A Canadian Provincial Screening Program for Lynch Syndrome.

INTRODUCTION: Manitoba implemented the first Canadian provincial program of reflex screening through mismatch repair immunohistochemistry (MMR-IHC) for all colorectal cancers diagnosed at age 70 years or younger in December 2017. We evaluated compliance to universal reflex testing and for referrals to Genetics for individuals with MMR-deficient tumors. METHODS: We searched the provincial pathology database with "adenocarcinoma" in the colorectal specimen pathology reports between March 2018 and December 2020. We cross-referenced with paper and electronic records in the Program of Genetics and Metabolism to determine whether patients with MMR-deficient tumors had been referred for Genetic assessment and what proportion of patients and first-degree relatives accepted an appointment and genetic testing. We performed logistic regression analysis to identify predictors of testing. RESULTS: We identified 3,146 colorectal adenocarcinoma specimens (biopsies and surgical resections) from 1,692 unique individuals (mean age 68.66 years, male 57%). Of those aged 70 years or younger (n = 936), 89.4% received MMR-IHC screening. Individual pathologists (categorized by the highest, average, and lowest screening rates) were the biggest predictors of MMR-IHC screening on multivariable analysis (highest vs lowest: odds ratio 17.5, 95% confidence interval 6.05-50.67). While only 53.4% (n = 31) of 58 screen-positive cases were referred by pathologists for genetic assessment, other clinicians referred an additional 22.4% (n = 13), resulting in 75.8% overall referral rate of screen-positive cases. Thirteen (1.4%) patients (1.1%, aged 70 years or younger) were confirmed to experience Lynch syndrome through germline testing, and 8 first-degree relatives (an average of 1.6 per patient) underwent cascade genetic testing. DISCUSSION: The first Canadian Lynch syndrome screening program has achieved high rates of reflex testing.

Influence of adjuvant antibiotics on fistula formation following incision and drainage of anorectal abscesses: a systematic review protocol.

BACKGROUND: Development of fistula-in-ano following incision and drainage (I&D) of anorectal abscesses occurs in over 30% of patients. It is associated with significant patient morbidity and societal cost. The use of antibiotics following drainage is controversial, with randomized controlled trials reporting opposing conclusions regarding their influence on the rate of fistula formation. Given the significant burden associated with their development, it is imperative to determine strategies to minimize their occurrence. The objective of this review is to summarize the available evidence on the role of antibiotics following I&D of anorectal abscesses on fistula formation. Secondary objectives include determining if antibiotics are associated with morbidity, repeat presentation to the emergency department, and requirement for reoperation. METHODS/DESIGN: MEDLINE, EMBASE, CINAHL, Cochrane Central Registry of Controlled Trials, http://apps.who.int/trialsearch , and clinicaltrials.gov will be searched to identify published and ongoing unpublished interventional and observational studies evaluating the role of antibiotics post I&D on the incidence of fistula formation. There will be no restriction on language, date, or journal. Title and abstracts as well as full texts will be screened in duplicate based on inclusion and exclusion criteria. The Cochrane Risk of Bias tool and ROBINS-I will be used to assess risk of bias in randomized and non-randomized studies, respectively. Our primary outcome is the incidence of fistula formation; secondary outcomes include morbidity, representation to ED, and reoperation. Study heterogeneity will be calculated with Cochran's Q test, P value, and I 2 index. SASS (version 9.4) will be used for meta-analysis. DISCUSSION: This is the first study to review the available evidence on adjuvant antibiotics and incidence of fistula formation following I&D of anorectal abscesses. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018092044.

Surgical Exploration and Discovery Program: Early Exposure to Surgical Subspecialties and Its Influence on Student Perceptions of a Surgical Career.

OBJECTIVE: Interest in pursuing a surgical career has been declining among North American medical students. Numerous factors are known to influence student interest in pursuing surgery as a career, such as prestige, income potential, and overall lifestyle. Given that many of these factors are rooted in bias, it may be possible to properly address several of these stereotypes through first-hand, early exposure to the field of surgery via the Surgical Exploration and Discovery (SEAD) Program. The purpose of this study is twofold: (1) to investigate whether participation in an intensive, 2-week surgical program may alter student opinion, bias, and/or preconceived assumptions of a career in surgery, and (2) to determine whether these changes in perception, if present, has an impact on student interest in pursuing a surgical career compared to baseline. DESIGN: This was a prospective cohort study. The analysis cohort consisted of 30 first-year medical students who participated in the 2-week SEAD program. The control group consisted of 29 first-year medical students who did not participate in the SEAD program. Both the SEAD and control groups completed two surveys: (1) an entry survey distributed prior to the start of the SEAD program, and (2) an exit survey distributed upon completion of the SEAD program. The surveys were designed to assess students' motivations for choosing a specialty in medicine, previous surgical experience, as well as perceptions and biases surrounding a surgical career, pre- and post-exposure. SETTING: Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada. PARTICIPANTS: 30 medical students in the SEAD group, and 29 in the control group. RESULTS: Students' perceptions of the lifestyle, call schedule as a staff or resident, diversity of practice and gender changed significantly following the SEAD program compared to students in the control group. Furthermore, students' perceptions of surgeons as intimidating declined following the 2-week program (p = 0.003), however they were more likely to view surgery as a field requiring physical strength (p = 0.022). Overall, there was no significant change with regards to desire to pursue a career in surgery in the treatment group (p = 0.625) or in the control group (p = 1.00). CONCLUSIONS: Early exposure to surgery through the SEAD program alters student perceptions of surgical specialties, yet it does not significantly influence students to pursue a career in the surgical field. Nonetheless, participation in the SEAD program continues to assist medical students with career decision making.

The Efficacy of Postoperative Iron Therapy in Improving Clinical and Patient-Centered Outcomes Following Surgery: A Systematic Review and Meta-Analysis.

Postoperative anemia is a common occurrence in surgical patients and leads to an increased risk for allogeneic blood transfusions. The efficacy of iron therapy in treating postoperative anemia has not been firmly established. The objective of this systematic review was to evaluate the efficacy of postoperative oral and intravenous (IV) iron therapy in increasing hemoglobin levels and improving patient outcomes following elective surgery. The databases Medline, EMBASE, CENTRAL, the Transfusion Evidence Library, and ClinicalTrials.gov were searched. Eligible studies were randomized controlled trials or prospective cohorts having a control group, where postoperative oral or IV iron was administered to elective surgery patients. Primary outcomes were hemoglobin levels and patient-centered outcomes of quality of life and functioning. Secondary outcomes were the safety of postoperative iron and blood transfusion requirement. Meta-analysis using a random-effects model was performed. Seventeen relevant studies were identified, of which 7 investigated IV iron, 7 investigated oral iron, and 3 compared IV with oral iron. Postoperative oral and IV iron therapies were ineffective in improving quality of life and functioning (the Grading of Recommendations Assessment, Development and Evaluation [GRADE]: moderate-low quality). Compared with control, IV iron increased mean hemoglobin levels by 3.40 g/L (95% confidence interval [CI]: 1.18-5.62) (GRADE: moderate quality); however, this increase is likely not clinically meaningful. Overall, oral iron was ineffective in increasing hemoglobin concentrations compared with control (mean difference=0.77, 95% CI: -1.48-3.01) (GRADE: moderate quality). Postoperative iron therapy did not significantly reduce the risk of blood transfusion (relative risk=0.75; 95% CI: 0.53-1.07) (GRADE: low quality). IV iron was not associated with a significantly increased risk of adverse events (relative risk=4.50, 95% CI: 0.64-31.56). There was insufficient information to determine the risk of adverse events for postoperative oral iron. This systematic review found no evidence to support the routine use of postoperative iron therapy in all elective surgery patient populations; however, results are based largely on studies with non-iron-deficient patients preoperatively. Further research on the role of postoperative IV iron is warranted for certain high-risk groups, including patients with iron deficiency or anemia prior to surgery. This systematic review is registered in PROSPERO (CRD42017057837).