A91 CANADIAN FEMALE FELLOW PERSPECTIVES ON TRAINING IN THE BOYS CLUB: ADVANCED THERAPEUTIC ENDOSCOPY

Background

Unequal female representation in the field of advanced therapeutic endoscopy (ATE) has been recently highlighted in the United States. Previous attempts to determine the barriers of entry into the career have found reasons including lack of mentorship, patriarchy, inflexible hours/call and exposure to fluoroscopy. There is no current literature describing the landscape of exposure to ATE for trainees in Canada or determining differences in experience based on gender.

Aims

We sought to determine the barriers to pursuing a career in advanced therapeutic endoscopy, specifically focussing on the perspectives of Canadian female gastroenterology fellows.

Methods

A survey was developed and distributed to the gastroenterology fellows enrolled in Royal College accredited programs across Canada via an online survey platform.

Results

Responses were received from gastroenterology fellows at 12 out of the 14 Canadian universities with Royal College accredited programs. The response rate was 46% (n=42, 16 female respondents, 26 male respondents). An equal proportion of male (42%, n=11) and female (38%, n=6) trainees indicated interest in a career in ATE. 38% (n=6) of female trainees felt that they had inadequate mentorship opportunities/role models within ATE, in comparison to 4% (n=1) of males (p=0.004). Furthermore, 19% (n=3) of females felt that this lack of mentorship/role models was a primary deterrent from pursuing ATE as a career, in comparison to 0% of males (p=0.02). There was equal self-perceived competency surrounding ATE knowledge between both genders.

Conclusions

Female gastroenterology fellows in Canada lack mentorship and role models in ATE, which they also indicated as a primary deterrent from pursuing it as a career when compared to their male counterparts. Recognizing and addressing the lack of female leadership and visibility is necessary to improve parity and encourage women to train in the male-dominated field of ATE.

Funding Agencies

None

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Single-molecule analysis of specificity and multivalency in binding of short linear substrate motifs to the APC/C

Robust regulatory signals in the cell often depend on interactions between short linear motifs (SLiMs) and globular proteins. Many of these interactions are poorly characterized because the binding proteins cannot be produced in the amounts needed for traditional methods. To address this problem, we developed a single-molecule off-rate (SMOR) assay based on microscopy of fluorescent ligand binding to immobilized protein partners. We used it to characterize substrate binding to the Anaphase-Promoting Complex/Cyclosome (APC/C), a ubiquitin ligase that triggers chromosome segregation. We find that SLiMs in APC/C substrates (the D box and KEN box) display distinct affinities and specificities for the substrate-binding subunits of the APC/C, and we show that multiple SLiMs in a substrate generate a high-affinity multivalent interaction. The remarkably adaptable substrate-binding mechanisms of the APC/C have the potential to govern the order of substrate destruction in mitosis.

Demise of the stethoscope

Medical practice has undergone a massive drift over the past several years. With the advent of modernization and technical advancements in both diagnostic and therapeutic fields, bedside clinical skills have suffered a setback. Increasing patient load in the hospitals, administrative commitments of the physicians, and need to get superspecialty fellowships are some of the factors which preclude resident teaching, which, in-turn hamper their long-term clinical skills and influence the patient-doctor relationship. In this perspective, I narrate my own experience regarding changing attitude of the younger generation of doctors toward patient care and also describe the role of a mentor in shaping the believes and practices of his medical students. Using real-world examples, I further discuss the obstacles which hamper good medical practice and suggest possible ways to overcome some of them.

Efficacy and safety of high versus standard dose ibuprofen for patent ductus arteriosus treatment in preterm infants: A systematic review and meta-analysis

BACKGROUND

Several small randomized controlled trials (RCTs) and observational studies have compared high (15-20/7.5-10/7.5-10 mg/kg/dose) versus standard dose (10/5/5 mg/kg/dose) ibuprofen for patent ductus arteriosus (PDA) closure, with limited evidence on efficacy and safety.

OBJECTIVE

To systematically review and meta-analyze studies of high versus standard dose ibuprofen for the closure of PDA in preterm infants.

METHODS

Databases were searched for RCTs and observational studies assessing high compared to standard dose of ibuprofen for PDA closure for preterm infants until August 2021. The primary outcome was failure of PDA closure after the first course of ibuprofen. The secondary outcomes were the failure of PDA closure after a second course of ibuprofen, rates of PDA ligation, all-cause mortality prior to hospital discharge, bronchopulmonary dysplasia, necrotizing enterocolitis, bleeding disorders, oliguria, and serum creatinine after treatment.

RESULTS

There were 6 studies with 369 patients (3 RCT, N = 190; 3 observational studies, N = 179). Compared to standard dose, high dose ibuprofen did not significantly decrease the failure rate of PDA closure in preterm infants after the first course (Relative risk (RR) 0.74, 95% confidence interval (CI) 0.53 -1.03, 6 studies, N = 369). High dose ibuprofen significantly decreased the rates of PDA ligation compared to standard dose (RR 0.33, 95% CI 0.16 -0.70, 5 studies, N = 309).

INTERPRETATION

Based on low-grade evidence, high dose ibuprofen may more effectively reduce rates of PDA ligation compared to standard dose with no increase in adverse effects, neonatal morbidities and mortality.

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Factors associated with antibiotic administration delay among preterm infants with late-onset bloodstream infection

Early antibiotic administration is an important modifiable factor in reducing mortality from late-onset bloodstream infections in preterm infants. In a cohort study including 142 infants with non-coagulase negative staphylococcus bloodstream infection at two tertiary neonatal intensive care units, we identified typical practice-related factors that may be targeted to prevent delays in antibiotic administration. Collection of cerebrospinal fluid or urine sample before administering antibiotics, a longer time taken to site a peripheral intravenous catheter among those without pre-existing access, and a longer time taken to administer fluid boluses were associated with a longer than median time to antibiotic administration.

1697 Undergraduate Otolaryngology: Enhancing Interest and Education with Hands-on Simulation

Introduction

With cancelled student placements due to the COVID-19 pandemic, there is a shift towards non-patient-facing methods to deliver medical education. The aim was to design, deliver and evaluate an ENT course for undergraduate medical students.

Method

A three-part simulation course on common and emergency ENT conditions was delivered by ENT trainees to undergraduate medical students (n = 50). It involved theoretical and hands-on experience with otoscopy on head models; nasoendoscopy and epistaxis management with upper airway head models and nasal packing kits; and management of compromised airways using critical airway models, airway adjuncts, intubation and cricothyroidotomy kits. Delegates were given pre- and post-course questionnaires, with another at six-weeks to test knowledge retention. Results were statistically analysed using paired and independent sample t-tests.

Results

A statistically significant improvement in post-test knowledge of 55% (p<0.01) was observed. Delegates also demonstrated a sustained improvement of 51% (p<0.01) six-weeks later compared to baseline knowledge. 76% and 80% reported improved confidence managing epistaxis and performing intubation respectively; 46% reported increased interest in pursuing ENT as a potential career.

Conclusions

This study demonstrated statistically significant and sustained improvements in knowledge about common and emergency ENT concepts. ENT simulation therefore represents an efficacious mechanism for teaching key ENT concepts and improving confidence in undergraduate medical students, whilst improving interest in pursuing ENT as a career. Additionally, simulation is an invaluable educational adjunct that may foster more realistic, impactful, and safer educational experiences for medical students whilst exposure to patients is minimised due to the current pandemic.

Oral health and atherosclerotic cardiovascular disease: A review

Periodontal disease (PD) is common in the US and globally. Evidence suggests that poor oral health is associated with atherosclerotic cardiovascular disease (ASCVD); however, this relationship has not been a major focus in clinical cardiology. This manuscript will review the growing evidence linking PD to ASCVD, including pathophysiologic mechanisms and coexistent risk factors. Public health considerations with a focus on disparities, social determinants, preventive strategies, and a call to action to reduce the burden of coincident ASCVD and PD are also reviewed.

Modified vertical osteotomy cut in bilateral sagittal split osteotomy

Bilateral sagittal split osteotomy (BSSO) is the most common orthognathic surgical procedure for the correction of facial deformities. Like any other surgical procedure, it is also associated with a risk of complications. One of these is described in the literature as notching at the lower inferior border of the mandible. Such discontinuity in the contour of the lower border is often a concern for patients. To overcome this complication, we recommend a modified vertical osteotomy cut while performing BSSO.

Functional Outcome and Complications in Management of Proximal Humerus Fractures Operated with Proximal Humerus Locking Plate

Introduction:

Controversies exist in treatment of proximal humerus fractures as treatment options vary greatly from conservative management, closed pinning, stacked intramedullary nails, plating and hemi-arthroplasty. The purpose of this study is to study the fracture patterns of each case and document the functional outcome and complications post-operative in the management of proximal humerus fractures operated with proximal humerus plate.

Material and Methods:

Thirty five patients with closed proximal humerus fractures, above 18 years old, admitted in our tertiary care hospital during the study period were enrolled. Patients underwent open reduction internal fixation with proximal humerus locking plate under general anaesthesia. Post-operative patients were assessed using Constant and DASH scores. Complications were recorded.

Results:

In our study the absolute Constant score of the study population increases at three months and six months and was found to be significant. Mean Constant score for 4-part fractures was 45.6 which were inferior as compared to 2-part and 3-part fractures (43.1 and 44.6, respectively). The mean Constant score at six months was 51.80 +/- 6.71. All three types of proximal humerus fractures showed significant improvement in the mean DASH score over our study period of six months and was found to be significant. Mean DASH score at six months was 27.97+/-12.84. Out of the 35 cases in the study two had complications. One had implant failure (Neer’s type 3, 60-year-old female) and one had varus collapse (Neer’s type 3, 45-year-old male).

Conclusion:

Due to angular stability and effective maintenance of the intraoperative fracture reduction during follow-up period, early post-operative mobilisation is possible which helps the patient to attain better shoulder range of motion and return to activity faster.

Primary hyperparathyroidism misdiagnosed as metastatic disease, with trans-oral endoscopic surgical management

Primary hyperparathyroidism is not so uncommon a disease. In high-income countries, with the introduction of routine biochemical testing in 1980s, it is diagnosed early, and the majority are seen as asymptomatic disease. However, in India, a severe symptomatic form is still seen, and many times patients are undiagnosed, thus continuing to suffer debilitating disease. Here, we report such a patient who was being treated as having bony metastases from an unknown primary source, when in fact he had osteitis fibrosa cystica due to primary hyperparathyroidism and was cured after surgery.

Absence of Meckel Cave: A Rare Cause of Trigeminal Neuralgia

Trigeminal neuralgia is a debilitating condition with numerous etiologies. In this retrospective case series, we report a cohort of patients with a rarely described entity, absence of Meckel cave, and propose this as a rare cause of trigeminal neuralgia. A search of the electronic medical record was performed between 2000 and 2020 to identify MR imaging reports with terms including "Meckel's cave" and "hypoplasia," "atresia," "collapse," or "asymmetry." Images were reviewed by 2 blinded, board-certified neuroradiologists. Seven cases of the absence of Meckel cave were identified. Seven patients (100%) had ipsilateral trigeminal neuralgia and ipsilateral trigeminal nerve atrophy, suggesting an association between absence of Meckel cave and trigeminal neuralgia. Absence of Meckel cave is a rare entity of unknown etiology, with few existing reports that suggest the possibility of an association with trigeminal neuralgia. Its recognition may have important implications in patient management. Future studies and longitudinal data are needed to assess treatment outcomes and added risks from surgical intervention in these patients.

A proposed "Radiological Evaluation Score for Bone Tumors" (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor

BACKGROUND

Although radiographs have been widely used in the evaluation of patients with suspected bone tumors, the lack of an objective radiological assessment method leads to a challenge in reaching correct diagnosis. The study aimed to propose a Radiological Evaluation Score for Bone Tumors (REST) which includes eight radiological factors [characteristics, content, cortical breach, distinctiveness, distribution, periosteal reaction, fracture, and soft tissue swelling] to form a single score along with its validation by multidisciplinary observers.

METHODS

We reviewed the radiographs of 100 patients with a primary bone tumor which were selected at random from the database between January 2017 and January 2019 of a tertiary cancer center. Four reviewers (two orthopedic oncologists and two surgical oncologists) independently assessed the radiographs, based on the reporting system of REST. We constituted two groups according to the probable diagnosis of bone tumor (suspected benign tumor and suspected malignant tumor).

RESULTS

The mean score in the suspected benign tumor group was 1.1 (range 0-3, 95% CI 0.8-1.3) and in malignant tumor group was 6.1 (range 2-8, 95% CI 5.8-6.4). A receiver operator characteristic (ROC) curve for REST was with a cutoff of 3.5, with the most diagnostic value area under curve (AUC) of 0.99. The sensitivity was 98% and specificity was 100% with a positive predictive value of 100% and a negative predictive value of 98%. The inter-observer correlation coefficient was 0.985 (p value < 0.05), and Fleiss kappa value for the prediction of the benign or malignant lesion was 0.97 (p value < 0.05). The characteristics and content of tumor, cortical erosion, distinctiveness, distribution, periosteal reaction, and soft tissue mass had a significant correlation with the aggressiveness of bone lesion p value < 0.05.

CONCLUSIONS

The Radiological Evaluation Score for Bone Tumors (REST) is a structured reporting and objective method for the assessment of radiographs in patients with suspected bone tumors. This method is a reliable and helpful tool for clinicians in their outdoor patient department to differentiate a radiograph of a suspected benign tumor from a malignant bone tumor.