Barriers to Black Medical Students and Residents Pursuing and Completing Surgical Residency in Canada: A Qualitative Analysis.

BACKGROUND: The limited available data suggest that the Canadian surgical workforce does not reflect the racial diversity of the patient population it serves, despite the well-established benefits of patient-provider race concordance. There have been no studies to date that characterize the systemic and individual challenges faced by Black medical students in matching to and successfully finishing training in a surgical specialty within a Canadian context that can explain this underrepresentation. STUDY DESIGN: Using critical qualitative inquiry and purposive sampling to ensure sex, geographical, and student or trainee year heterogeneity, we recruited self-identifying Black medical students and surgical residents across Canada. Online in-depth semistructured interviews were conducted and transcribed verbatim. Transcripts were analyzed through an inductive reflexive narrative thematic process by 4 analysts. RESULTS: Twenty-seven participants including 18 medical students and 9 residents, were interviewed. The results showed 3 major themes that characterized their experiences: journey to and through medicine, perceptions of the surgical culture, and recommendations to improve the student experience. Medical students identified lack of mentorship and representation as well as experiences with racism as the main barriers to pursuing surgical training. Surgical trainees cited systemic racism, lack of representation, and insufficient safe spaces as the key deterrents to program completion. The intersection with sex exponentially increased these identified barriers. CONCLUSIONS: Except for a few surgical programs, medical schools across Canada do not offer a safe space for Black students and trainees to access and complete surgical training. An urgent change is needed to provide diverse mentorship that is transparent, acknowledges the real challenges related to systemic racism and biases, and is inclusive of different racial and ethnic backgrounds.

Incidence, Mortality, and Survival of Merkel Cell Carcinoma: A Systematic Review of Population Based-Studies.

BACKGROUND: Merkel Cell Carcinoma (MCC) is a rare, aggressive skin cancer that most commonly occurs in UV-exposed body sites. Its epidemiology in different geographies and populations is not well characterised. OBJECTIVE: The objective of this systematic review is to summarize evidence on the incidence, mortality, and survival rates of MCC from population-based studies. METHODS: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from database inception to June 6th, 2023. No geographic, age or date exclusions were applied. We included population-based studies of MCC that reported the incidence, survival, or mortality rate, and considered systematic reviews. A data-charting form was created and validated to identify variables to extract. Two reviewers then independently charted the data for each included study with patient characteristics, and estimates of incidence rate, mortality rate, and survival rate and assessed the quality of included studies using the Joanna Briggs Institute Checklist for Prevalence studies, Newcastle-Ottawa Scale and Assessment of Multiple Systematic Reviews. We abstracted age-, sex-, stage- and race-stratified outcomes, and synthesized comparisons between strata narratively and using vote counting. We assessed the certainty of evidence for those comparisons using the Grading of Recommendations, Assessments, Developments and Evaluations framework. RESULTS: We identified 11,472 citations, of which 52 studies from 24 countries met our inclusion criteria. Stage 1 and the head and neck were the most frequently reported stage and location at diagnosis. The incidence of MCC is increasing over time (high certainty), with the highest reported incidences reported in Southern hemisphere countries (Australia [2.5 per 100,000], New Zealand [0.96 per 100,000]) (high certainty). Male patients generally had higher incidence rates compared to female patients (high certainty), although there were some variations over time periods. Survival rates varied, with lower survival and/or higher mortality associated with male sex (moderate certainty), higher stage at diagnosis (moderate-to-high certainty), older age (moderate certainty), and immunosuppression (low-to-moderate certainty). CONCLUSIONS: MCC is increasing in incidence and may increase further given the ageing population of many countries. The prognosis of MCC is poor, particularly for males, those who are immunosuppressed, and patients diagnosed at higher stages or at an older age.

Current Understanding of "Mixed Corticomedullary Adrenal Tumor" and an Insight into Genomic Profiling.

BACKGROUND: Malignant mixed corticomedullary adrenal tumors (MCMTs) are extremely rare, with limited cases reported in the literature. The pathophysiology of malignant MCMTs is not well understood; the most prevailing theories are that it is a composite tumor of embryologically derived mesodermal (adrenal cortex) and neural crest (medulla) origin, perpetuating as two distinct cell lines forming a singular mass. Clinical features and laboratory diagnosis are associated with hypersecretions of the adrenal cortex and medulla. Surgical resection is curative in an isolated tumor. We reviewed and compared cases in the literature highlighting the pathogenesis and genetics of benign and malignant MCMT. METHODS: Comprehensive literature analysis was conducted on PubMed and all the cases of mixed corticomedullary adrenal tumor published in English were included. RESULTS: Most patients were female (73.1%) with a median age of 49 in women and 50 in men. Surgery was performed in all patients, and in four patients with malignant disease, chemotherapy was used as well. Clinically, most patients presented with hypertension (69%) followed by Cushing syndrome (42%) and diabetes (19%). Tumors often produced cortisol (74%), catecholamines (50%), and adrenocorticotrophic hormone (ACTH) (38%), with lower incidence of aldosterone- (7%) or dopamine (4%)-producing tumors. Immunohistochemical staining of 96% of cases showed Chromogranin-A (73%) and Synaptophysin (62%), followed by Inhibin-α (50%), Melan-A (31%), and S-100 (23%). Of the reported four cases with malignant disease, three showed a Ki-67 index of 40-50% with one showing less than 5%. CONCLUSION: Mixed corticomedullary adrenal tumors rarely present as a malignant disease requiring chemotherapy. Most MCMTs confer a good prognosis and respond well to surgical resection, though their pathogenesis is largely up to speculation because of limited data. Current theories regarding MCMT pathogenesis should be investigated further with genetic testing. Future research on MCMT may provide ways to guide physician diagnosis and subsequent treatment for refractory cases.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study.

OBJECTIVE: To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU. DESIGN: Retrospective cohort study. SETTING: Medical-surgical ICUs in Alberta, AB, Canada. PATIENTS: A population of 25,537 unique patients admitted at least once to an Alberta ICU. METHODS: We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39-0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] -1.87 d; 95% CI, -2.01 to -1.81; p < 0.001) and telephone calls (AMD -1.41 d; 95% CI, -1.52 to -1.31; p < 0.001) were associated with decreased duration of delirium in all patients. CONCLUSIONS: The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

Autophagy Agents in Clinical Trials for Cancer Therapy: A Brief Review.

Autophagy has been of novel interest since it was first demonstrated to have effect in Burkitt's lymphoma. Since that time, the autophagy agents chloroquine and hydroxychloroquine have become the only FDA (Food and Drug Administration)-approved autophagy inhibitors. While not approved for cancer therapy, there are ongoing clinical trials to evaluate their safety and efficacy. Pevonedistat has emerged as a novel inhibitor through the neddylation pathway and is an autophagy activator. This paper summarizes and presents current clinical trials for hydroxychloroquine (HCQ), chloroquine (CQ), and Pevonedistat for the clinician.

Update on the adverse effects of antimicrobial therapies in community practice.

OBJECTIVE: To gather information about antibiotic side effects to be used as a reference and learning resource for prescribing physicians. QUALITY OF EVIDENCE: A search of websites of various independent national agencies and recent review articles was performed. A summary table of adverse effects for each group of antimicrobials was then created, identifying allergies, short-term harms, and serious harms. The occurrence rate of each was listed when available. MAIN MESSAGE: Antimicrobials are necessary to treat various diseases. However, they cause adverse effects, such as allergic reactions, in addition to increased bacterial resistance. There is increasing awareness of the need to detect and evaluate adverse effects associated with medicines. Recently, severe and serious harms have been described for commonly used antibiotics. Therefore, current knowledge of harms from systemic oral antibiotics that are regularly used in family medicine is summarized in this article. CONCLUSION: It is difficult to identify and ascribe exact probabilities of most harms. However, all common antimicrobials create harms that must be considered when choosing whether to prescribe. Many adverse effects go unrecognized by prescribers. As side effects are inevitable, antimicrobials must be prescribed for as short a course as possible, only when the probability of benefit is greater than the risk of harm.

Mise à jour sur les effets indésirables des traitements antimicrobiens en pratique communautaire.

OBJECTIF: Rassembler l'information sur les effets indésirables des antibiotiques, que pourront utiliser les médecins prescripteurs comme référence et ressource d'apprentissage. QUALITÉ DES DONNÉES: Une recherche a été effectuée dans les sites web de diverses agences nationales indépendantes et dans de récentes revues de synthèse. Un tableau résume les effets indésirables de chaque groupe d'antimicrobiens et en indique les allergies, les effets nocifs à court terme et les effets nocifs graves. La fréquence de chaque effet indésirable apparaît au tableau lorsque disponible. MESSAGE PRINCIPAL: Les antimicrobiens sont nécessaires pour traiter diverses maladies. Ils causent cependant des effets indésirables, tels que des réactions allergiques, en plus d'augmenter la résistance bactérienne. Nous sommes de plus en plus conscients du besoin de détecter et d'évaluer les effets indésirables associés aux médicaments. Des effets nocifs graves ont récemment été associés à des antibiotiques couramment utilisés. Ainsi, nous avons résumé, dans le présent article, les connaissances actuelles en matière d'effets nocifs liés aux antibiotiques oraux à action générale qui sont régulièrement utilisés en pratique familiale. CONCLUSION: Il est difficile d'identifier et d'attribuer les probabilités exactes de la plupart des effets nocifs. Cependant, tous les antimicrobiens courants produisent des effets nocifs dont il faut tenir compte lors de la décision de prescrire. Nombreux sont les effets indésirables qui ne sont pas reconnus par les prescripteurs. Puisque les effets indésirables sont inévitables, les antimicrobiens doivent être prescrits pour la durée la plus brève possible, seulement lorsque la probabilité d'un bienfait surpasse le risque d'effets nocifs.