Effect of a surgical observership on the perceptions and career choices of preclinical medical students: a mixed-methods study.

BACKGROUND: Medical students are increasingly choosing nonsurgical specialties; observership programs can address factors influencing them toward surgical careers by allowing preclerkship exposure and mentorship, and correcting misconceptions. The aims of this study were to assess the influence of a peer-led observership program at the Université de Montréal on the career choices of preclinical medical students and to determine the factors associated with a positive observership experience. METHODS: We used a quasi-experimental convergent mixed-methods questionnaire design. From Nov. 19 to Dec. 31, 2018, and Mar. 1 to Apr. 4, 2019, all medical students participating in the observership program were eligible for the study; there were no ineligibility criteria. Using a prospective purposive sampling method, we recruited students via the email sent to confirm their observership. In the week after their observership, we invited the students by email to complete a postintervention survey. We used nonparametric tests to evaluate the impact of the observership on participants' career choices and an inductive data-driven thematic analysis to analyze their responses. RESULTS: Of the 204 students who participated, 157 provided consent, of whom 85 (54.1%) completed questionnaires both before and after the observership. The majority of participants were interested in a surgical specialty before (72 [85%]) and after (68 [84%]) the observership. There was no significant change in the students' choices of surgical specialties after the observership. However, most (68 [81%]) reported being more interested in a surgical career as a result of the observership, which allowed them to see that the type of practice they considered was congruent with a surgical career. Their perceptions of the field of surgery became positive, particularly regarding its pace and atmosphere and the humanistic patient-doctor relationship it required. The experience was influenced by surgeons' and teams' attitudes toward students, knowledge-sharing and quality of exposure. Participants mentioned that their willingness to participate was in part responsible for the success of their experience. CONCLUSION: This observership program allowed an early, positive introduction of students to surgery while challenging stereotypes. It provided a better understanding of surgery, enabling participants to consider this field and potentially influencing their residency application.

Educators and practitioners' perspectives in the development of a learning by concordance tool for medical clerkship in the context of the COVID pandemic.

BACKGROUND: The COVID-19 pandemic has forced medical schools to create educational material to palliate the anticipated and observed decrease in clinical experiences during clerkships. An online learning by concordance (LbC) tool was developed to overcome the limitation of students' experiences with clinical cases. However, knowledge about the instructional design of an LbC tool is scarce, especially the perspectives of collaborators involved in its design: 1- educators who wrote the vignettes' questions and 2- practitioners who constitute the reference panel by answering the LbC questions. The aim of this study was to describe the key elements that supported the pedagogical design of an LbC tool from the perspectives of educators and practitioners. METHODS: A descriptive qualitative research design has been used. Online questionnaires were used, and descriptive analysis was conducted. RESULTS: Six educators and 19 practitioners participated in the study. Important to the educators in designing the LbC tool were prevalent or high-stake situations, theoretical knowledge, professional situations experienced and perceived difficulties among students, and that the previous workshop promoted peer discussion and helped solidify the writing process. Important for practitioners was standards of practice and consensus among experts. However, they were uncertain of the educational value of their feedback, considering the ambiguity of the situations included in the LbC tool. CONCLUSIONS: The LbC tool is a relatively new training tool in medical education. Further research is needed to refine our understanding of the design of such a tool and ensure its content validity to meet the pedagogical objectives of the clerkship.

CONTEXTE: Face à la pandémie de la COVID-19, les facultés de médecine ont été contraintes à créer du matériel pédagogique pouvant pallier la diminution prévue et avérée de l'exposition clinique pendant les stages d'externat. Un outil numérique de formation par concordance (FpC) a été développé pour combler le manque d'exposition à des cas cliniques. Cependant, les connaissances sur la conception pédagogique des outils de FpC sont limitées, en particulier en ce qui concerne les perspectives des collaborateurs participant à leur réalisation : 1 ­ les éducateurs qui rédigent les questions des vignettes et 2 ­ les praticiens composant le groupe d'experts qui fournissent les réponses de référence aux questions de FpC. L'objectif de cette étude était de décrire les éléments clés qui ont étayé la conception pédagogique d'un outil FpC du point de vue des éducateurs et des praticiens. MÉTHODES: Il s'agit d'une recherche qualitative de type descriptif, pour laquelle on s'est servi de questionnaires en ligne et d'une méthode d'analyse descriptive. RÉSULTATS: Six éducateurs et 19 praticiens ont participé à l'étude. Dans la conception de l'outil FpC, les éducateurs ont attribué une importance particulière aux situations courantes ou à enjeu élevé, aux connaissances théoriques, aux situations professionnelles vécues par les étudiants et aux difficultés qu'ils ont perçues chez eux. Ils ont également tenu à faire en sorte que l'atelier qui précédait la conception favorise le débat entre pairs et contribue à solidifier le processus de rédaction. Les praticiens ont privilégié les normes de pratique et l'existence d'un consensus entre experts. Cependant, ils doutaient de la valeur pédagogique de leurs commentaires, compte tenu de l'ambiguïté des situations décrites dans l'outil FpC. CONCLUSIONS: Les outils FpC sont relativement nouveaux en éducation médicale. Des recherches plus poussées sont nécessaires pour affiner notre compréhension de la conception d'un tel outil et pour nous assurer de sa validité de contenu, pour bien répondre aux objectifs pédagogiques de l'externat.

Cholecystocolonic fistula with a giant colonic gallstone: the mainstay of treatment in an acute setting.

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8-26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm2 gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

Validation of the PMD100 and its NOL Index to detect nociception at different infusion regimen of remifentanil in patients under general anesthesia.

BACKGROUND: The NOL index is based on multiparametric analysis of heart rate (HR), skin conductance, wave plethysmography, and their time derivative. The aim of this study was to evaluate the NOL to detect standardized nociceptive stimuli with various remifentanil dosages under general anesthesia. METHODS: A prospective, observational study at a single center (NCT02602379) included 40 ASA I to III patients undergoing laparotomy under remifentanil-desflurane anesthesia with epidural analgesia. A tetanic stimulation was applied (forearm) at remifentanil intravenous (IV) infusion of 0.005, 0.05, 0.1, and 0.15 µg/kg/min. NOL and its variations were compared with other parameters namely heart rate, mean arterial pressure, Bispectral Index, and Analgesia Nociception Index (ANI). Receiver operating characteristic (ROC) curves were plotted to assess the response to both intubation and standardized stimulus under remifentanil infusion of 0.005 µg/kg/min. RESULTS: The post-stimulation NOL values at remifentanil doses of 0.005, 0.05, 0.1 and 0.15 µg/kg/min (39 [23-55], 15 [7-30], 8 [4-14] and 8.5 [4-15]) were significantly higher than pre-stimulation counterparts (P<0.0001). For all other parameters, there was also significant difference between pre- and post-stimulation values at all remifentanil dosages (P<0.0001). Area under the ROC curve (AUC) for the NOL during standardized stimulation was larger than for all other parameters at the exception of ANI (P=0.94). The AUC of NOL for nociception during tracheal intubation was greater (0.93 vs. 0.84 and 0.64 for ANI and HR, respectively). CONCLUSIONS: NOL monitoring is a promising index to assess the level of nociception in patients under general anesthesia.

Pheochromocytoma presenting as inverted Takotsubo cardiomyopathy: a case report and review of the literature.

The classical entity of Takotsubo cardiomyopathy is well established in the literature, but mechanisms explaining it remain unelucidated. Recently, the uncommon inverted Takotsubo type (sparing apical ballooning) has been more frequently described. We report the case of a 26-year-old man admitted with gastrointestinal symptoms, whose clinical presentation for a stress-related cardiomyopathy, which usually presents with cardiopulmonary symptoms, was rather atypical. The cardiac assessment including echocardiography and cardiac magnetic resonance imaging (MRI) demonstrated a dilated cardiomyopathy, whereas coronary angiography showed the absence of atherosclerotic disease. The abdominal computed tomography (CT) scan revealed a left adrenal mass, and elevated urinary catecholamine levels were highly suggestive of a pheochromocytoma. Prompt medical and surgical treatments were instituted. During the left adrenalectomy the patient suffered from brief electromechanical dissociation requiring aggressive resuscitation. Postoperative course was unremarkable. Reverse Takotsubo heart failure is a recently recognized syndrome and a systematic review of the literature of 10 cases of pheochromocytoma-induced inverted Takotsubo is presented in the present article.

A new device for sentinel node detection in laparoscopic colon resection.

OBJECTIVE: To test the feasibility of using a newly developed device for laparoscopic lymphatic mapping of the colon by simultaneous and quantitative detection of both tissue coloration and radioactivity. METHODS: Four pigs were used in this study. In each animal, both blue dye and radioisotope injections were utilized. Lymphatic mapping was performed laparoscopically in the sigmoid mesocolon and in the right mesocolon. A solution containing a mix of 35 microcuries of Technetium Tc-99 sulfur Colloid and 1 mL of a vital blue dye was administered subserosally by percutaneous insertion of a 25 gauge needle under laparoscopic control. The new device for automated sentinel-node detection consists of a gamma-probe coupled with a laser device and can be passed through a regular 10-mm trocar. The device detects simultaneously both radioactivity and quantitative tissue coloration. Nodes showing a radioactivity at least 5 times higher than that of the background or that had a blue colorant concentration were considered our sentinel nodes. RESULTS: Laparoscopic simultaneous and quantitative detection of sentinel nodes was feasible in all pigs. One or more sentinel nodes were identified by either the blue dye or radioisotopic technique in both the sigmoid and right mesocolon. Quantitative tissue coloration detection led to the recognition of additional nodes that were not apparently colored to the naked eye. CONCLUSION: Laparoscopic sentinel node detection using a device combining gamma and color detection is feasible in the porcine model. The significance of nodes apparently clear but positive with the quantitative detection technique should be further evaluated.