 3 months and 17 years. Patients were enrolled between March 2011 and January 2012 when presenting to a tertiary-care pediatric emergency department with lacerations requiring closure with tissue adhesive. Patients received either lidocaine-epinephrine-tetracaine or placebo before undergoing wound closure. Our primary outcome was the pain rating of adhesive application according to the colour Visual Analogue Scale and the Faces Pain Scale--Revised. Our secondary outcomes were physician ratings of difficulty of wound closure and wound hemostasis, in addition to their prediction as to which treatment the patient had received. RESULTS: Children who received the analgesic before wound closure reported less pain (median 0.5, interquartile range [IQR] 0.25-1.50) than those who received placebo (median 1.00, IQR 0.38-2.50) as rated using the colour Visual Analogue Scale (p=0.01) and Faces Pain Scale--Revised (median 0.00, IQR 0.00-2.00, for analgesic v. median 2.00, IQR 0.00-4.00, for placebo, p<0.01). Patients who received the analgesic were significantly more likely to report having or to appear to have a pain-free procedure (relative risk [RR] of pain 0.54, 95% confidence interval [CI] 0.37-0.80). Complete hemostasis of the wound was also more common among patients who received lidocaine-epinephrine-tetracaine than among those who received placebo (78.2% v. 59.3%, p=0.008). INTERPRETATION: Treating minor lacerations with lidocaine-epinephrine-tetracaine before wound closure with tissue adhesive reduced ratings of pain and increased the proportion of pain-free repairs among children aged 3 months to 17 years. This low-risk intervention may benefit children with lacerations requiring tissue adhesives instead of sutures. TRIAL REGISTRATION: ClinicalTrials.gov, no. PR 6138378804.

International plastic surgery missions: a framework for resident education using the CanMEDS competencies.

Residency education has shifted over the past decade in an attempt to graduate well-rounded physicians. There is a recognition that a physician's abilities must extend beyond medical knowledge. The Royal College of Physicians and Surgeons of Canada introduced the CanMEDS physician competency framework in 2005. The framework provides 7 areas of competencies that are aimed at providing improved patient care. These competencies are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Teaching and evaluating many of these competencies is often challenging for residency training programs. We believe that international surgical missions provide a prime opportunity to teach and evaluate all CanMEDS' roles.Plastic surgery is a field with many different organizations involved in international surgery. Many plastic surgery training programs offer opportunities for residents to become involved in these international surgical missions. Through these trips, residents gain surgical experience, see a variety and volume of clinical cases, and have the opportunity to travel to a foreign country and experience different cultures. We believe that international plastic surgery surgical missions also provide an exceptional micro environment for the teaching of CanMEDS roles. Using examples from residents' personal experiences on international plastic surgery missions to China, Mali, and Cambodia, we describe the benefits of these missions in transferring the CanMEDS competencies to resident training.

A forme-fruste variant of congenital midline cervical cleft with hamartomatous adnexal elements managed without Z-plasty.

Congenital midline cervical cleft is a relatively uncommon malformation of the anterior neck for which most of the current literature comprises case reports. There is a spectrum in clinical features, but the prototypical description is of a midline groove or cleft of atrophic skin with a skin tab at the cephalic end and an inferiorly oriented sinus tract at the caudal end. An underlying dense fibrous cord is usually described. The most widely postulated etiology is impaired midline fusion of the upper branchial arches. Some of the recent case reports advocate for removal of the defect and closure with Z-plasty. Here we report a case of a similar congenital lesion in a male patient. In our case, there was a conspicuous skin tab caudal to which there was a dense fibrous cord running vertically in the midline under the skin documented since the child was first examined at 5 months of age. The skin overlying the fibrous cord was mildly atrophic and only very subtly indented but was not desquamating or edematous. There was no open sinus tract at the caudal end, but within the skin tab, on histology, we did note an inclusion cyst lined by respiratory type mucosa with squamous metaplasia. The cord was composed of fibrous tissue and skeletal muscle, as has been described. In our case, we describe hamartomatous proliferations within the dermis of the skin tab, not previously described, which we feel provides further support to the embryologic closure defect hypothesis. Our case is distinct because the absence of an external cleft allowed for a more conservative surgical approach.