Approach to nail trauma for primary care physicians.

OBJECTIVE: To provide an overview and approach to common nail bed injuries seen by primary care practitioners. SOURCES OF INFORMATION: An Ovid MEDLINE literature search was performed using search terms and studies were graded based on level of evidence. MAIN MESSAGE: Nail trauma is common in primary care practice and requires proper and prompt treatment to avoid lasting effects on finger function and cosmesis. When presented with a fingernail injury, primary care physicians should perform a thorough physical examination to determine extent of injury; take a history to rule out notable risk factors; perform a comprehensive neurovascular examination to assess pulp capillary refill, to do a 2-point discrimination, and to compare with an uninjured digit; and evaluate range of motion. Clinical evaluation may require local anesthesia and a tourniquet. Nail bed trauma can present in different ways and includes subungual hematomas, distal phalanx fractures, Seymour fractures, and-in more severe cases-fragmentation or avulsion of the nail bed. Treatment for subungual hematomas where the nail plate is intact does not require nail plate removal and nail bed exploration; however, exploration and repair are indicated for a nail plate injury, a proximal fracture involving the germinal matrix, and a distal phalanx fracture requiring stabilization. CONCLUSION: Fingertips are essential to normal hand function. Nail trauma is common and can be managed by primary care physicians. Shared decision making concerning management is based on the mechanism and extent of the injury and aims to prevent secondary deformities.

Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training.

North American residency programs are transitioning to competency-based medical education (CBME) to standardize training programs, and to ensure competency of residents upon graduation. At the centre of assessment in CBME are specific surgical procedures, or procedural competencies, that trainees must be able to perform. A study previously defined 31 procedural competencies for aesthetic surgery. In this transition period, understanding current educational trends in resident exposure to these aesthetic procedures is necessary. The aim of this study was to characterize aesthetic procedures performed by Canadian plastic surgery residents during training, as well as to describe resident performance confidence levels and degree of resident involvement during those procedures. Case logs were retrieved from all 10 English-language plastic surgery programs. All aesthetic procedures were identified, and coded according to previously defined core procedural competencies (CPCs) in the aesthetic domain of plastic surgery. Data extracted from each log included the procedure, training program, resident academic year, resident procedural role, and personal competence. From July 2004 to June 2014, 6113 aesthetic procedures were logged by 55 graduating residents. Breast augmentation, mastopexy, and abdominoplasty were the most commonly performed CPCs, and residents report high levels of competence and surgical role in these procedures. Facial procedures, in particular rhinoplasty, as well as nonsurgical CPCs are associated with low exposure and personal competence levels. Canadian plastic surgery residents are exposed to most of the core aesthetic procedural competencies, but the range of procedures performed is variable. With the implementation of CBME, consideration should be given to supplementation where gaps may exist in aesthetic case exposure.

Canadian Plastic Surgery Resident Operative Experience in Hand Surgery.

PURPOSE: Core procedural competencies (CPCs) in hand surgery have been previously described. However, it is unknown whether plastic surgery residents receive sufficient operative experience with these procedures. This study aimed to determine whether Canadian plastic surgery residents are receiving adequate exposure to CPCs in hand surgery during residency training. METHODS: Hand surgery case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014 were reviewed from 3 databases. For each CPC in hand surgery, perceived resident role and self-competence scores were collected and analyzed. Core procedural competencies encompass core essential procedural competencies (CEPCs) and nonessential procedural competencies. RESULTS: There were 55 graduating plastic surgery residents included in the study. A total of 14,909 procedures were logged for 42 CPCs, with an average of 271 procedures/resident. When grouped by subdomain within hand surgery, procedures with the most exposure were related to traumatic finger injuries (29%) and neuropathies (22%). The least common procedures were related to flap reconstructions (0.3%) and muscle release (0.1%). Many residents reported receiving no operative experience (range, 2% to 100%) or between 1 and 10 cases of CEPCs (range, 7% to 50%). Most graduating residents (58% to 72%) did not feel competent independently performing 60% of the most common procedures. There were weak to moderate correlations between role and self-competence, and between postgraduate year and self-competence. CONCLUSIONS: Currently, many plastic surgery residents graduate from training programs with little to no exposure for over half of the CEPCs in hand surgery. CLINICAL RELEVANCE: Given the great diversity in hand surgery CPCs, it is difficult for residents to gain adequate operative experience during their residency in all of the CPCs.

Approche à l'égard des traumatismes unguéaux pour les médecins de soins primaires.

OBJECTIF: Présenter un aperçu et une approche concernant les lésions courantes au lit unguéal traitées par les professionnels des soins primaires. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée dans Ovid MEDLINE, et les études ont été classées selon le niveau des données probantes. MESSAGE PRINCIPAL: Les traumatismes à l'ongle sont vus couramment dans la pratique des soins primaires; ils exigent un traitement sans retard pour éviter des effets persistants sur le fonctionnement et l'apparence du doigt. En présence d'une blessure à l'ongle d'un doigt, les médecins de soins primaires devraient effectuer un examen physique rigoureux pour déterminer l'étendue de la lésion; faire une anamnèse pour exclure des facteurs de risque manifestes; procéder à un examen neurovasculaire complet pour évaluer le temps de remplissage capillaire à la pulpe du doigt; faire une discrimination tactile en 2 points et comparer avec un doigt intact; et évaluer l'ampleur du mouvement. L'évaluation clinique peut nécessiter une anesthésie locale et un tourniquet. Les lésions au lit unguéal peuvent se présenter de diverses façons; ils comprennent des hématomes sous-unguéaux, des fractures à la phalange distale, des fractures de Seymour et, dans les cas plus graves, une fragmentation ou une avulsion du lit unguéal. Le traitement des hématomes unguéaux lorsque la lame ou tablette de l'ongle est intacte n'exige pas l'ablation de la lame ni l'exploration du lit unguéal; toutefois, une exploration et une réparation sont indiquées pour une lésion au lit unguéal, une fracture proximale impliquant la matrice germinale et une fracture à la phalange distale qui nécessite une stabilisation. CONCLUSION: Le bout des doigts est essentiel au fonctionnement normal de la main. Les traumatismes unguéaux sont fréquents et peuvent être pris en charge par les médecins de soins primaires. La prise de décision partagée concernant la prise en charge se fonde sur le mécanisme et l'ampleur de la blessure, et vise à prévenir des difformités secondaires.

Predictors of Mastectomy Flap Necrosis in Patients Undergoing Immediate Breast Reconstruction: A Review of 718 Patients.

BACKGROUND: Mastectomy flap necrosis (MFN) after mastectomy and immediate breast reconstruction can compromise postsurgical recovery, lead to additional surgeries, and compromise aesthetic outcome. The objective of this study was to determine if there is a difference in the rate of MFN in patients undergoing immediate alloplastic versus immediate autologous breast reconstruction. The secondary objective was to identify additional patient and surgical factors that may influence the rate of MFN. METHODS: A retrospective chart review of patients who underwent immediate breast reconstruction between 2003 and 2011 in the University of British Columbia Breast Program was performed. Demographic, oncologic, reconstructive, and surgical data were compiled. RESULTS: Approximately 404 alloplastic and 314 autologous patients were reviewed. The overall rate of MFN was 12.9%. There was a trend toward a higher MFN rate in the autologous patient group (15.2% vs 11.6%, P = 0.095). After controlling for age, body mass index (BMI), smoking status, preoperative breast radiation, surgery duration, cancer side, mastectomy type, and postoperative chemotherapy, no association was found between reconstruction type and MFN. BMI greater than 30, smoking status, and preoperative radiation were independent predictors of MFN. Surgical factors including longer duration of surgery and Wise pattern mastectomy incision were also found to be associated with increased odds of MFN. CONCLUSION: We found no difference in the rate of MFN when comparing immediate alloplastic and autologous reconstruction methods. A number of patient and surgical factors were found to be predictors of MFN. The results of this large, retrospective study will help surgeons to tailor their reconstruction based on a patient's risk factors to minimize the incidence of MFN.

The Development of Assessment Tools for Plastic Surgery Competencies.

BACKGROUND: Objective tools to assess procedural skills in plastic surgery residency training are currently lacking. There is an increasing need to address this deficit in order to meet today's training standards in North America. OBJECTIVES: The purpose of this pilot study was to establish a methodology for determining the essential procedural steps for two plastic surgery procedures to assist resident training and assessment. METHODS: Following a literature review and needs assessment of resident training, the authors purposefully selected two procedures lacking robust assessment metrics (breast augmentation and facelift) and used a consensus process to complete a list of procedural steps for each. Using an online survey, plastic surgery Program Directors, Division Chiefs, and the Royal College Specialty Training Committee members in Canada were asked to indicate whether each step was considered essential or non-essential when assessing competence among graduating plastic surgery trainees. The Delphi methodology was used to obtain consensus among the panel. Panelist reliability was measured using Cronbach's alpha. RESULTS: A total of 17 steps for breast augmentation and 24 steps for facelift were deemed essential by consensus (Cronbach's alpha 0.87 and 0.85, respectively). CONCLUSION: Using the aforementioned technique, the essential procedural steps for two plastic surgery procedures were determined. Further work is required to develop assessment instruments based on these steps and to gather validity evidence in support of their use in surgical education.

Modeling luminal breast cancer heterogeneity: combination therapy to suppress a hormone receptor-negative, cytokeratin 5-positive subpopulation in luminal disease.

INTRODUCTION: Many Luminal breast cancers are heterogeneous, containing substantial numbers of estrogen (ER) and progesterone (PR) receptor-negative cells among the ER+ PR+ ones. One such subpopulation we call "Luminobasal" is ER-, PR- and cytokeratin 5 (CK5)-positive. It is not targeted for treatment. METHODS: To address the relationships between ER+PR+CK5- and ER-PR-CK5+ cells in Luminal cancers and tightly control their ratios we generated isogenic pure Luminal (pLUM) and pure Luminobasal (pLB) cells from the same parental Luminal human breast cancer cell line. We used high-throughput screening to identify pLB-specific drugs and examined their efficacy alone and in combination with hormone therapy in mixed-cell tumor models. RESULTS: We show that pLUM and MCF7 cells suppress proliferation of pLB cells in mixed-cell 3D colonies in vitro and that pLUM cells suppress growth of pLB cells in mixed-cell xenografts in vivo. High-throughput screening of 89 FDA-approved oncology drugs shows that pLB cells are sensitive to monotherapy with the epidermal growth factor receptor (EGFR) inhibitors gefitinib and erlotinib. By exploiting mixed-cell 3D colonies and mixed-cell solid mouse tumors models we demonstrate that combination therapy with gefitinib plus the anti-estrogen fulvestrant constitutes a robust treatment strategy. CONCLUSIONS: We propose that response to combination endocrine/EGFR inhibitor therapies in heterogeneous Luminal cancers may improve long-term survival in patients whose primary tumors have been preselected for appropriate biomarkers, including ER, PR, CK5 and EGFR.

Resident Exposure and Involvement in Core Procedural Competencies within Pediatric Plastic Surgery.

Introduction: The implementation of competency-based residency training in plastic surgery is underway. Key competencies in plastic surgery have been previously identified, however, within the domain of pediatrics, data suggest limited exposure throughout training for Canadian graduates. This study aims to identify the exposure and involvement of residents in core pediatric cases. Methods: We performed a retrospective, multicenter review of plastic surgery resident case logs (T-Res, POWER, New Innovations) across 10 Canadian, English-speaking training programs between 2004 and 2014. Case logs were coded according to the 8 core pediatric competencies previously identified by a modified Delphi technique. Results: A total of 3061 of 59 405 cases (5.2%) logged by 55 graduating residents were core pediatric procedures with an average of 55.6 ± 23.0 cases logged per resident. The top 3 most commonly logged procedures were cleft lip repair, cleft palate repair, and setback otoplasty. The number of cases per program varied widely with the most at 731 and least at 85 logged cases. Roles across procedures have wide variation and residents are most commonly identified as the assistant rather than surgeon or co-surgeon. Conclusion: These findings highlight variability both within and across residency programs with a paucity of exposure and involvement in pediatric plastic surgery cases. This may present a conflict between current recommendations for residency-specific procedural competencies and true clinical exposure. Further curriculum development and simulation may be of benefit.

Introduction: La formation des résidents fondée sur les compétences est en voie d'être adoptée en chirurgie plastique. Les compétences clés sont d'ailleurs déjà établies, mais dans le domaine de la pédiatrie, les données indiquent que les diplômés canadiens y sont peu exposés pendant leur formation. La présente étude vise à déterminer l'exposition et la participation des résidents aux cas fondamentaux en pédiatrie. Méthodologie: Les chercheurs ont procédé à une analyse multicentrique rétrospective des registres de cas des résidents en chirurgie plastique (T-Res, POWER, New Innovations) de dix programmes de formation anglophones canadiens entre 2004 et 2014. Ils ont codé ces registres en fonction des huit compétences pédiatriques fondamentales préalablement déterminées par une technique Delphi modifiée. Résultats: Au total, 3 061 des 59 405 cas enregistrés (5,2 %) par 55 résidents de dernière année étaient des interventions pédiatriques fondamentales, et chaque résident a enregistré une moyenne de 55,6 ± 23,0 cas. Les trois interventions les plus enregistrées étaient la réparation de la fissure labiale, la réparation de la fissure palatine et l'otoplastie. Le nombre de cas enregistrés variait énormément d'un programme à l'autre, le plus élevé étant de 731 et le plus bas, de 85. Les rôles au cours des interventions étaient très variables, et les résidents étaient davantage qualifiés d'assistants que de chirurgiens ou de cochirurgiens. Conclusion: Ces observations font ressortir la variabilité des pratiques à la fois au sein des programmes de résidence et entre eux et démontrent le peu d'exposition et de participation des résidents aux cas de chirurgie plastique pédiatrique. Elles peuvent révéler un conflit entre les recommandations actuelles en matière de compétences interventionnelles des résidents et la véritable exposition clinique. Il pourrait être utile de voir à l'élaboration plus poussée du programme et des simulations.

Z-DOC: a serious game for Z-plasty procedure training.

We present Z-DOC, a (prototype) serious game for training plastic surgery residents the steps comprising the Z-plasty surgical procedure. Z-DOC employs touch-based interactions and promotes competition amongst multiple players/users thus promote engagement and motivation. It is hypothesized that by learning the Z-plasty procedure in an interactive, engaging, and fun gaming environment, trainees will have a much better understanding of the procedure than by traditional learning modalities.

A novel preclinical model of craniospinal irradiation in pediatric diffuse midline glioma demonstrates decreased metastatic disease.

Background: Diffuse midline glioma (DMG) is an aggressive pediatric central nervous system tumor with strong metastatic potential. As localized treatment of the primary tumor improves, metastatic disease is becoming a more important factor in treatment. We hypothesized that we could model craniospinal irradiation (CSI) through a DMG patient-derived xenograft (PDX) model and that CSI would limit metastatic tumor. Methods: We used a BT245 murine orthotopic DMG PDX model for this work. We developed a protocol and specialized platform to deliver craniospinal irradiation (CSI) (4 Gy x2 days) with a pontine boost (4 Gy x2 days) and compared metastatic disease by pathology, bioluminescence, and MRI to mice treated with focal radiation only (4 Gy x4 days) or no radiation. Results: Mice receiving CSI plus boost showed minimal spinal and brain leptomeningeal metastatic disease by bioluminescence, MRI, and pathology compared to mice receiving radiation to the pons only or no radiation. Conclusion: In a DMG PDX model, CSI+boost minimizes tumor dissemination compared to focal radiation. By expanding effective DMG treatment to the entire neuraxis, CSI has potential as a key component to combination, multimodality treatment for DMG designed to achieve long-term survival once novel therapies definitively demonstrate improved local control.

Something Stinks! Finding Ways to Manage Noxious Odours in the Operating Room and Other Clinical Settings A Randomized Controlled Trial.

Objectives: The hospital can be saturated with noxious smells. Anecdotally, medical staff apply products to surgical masks to lessen the impact of these smells. This study aimed to determine the odour-masking ability of 4 inexpensive and convenient products. Methods: A randomized, single-blinded crossover study was conducted in Vancouver, Canada. Participants, 19 to 30 years old, were invited to participate. Participants with active allergies, upper respiratory tract infection, alteration to sense of smell, or failure of olfactory screen were excluded from the study. An experimental odour was used in lieu of a noxious surgical odour. After smelling the experimental odour without barriers, participants were re-exposed to the odour using 5 surgical masks in randomized order. Each mask was lined with a test product (cherry lip balm, tincture of benzoin, Mastisol, mint toothpaste, and control [plain mask]). Participants rated the effectiveness of products at masking the experimental odour from 0 to 100 (0 = completely ineffective, 100 = completely effective). Participants also rated the pleasantness of the products, recorded if the products made them feel unwell, and identified their preferred product overall. Results: Eighty participants were included in the study (33 male, 47 female), averaging 24.2 years of age. Mean odour-masking effectiveness for cherry lip balm was 66.5 (±24.6), tincture of benzoin: 62.6 (±25.0), Mastisol: 61.3 (±23.9), mint toothpaste: 57.5 (±27.4), and control: 21.9 (±21.8). All products performed better than the control (P < .001), but there was no significant difference in performance between products. Cherry lip balm was the most preferred odour-masking product (29 participants), followed by mint toothpaste (22), Mastisol (14), tincture of benzoin (10), and control (5). Conclusions: All tested products demonstrated equivalent odour-masking abilities. If health care professionals choose to use an odour-masking product, they should consider their own olfactory preferences.

Objectifs: L'hôpital peut être saturé d'odeurs nauséabondes. On rapporte que le personnel médical applique des produits sur leurs masques chirurgicaux pour atténuer l'impact de ces odeurs. Cette étude visait à déterminer l'efficacité de quatre produits masqueurs d'odeurs, et ce de façon pratique et peu couteuse. Méthodes: Une étude croisée a simple insu et a répartition aléatoire a été menée à Vancouver, Canada. Des participants âgés de 19 à 30 ans, ont été invités à participer. Les participants souffrant d'allergies actives, d'une infection des voies respiratoires supérieures, d'une altération olfactive, ou aillant échoué la procédure de sélection ont été exclus de l'étude. Une odeur expérimentale a été utilisée au lieu d'une odeur nauséabonde chirurgicale. Après avoir senti l'odeur expérimentale, les participants ont été réexposés à la même odeur à cinq reprises. A chaque reprise, le participant était muni d'un de 5 masques tapissé d'un agent masquant d'odeur (baume à lèvres aux cerises, teinture de benzoïne, mastisol, dentifrice à la menthe, et contrôle [masque standard]). L'ordre des masques a été déterminé de façon aléatoire. Les participants ont noté sur une échelle de 0 à 100 l'efficacité des produits à masquer l'odeur (0: complètement inefficace, 100: complètement efficace). Les participants ont également évalué la qualité plaisante des agents, si ceux-ci les rendaient nauséeux, et ont ensuite identifié leur produit préféré parmi l'ensemble. Résultats: Quatre-vingts participants ont été inclus dans l'étude (33 hommes, 47 femmes), âgés en moyenne de 24,2 ans. L'efficacité des produits à masquer l'odeur expérimentale étaient d'une moyenne de 66,5 (+24,6) pour le baume à lèvres aux cerises ; 62,6 (+25,0) pour la teinture de benzoine ; 61,3 (+23,9) le mastisol ; 57,5 (+27,4) pour le dentifrice à la menthe, et 21,9 (+21,8) le contrôle. Tous les agents testés ont reçu une note supérieure au contrôle (P < .001). Par-contre, il n'y avait pas de différence significative entre les agents. Le baume à lèvres aux cerises était le produit préféré (29 participants), suivi du dentifrice à la menthe (22), du mastisol (14), de la teinture de benzoine (10), et finalement du contrôle (5). Conclusions: Tous les produits testés ont démontré une efficacité similaire, celle-ci supérieure comparée au contrôle. Si les professionnels de la santé souhaitent d'utiliser un produit qui masque les odeurs, ils devraient tenir compte de leurs propres préférences.

High risk of sleep disordered breathing in the enuresis population.

PURPOSE: Enuresis is 1 of the most common complaints facing pediatric urologists and it has significant implications with respect to quality of life. Although the pathophysiology is incompletely understood, there is growing evidence that sleep disordered breathing in children, including obstructive sleep apnea, has a fundamental role. There are also potentially fundamental differences between monosymptomatic enuresis, which may be a sleep disorder, and nonmonosymptomatic enuresis, which may relate to a primary bladder storage problem. We prospectively evaluated the incidence of obstructive sleep apnea in patients with enuresis and analyzed differences between patients with monosymptomatic and nonmonosymptomatic enuresis. MATERIALS AND METHODS: A total of 69 children with enuresis were given 3 validated questionnaires to complete, including the Dysfunctional Voiding and Incontinence Symptom Score, the Obstructive Sleep Apnea Quality of Life survey and the Modified Pediatric Sleep Questionnaire. The Dysfunctional Voiding and Incontinence Symptom Score quantifies patient dysfunctional voiding habits. The Obstructive Sleep Apnea Quality of Life survey evaluates patient quality of life in regard to obstructive sleep apnea and its effects. Modified Pediatric Sleep Questionnaire results describe the severity of patient sleep disturbances. RESULTS: The mean Obstructive Sleep Apnea Quality of Life Survey score was 43 and 54% of patients had positive Modified Pediatric Sleep Questionnaire results, indicating that obstructive sleep apnea was prevalent in our population. Those with enuresis and daytime incontinence were significantly more likely to have sleep disordered breathing than those with monosymptomatic enuresis (p <0.05). CONCLUSIONS: Our study confirms the link between sleep disordered breathing and enuresis. All pediatric health care providers should be aware of this risk. The risk may be magnified in patients with concomitant daytime incontinence.

Novel RAF Fusions in Pediatric Low-Grade Gliomas Demonstrate MAPK Pathway Activation.

Brain tumors are the most common solid tumor in children, and low-grade gliomas (LGGs) are the most common childhood brain tumor. Here, we report on 3 patients with LGG harboring previously unreported or rarely reported RAF fusions: FYCO1-RAF1, CTTNBP2-BRAF, and SLC44A1-BRAF. We hypothesized that these tumors would show molecular similarity to the canonical KIAA1549-BRAF fusion that is the most widely seen alteration in pilocytic astrocytoma (PA), the most common pediatric LGG variant, and that this similarity would include mitogen-activated protein kinase (MAPK) pathway activation. To test our hypothesis, we utilized immunofluorescent imaging and RNA-sequencing in normal brain, KIAA1549-BRAF-harboring tumors, and our 3 tumors with novel fusions. We performed immunofluorescent staining of ERK and phosphorylated ERK (p-ERK), identifying increased p-ERK expression in KIAA1549-BRAF fused PA and the novel fusion samples, indicative of MAPK pathway activation. Geneset enrichment analysis further confirmed upregulated downstream MAPK activation. These results suggest that MAPK activation is the oncogenic mechanism in noncanonical RAF fusion-driven LGG. Similarity in the oncogenic mechanism suggests that LGGs with noncanonical RAF fusions are likely to respond to MEK inhibitors.

Resident Behaviours to Prioritize According to Canadian Plastic Surgeons.

INTRODUCTION: Many articles have been published outlining the resident selection process for plastic surgery training programs. However, which qualities Canadian plastic surgeons value most in their current residents remains unclear. A national survey study was conducted to identify which attributes surgeons associate with the highest resident performance and which behaviours trainees should prioritize during their training. METHODS: A literature review was performed to identify studies that documented attributes valued in plastic surgery applicants and characteristics of high-performing surgical residents. These qualities were extracted to construct a survey consisting of both ranking and open-ended questions. After an iterative review process, the survey was disseminated nationally to consultants and trainees of Canadian plastic surgery training programs. RESULTS: Survey responses were obtained from 120 invitees and a weighted rank was calculated for each evaluated attribute. The terms integrity, professional, and work ethic were viewed as the most important attributes prized by surgeons. Dishonesty, lack of dependability, and unprofessionalism were viewed as the most concerning behaviours. Additionally, disinterest and arrogance were identified by the open-ended questions as behaviours surgeons would like to see less frequently in their trainees. When compared to surgeons, trainees undervalued the importance of knowledge and the impact of unprofessional behaviour. CONCLUSIONS: With the multiple roles that a resident must fulfill, understanding which attributes are of the most importance will help focus self-directed learning and development within residency programs. Ultimately, instilling the importance of integrity and professionalism is most highly valued by members of the Canadian plastic surgery community.

Variable Experience in Microsurgery and Flap-Based Procedures Among Canadian Plastic Surgery Residents.

TITLE: Variable experience in microsurgery and flap-based procedures among Canadian plastic surgery residents. OBJECTIVE: Plastic surgery residencies are transitioning toward a competency-based education model. It is not known whether trainees can realistically achieve proficiency in microsurgical techniques during their training. This study aims to define the operative experience in the core microsurgical flap procedures among Canadian plastic surgery residents. DESIGN: Microsurgical core procedural competencies (CPCs) have been described. A retrospective review was conducted, evaluating case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014. Perceived role and competence scores were also collected and analyzed. SETTING: University of Toronto, Toronto, ON, Canada; University of British Columbia, Vancouver, BC, Canada. RESULTS: Among 27 microsurgical CPCs, 2082 procedures were logged and each resident performed an average of 37.9 (±21.7) procedures. Anterolateral thigh flaps, radial forearm-based flaps, and digit replants were the most common; however, 10.9% to 14.5% of residents did not have any operative experience with these flaps. Most residents reported zero operative experience with many of the CPCs (10.9%-100%). Co-Surgeon (50%) and First Assistant (30%) were the most common roles. None of the graduating residents reported feeling competent enough to independently perform 50% of the microsurgery CPCs. There was no difference in perceived roles when programs with ≥5 residents were compared against programs with fewer trainees. There were weak to moderate correlations between role and self-perceived competence, and between Post Graduate Year and self-perceived competence. CONCLUSIONS: There is wide variation in resident operative experience in microsurgical CPCs. Many residents graduate with little to no experience in many of the core procedures. Identifying areas of deficiency may help guide curriculum development in the new competency-based education model.

Preclinical and clinical investigation of intratumoral chemotherapy pharmacokinetics in DIPG using gemcitabine.

BACKGROUND: Hundreds of systemic chemotherapy trials in diffuse intrinsic pontine glioma (DIPG) have not improved survival, potentially due to lack of intratumoral penetration, which has not previously been assessed in humans. METHODS: We used gemcitabine as a model agent to assess DIPG intratumoral pharmacokinetics (PK) using mass spectrometry. RESULTS: In a phase 0 clinical trial of i.v. gemcitabine prior to biopsy in children newly diagnosed with DIPG by MRI, mean concentration in 4 biopsy cores in patient 1 (H3K27M diffuse midline glioma) was 7.65 µM. These compare favorably to levels for patient 2 (mean 3.85 µM, found to have an H3K27-wildtype low-grade glioma on histology), and from a similar study in adult glioblastoma (adjusted mean 3.48 µM). In orthotopic patient-derived xenograft (PDX) models of DIPG and H3K27M-wildtype pediatric glioblastoma, gemcitabine levels and clearance were similar in tumor, pons, and cortex and did not depend on H3K27 mutation status or tumor location. Normalized gemcitabine levels were similar in patient 1 and the DIPG PDX. CONCLUSIONS: These findings, while limited to one agent, provide preliminary evidence for the hypotheses that lack of intratumoral penetration is not why systemic chemotherapy has failed in DIPG, and orthotopic PDX models can adequately model intratumoral PK in human DIPG.

Correction: BPTF regulates growth of adult and pediatric high-grade glioma through the MYC pathway.

The original version of this Article omitted the following from the Acknowledgements: This work was supported by the Luke's Army Pediatric Cancer Research Fund St. Baldrick's Scholar Award. This has now been corrected in both the PDF and HTML versions of the Article.

BPTF regulates growth of adult and pediatric high-grade glioma through the MYC pathway.

High-grade gliomas (HGG) afflict both children and adults and respond poorly to current therapies. Epigenetic regulators have a role in gliomagenesis, but a broad, functional investigation of the impact and role of specific epigenetic targets has not been undertaken. Using a two-step, in vitro/in vivo epigenomic shRNA inhibition screen, we determine the chromatin remodeler BPTF to be a key regulator of adult HGG growth. We then demonstrate that BPTF knockdown decreases HGG growth in multiple pediatric HGG models as well. BPTF appears to regulate tumor growth through cell self-renewal maintenance, and BPTF knockdown leads these glial tumors toward more neuronal characteristics. BPTF's impact on growth is mediated through positive effects on expression of MYC and MYC pathway targets. HDAC inhibitors synergize with BPTF knockdown against HGG growth. BPTF inhibition is a promising strategy to combat HGG through epigenetic regulation of the MYC oncogenic pathway.

Proteasomal regulation of the proliferation vs. meiotic entry decision in the Caenorhabditis elegans germ line.

Reproductive fitness in many animals relies upon a tight balance between the number of cells that proliferate in the germ line and the number of cells that enter meiosis and differentiate as gametes. In the Caenorhabditis elegans germ line, the GLP-1/Notch signaling pathway controls this balance between proliferation and meiotic entry. Here we describe the identification of the proteasome as an additional regulator of this balance. We show that a decrease in proteasome activity, through either genetic mutation or RNAi to core components of the proteasome, shifts this balance toward excess germ-line proliferation. We further demonstrate that there are likely two or more proteasome targets that contribute to excess germ-line proliferation when proteasome activity is reduced. One of these targets is likely a component or regulator of the Notch-signaling pathway, while the other functions on one of the two major redundant genetic pathways downstream of GLP-1/Notch signaling. We propose a model in which the proteasome degrades proteins that are necessary for proliferation as cells switch from proliferation to meiotic entry.

Burn Care and Surgical Exposure amongst Canadian Plastic Surgery Residents: Recommendations for Transitioning to a Competency-Based Medical Education Model.

With the ongoing implementation of a competency-based medical education (CMBE) model for residency programs in North America, emphasis on the duration of training has been refocused onto ability and competence. This study aims to determine the exposure of burn-related core procedural competencies (CPCs) in Canadian Plastic Surgery Residents in order to enhance curricular development and help define its goals. A retrospective review of burn-related resident case logs encompassing all 10 English-speaking plastic surgery residency programs from 2004 to 2014 was performed, including analysis of personal competence scores and resident role by Postgraduate Year (PGY)-year. Case logs of a total of 55 graduating plastic surgery residents were included in the study. Overall, 4033 procedures in burn and burn-related care were logged, accounting for 6.8% of all procedures logged. On average, each resident logged 73 burn procedures, 99% of which were CPCs. The most frequently performed procedure was harvest and application of autograft, allograft, or xenograft, while emergent procedures such as escharotomy and compartment release were performed on average less than one time per resident. Personal competence scores as well as role of the resident (surgical responsibility) increased as PGY-year progressed during residency. Canadian plastic surgery residency programs provide adequate exposure to the majority of the scope of burn care and surgery. However, infrequently encountered but critical procedures such as escharotomy and fasciotomy may require supplementation through dedicated educational opportunities. CMBE should identify these gaps in learning through facilitation of resident competency evaluation. With consideration for the amount of exposure to burn-related CPCs as identified, plastic surgery residency programs can work toward achieving competency in all aspects of burn care and surgery prior to the completion of residency.