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OBJECTIVE Female medical students and surgical trainees are more likely to lack confidence in their clinical abilities than their male peers despite equal or superior performance. This study aims to examine the role of gender in medical student experience and confidence performing technical skills in surgical clerkship. DESIGN This was a single-center survey study conducted over 2 academic years (2016-2018). Students were surveyed on their experience and confidence performing a set of 9 technical skills during surgical clerkship and to identify skill-specific barriers to learning. SETTING This study was performed at Western University, London, Ontario, Canada. PARTICIPANTS All third-year medical students were invited to participate. RESULTS A total of 253 students participated yielding a survey response rate of 74.0%. Both male and female students reported similar levels of preclerkship interest in a surgical career, enjoyment in performing technical skills, confidence in ability to learn surgical skills and pursuit of available learning opportunities. At the conclusion of their surgical rotations, female students reported less experience and confidence performing technical skills compared to their male colleagues. Female students were more likely to cite an insufficient number of learning opportunities from consultant and resident teachers, time constraints, and lack of confidence as barriers to the achievement of technical proficiency. CONCLUSIONS Female gender was associated with less procedural experience and inferior confidence performing procedural skills. It is important for educators to be aware of this gender disparity and to actively promote equitable learning opportunities for female trainees.

Low-grade appendiceal mucinous neoplasms (LAMN) are commonly managed by community surgeons at diagnosis. There is variability in the treatment of LAMN, both by community and specialist providers. We assessed current management practices for LAMN across surgeons with expertise in peritoneal surface malignancies (PSM).An online survey was sent to 106 international surgeons specializing in PSM. The survey assessed demographics, favored pre-referral management, and definitive management practices for LAMN.The response rate was 40% (67% USA, 33% international). Respondents had performed a median of 18 (interquartile range [IQR] 7.75-29) HIPEC cases in the last year, of which 10 (IQR 4-20) were for LAMN. Ninety-three percent reported more than half of LAMN referrals had already undergone surgery-an estimated 50% appendectomy and 20% right hemicolectomy (RH). No surgeon respondents supported performing right hemicolectomy before referral. For LAMN confined to the appendix, 86% of respondents would definitively treat with appendectomy. In the presence of mucinous implants, 24% would observe after appendectomy and 76% would proceed with HIPEC. All would perform HIPEC if implants contained tumor cells. When LAMN involved the appendiceal base, 67% of respondents would proceed with partial cecectomy, while 33% favored RH.Pre-referral management of LAMN is not standardized and 20% of patients were referred to a surgeon who performs CRS/HIPEC after a right hemicolectomy that would not have been recommended. Management of LAMN by surgeons who treat PSM is also variable. Long-term data and identification of prognostic features are necessary to generate consensus on the optimal management of these complex patients.

Background Laparoscopic splenectomy is a second-line therapy for immune thrombocytopenia with a sustained success rate of 66%. In a climate of new available medical therapies for immune thrombocytopenia, the comparative safety and efficacy of laparoscopic splenectomy are worthy of attention. The purpose of this study is to identify factors predictive of laparoscopic splenectomy success that will enable preoperative prognostication. Methods A retrospective cohort study was conducted of patients undergoing laparoscopic splenectomy for immune thrombocytopenia. The data collected evaluated response to medical and surgical therapy, which was defined on a platelet level of 50 × 109/L with no bleeding events. Univariate and multivariate analyses were conducted to evaluate factors predictive of laparoscopic splenectomy success, with an additional subanalysis planned to assess for laparoscopic splenectomy safety in individuals ≥65 years. Results One hundred forty-one patients were reviewed. Operative outcomes showed a 3.6% conversion rate and 8.5% complication rate. Disease remission was achieved in 78.7% of patients. Response to initial corticosteroid therapy was associated with a laparoscopic splenectomy success rate of 90% and increased odds of surgical success by 5.58 over individuals with no response to corticosteroids. Age did not confer an increased risk of failure or complications. Conclusion Laparoscopic splenectomy is a safe and effective intervention for immune thrombocytopenia regardless of age. Initial response to corticosteroids is associated with laparoscopic splenectomy success rate of 90% and improved odds of surgical success. Laparoscopic splenectomy should be the standard second-line therapy for immune thrombocytopenia, especially in patients responding to corticosteroids.

Purpose Our objective was to assess 30-day mortality and complication rates associated with percutaneous enteral feeding tube insertion using a single-puncture, dual-suture anchor gastropexy and peel-away sheath technique. We explored differences in complications based on indication and gastrostomy versus gastrojejunostomy tube. Methods A retrospective review was conducted of adult patients undergoing fluoroscopically guided gastrojejunostomy (GJ) and gastrostomy (G) tube insertions between July 2011 and 2014 by five interventional radiologists at a single tertiary care centre. A single-puncture dual-anchor gastropexy technique with a peel-away sheath was used for all patients. Complications within 30 day post-procedure were classified based on the Society of Interventional Radiology Standards of Practice for Gastrointestinal Access. Procedure-related mortality and complication rates, as well as indication-specific complication rates, were compared between GJ and G groups. Results 559 consecutive patients underwent G (86) or GJ (473) tube insertion. Primary technical success was 100%. Nine major (1.6%) and 60 minor (10.7%) complications occurred for an overall complication rate of 12.3%. The 30-day complication rate was significantly higher for GJ compared to G tube insertion (13.5% v. 5.8%, p = .049). There was a trend toward a higher 30-day minor complication rate for the GJ group (11.8% v. 4.7%, p = .057), but no significant difference between groups with respect to major complications (1.7% v. 1.2%, p = 1.0). Four procedure-related deaths occurred resulting in an overall procedure-related mortality of 0.7%. No significant difference in the procedure-related mortality was found between GJ and G groups (0.6% v. 1.2%, p = .49). Conclusion The 30-day major complication and procedure-related mortality rates from G and GJ tube insertion are low when using a single-puncture, dual-anchor gastropexy technique. GJ tube insertion is associated with a higher overall complication rate, likely due to more minor complications, but may avoid long-term adverse events.

At the turn of the 20th century, Dr Edwin Seaborn was starting his surgical and academic career at Western University in Ontario. When war was declared in 1914, Seaborn prevailed upon the university’s president to offer the Canadian government a fully staffed hospital for deployment overseas. Initially declined by the War Office in Ottawa, the university's offer was later accepted after mounting casualties stretched the capacity of the Canadian Army Medical Corps, and Seaborn was granted command of the new No. 10 Canadian Stationary Hospital. From 1916 to 1919, Seaborn’s medical, surgical, and administrative practices transformed the humble No. 10 Stationary Hospital into a General Hospital that was indispensable to the war effort and raised the standard for military medical practice. Upon the unit’s return to London, Ontario, Seaborn’s dedication was transferred to his extensive work as an author, historian, academic, and beloved physician. During the centennial of the First World War, this paper explores the impact of an academic medical unit by looking at the career of its Commanding Officer: a man who made an invaluable contribution to the Canadian war effort and set a precedent for exceptional medical care at home and at war.

Objective Medical students are expected to achieve proficiency in a prescribed set of technical skills during surgical clerkship. However, available literature indicates students routinely report a lack of confidence and proficiency in these skills. Our study aims to identify barriers to technical skill development encountered by medical students during surgical clerkship with the goal of developing interventions to address these barriers. Design Three hundred and forty two medical students were surveyed about their experience learning and performing technical skills during surgical clerkship. Students reported confidence in skill performance and subjective barriers to achieving competency using forced-choice and free-text responses. Multivariate regression models identified factors independently associated with specific barriers and more frequent technical skills performance. Setting Main and satellite campuses of a Medical Council of Canada accredited Canadian academic medical center. Participants All third-year medical students. Results A total of 253 students (74%) responded to the survey. Following surgical clerkship, the only technical skills participants felt confident performing independently were sterile technique (96%) and basic suturing (52%). Interest in a surgical career, observership experience, gender, and medical campus site were independently associated with the frequency of skill performance. With respect to developing technical proficiency, commonly cited barriers included lack of suitable cases for student participation (35.0%), time constraints (33.4%), and lack of opportunities provided by both consultants (29.1%) and residents (24.7%). Female gender was independently associated with decreased resident instruction, decreased confidence in skill performance, and fewer opportunities to perform requisite skills. Students at satellite campuses reported fewer barriers. Conclusions We identified (1) lack of suitable cases, (2) time constraints, and (3) failure to provide students opportunities as the most common barriers to technical skill proficiency. Female gender increased the perception of barriers, while there were fewer barriers perceived by students at satellite campuses. Skill-specific simulation training and other interventions may improve skill development in medical students given obstacles to developing proficiency in the clinical setting.

BACKGROUND: Biologic agents are commonly interrupted prior to surgical intervention for inflammatory bowel disease (IBD) to avoid risk of infection. Previous reviews report increased rates of post-operative infections, however, these included patients undergoing emergent surgeries, which have an inherently higher complication risk. AIMS: To conduct a systematic review and meta-analysis aims to quantify the risk of post-operative infection in IBD patients on biologic therapy undergoing elective surgery. METHODS: EMBASE, Medline, Cochrane CENTRAL, clinialtrials.gov, and the International Clinical Trials Registry Platform were searched without language restriction. Studies comparing infection rates for IBD patients on and off biologic therapy undergoing elective (non-emergent) surgery were eligible. The primary outcome was any post-operative infection. Secondary outcomes included overall complications and rates of specific infections. Meta-analyses were performed using a random-effects models. Studies were weighted by the inverse variance method. Pooled risk ratios were calculated for infectious complications, overall complications, and specific infectious outcomes. RESULTS: Fourteen studies totaling 3544 patients were included. Six assessed Crohn’s disease (CD), five assessed ulcerative colitis (UC), and three assessed both. All studies examined outcomes after elective surgeries for IBD. Infliximab was the intervention in eight studies, adalimumab in one, and five assessed any anti-TNFa. Pooled estimates of infectious complication rates were 13.7% [95% CI 8.9, 20.6] and 16.7% [95% CI 9.4, 27.8] in the control and therapy groups respectively, [risk difference 0.08% [95% CI -10.8, 11.0, p=0.99]]. For total complications, the between group risk difference was 3.5% [95% CI -1.3, 8.3, p=0.15]. No significant difference was identified between control and therapy groups for anastomotic leak, surgical site infection, urinary tract infection, nosocomial pneumonia, or C. difficile infection. CONCLUSIONS: In the setting of elective surgery, no difference in the risk of post-operative infections or other complications was observed in IBD on biologic therapy at the time of surgery versus those who were not. [Image: see text] Pooled analysis of studies reporting overall infectious complications. Absolute risk difference between groups is 0.08% [95% CI -10.8, 11.0, p=0.99]. RD - risk difference. Heterogeneity was moderate to high. FUNDING AGENCIES: None

Background: Laparoscopic splenectomy (LS) is a second-line therapy for Immune Thrombocytopenia (ITP). The reported sustained success rate of LS for ITP is 66%. There is concern that LS may be unsafe or ineffective in older patients. The purpose of this study is to identify factors predictive of LS success that will enable preoperative prognostication. Methods: A retrospective cohort study was conducted of patients undergoing LS for ITP. Data evaluating response to medical and surgical therapy was collected. Response to therapy and disease remission were defined as a platelet level of 50x109/L with no bleeding events. Univariate and multivariate analyses evaluating factors predictive of LS success were conducted.Results: 141 patients were reviewed. The operation was completed successfully in 96.4% of cases with a 3.6% conversion rate and 8.5% complication rate. Disease remission was achieved in 78.7% of patients. An increased number of pre-operative medical interventions decreased the odds of LS success. Age did not confer an increased risk of failure or complications. Response to initial corticosteroid therapy was associated with an LS success rate of 90% and increased odds of surgical success by 5.58 over individuals with no response to corticosteroids.Conclusions: LS is safe in patients u226565 years. A greater number of pre-operative medical interventions predicts a decreased LS success rate. Initial response to corticosteroids is associated with LS success rate of 90% and improved odds of surgical success. LS should be the standard second line therapy for ITP, especially in patients responding to corticosteroids.

Summary The Canadian government depended on chaotic civilian volunteerism to staff a huge medical commitment during the First World War. Offers from Canadian universities to raise, staff and equip hospitals for deployment, initially rejected, were incrementally accepted as casualties mounted. When its offer was accepted in 1916, Western University Hospital quickly adopted military decorum and equipped itself using Canadian Red Cross Commission guidelines. Staff of the No. 10 Canadian Stationary Hospital and the No. 14 Canadian General Hospital retained excellent morale throughout the war despite heavy medical demand, poor conditions, aerial bombardment and external medical politics. The overwhelming majority of volunteers were Canadian-born and educated. The story of the hospital’s commanding officer, Edwin Seaborn, is examined to understand the background upon which the urge to volunteer in the First World War was based. Although many Western volunteers came from British stock, they promoted Canadian independence. A classical education and a broad range of interests outside of medicine, including biology, history and native Canadian culture, were features that Seaborn shared with other leaders in Canadian medicine, such as William Osler, who also volunteered quickly in the First World War.

Purpose: The purpose of this study was to determine whether low fibrinogen levels (fibrinogen level Methods: A retrospective review was performed on patients undergoing extremity arterial or venous thrombolysis between 2005 and 2013. Results: Patients in the low fibrinogen group were younger ( P = .006) and had a higher number of venous occlusive events ( P = .004). The low fibrinogen group received a larger dose of tissue plasminogen activator (tPA; P = .009) and had a longer duration of thrombolysis ( P = .010). The rates of major bleeding were not significantly different ( P = .139). Univariate analysis showed that larger total dose and longer duration of tPA infusion were associated with increased bleeding complications ( P < .01 and P = .03). Conclusion: A fibrinogen level

Unilateral vestibular loss was characterized using a high torque rotatory test and spectral analysis. The vestibulo-ocular reflex (VOR) of unilaterally labyrinthectomized patients was measured during passive body rotation using sinusoidal (0.5-3 Hz) and pseudo-random (0.5-5 Hz) stimulation 1) while the patient fixated an earth-fixed target and 2) during fixation of a moving target. Asymmetrical responses towards the labyrinthectomized side (as postulated by Ewald's second law) were exhibited by all patients at and above approximately 2 Hz sinusoidal stimulation and during random stimulation under illuminated conditions. The most pronounced gain loss and minimal response variability between subjects was observed during VOR suppression (moving target fixation) and random stimulation. Therefore, clinical quantification as well as the side detection of peripheral vestibular loss is best based on a fixation suppression task under fully lit conditions with a random stimulus.

Visuo-vestibular interaction during randomized and sinusoidal head oscillations (0.5–5.0 Hz) was measured by power spectral analysis. It was shown that visual eye movement programmes can adjust the vestibulo-ocu-lar reflex (VOR) gain at frequencies exceeding the dynamic range of visual tracking: above 3 Hz, gains exceeded unity during attempted fixation of a target moving with the subject whereas unity gains prevailed during fixation of an earth-fixed target. At low frequencies, fixation suppression was more efficient (-10 dB) when sinusoidal stimuli rather than randomized oscillations (-3 dB) were employed. Identical results were obtained when the fixation target moved with a total visual surround or against an earth-fixed visual background. Therefore, peripheral vision is normally not important for visual suppression of the VOR, which is dominated by toveal visual tracking at low frequencies.

Pseudorandom vestibular rotatory stimuli covering the normal head movement range (0–6 Hz) and power spectrum analysis techniques are used to clinically evaluate the vestibulo-ocular reflex (v.o.r.). Measurements of compensatory eye movements are recorded during fixation of a stationary target, during fixation of a target moving with the subject and in darkness. The gain above 3 Hz quantifies vestibular function under all these conditions. A frequency-dependent v.o.r. asymmetry indicates the side of a peripheral lesion. The fixation suppression curve at medium frequencies quantifies visual-vestibular interaction. Thus the new test is a powerful diagnostic tool applicable to disease of the labyrinth and central vestibular pathways. This test is evaluated on monkeys before unilateral labyrinthectomy and for an extended period of time after.

International audience; Various researches in artificial intelligence are conducted to understand the transfer of expertise problem. Today we perceive two major independent research activities: the acquisition of knowledge which aims to define methods inspired specially from software engineering and cognitive psychology to better understand the transfer of expertise, and the automatic learning proposing the implementation of inductive, deductive, abductive techniques or by analogy to equip the system of learning abilities. The development of a knowledge-based support system “ACASYA” for the analysis of the safety guided transport systems insisted us to use jointly and complementary both approaches. The purpose of this tool is to first, to evaluate the completeness and consistency of accidents scenarios and secondly, to contribute to the generation of new scenarios that could help experts to conclude on the safe character of a new system. “ACASYA” consists of three learning modules: CLASCA, EVALSCA and GENESCA dedicated respectively to the classification, evaluation and generation accident scenarios.

International audience; The human operator is a paradoxical element: in situation of stress or tiredness, it can be an element of the loss of the reliability of a system. However, in certain critical situations of insecurity, it can be a factor of reliability, by restoring the good performance of the system, sometimes by actions not envisaged by the safety regulations of the exploitation but dependent on its knowledge and its experiment. It is thus necessary to optimize the place of the man in the transportation system in full knowledge of its capacities but also of its limits.Research in this field proposed several of approaches and of models primarily of a conceptual nature: the model of Rasmussen, the model of Reason, the model of Van Eslande, the model of Neboit and the model of Leplat. In spite of the undeniable interest of these models, their implementation in the field of transport safety in particular railway is not satisfactory.No model alone makes it possible to ensure the exhaustiveness of the analysis. Indeed, these models are complementary, but none deals with the problem as a whole what proves the difficulty of their exploitation. No model, except that of Van Eslande, is supported by an industrial application or a real case of accidents. From where interested the objective of this article which attempts to bring a brief reply in order to make these model exploitable and applicable in the field of transport safety railway.

International audience; The occurrence of new maritime accidents, and the seriousness of the damage caused by an insecurity event, prompt the authorities and scientists in the field to increasingly strengthen the analysis of safety in this sector. In fact, the scope of risk management methods has just increased in recent years with the evolution of this mode of transport and in particular with the appearance of “motorways of the sea”. In this context, recourse to a consistent risk analysis method is essential. The study presented in this paper falls within this context and aims to develop a new methodological approach to maritime risk management. The research objective is to improve and strengthen conventional methods of risk analysis applied in the maritime sector. To date, maritime safety regulations are abundant, heterogeneous and insufficient to guarantee a “good” level of safety. In addition, the conventions and safety analysis techniques implemented in the maritime sector come up against several obstacles, in particular the failure to systematically take into account concepts linked to the human factor during safety analysis. However, in the maritime sector, human errors are the cause of 70 to 80% of accidents. It is therefore essential to set up a security system that takes into account not only technical errors but above all human errors. This work proposes a new methodological approach to maritime risk analysis which calls on several complementary techniques and methods inspired by other risk sectors such as rail transport, the nuclear sector, etc. Indeed, the proposed methodology involves jointly with the method of Preliminary Risk Analysis (RPA), the process of Experience Feedback (REX), as well as the Human factors.; La survenu des nouveaux accidents maritime, et la gravité des dommages engendrés par un événement d'insécurité, incitent les autorités et les scientifiques du domaine de renforcer de plus en plus l'analyse de la sécurité dans ce secteur. En effet, l'ampleur des méthodes de management de risque vient de s'accentuer ces dernières années avec l'évolution de ce mode de transport et notamment avec l'apparition des « autoroutes de la mer ». Dans ce cadre, le recours à une méthode d'analyse de risque consistante s'impose. L'étude présentée dans ce papier s'inscrit dans ce contexte et vise l'élaboration d'une nouvelle approche méthodologique de management du risque maritime. L'objectif de la recherche consiste à l'amélioration et le renforcement des méthodes conventionnelles d'analyse des risques appliquées, dans le secteur maritime. A ce jour, la réglementation maritime en matière de sécurité s'avère abondante, hétérogène et insuffisante pour garantir un « bon » niveau de sécurité. En plus, les conventions et les techniques d'analyse de sécurité mises en œuvre dans le secteur maritime, se heurtent à plusieurs obstacles notamment la non prise en compte de manière systématique des concepts liés au facteur humain lors de l'analyse de la sécurité. Pourtant, dans le secteur maritime, les erreurs humaines sont à l'origine de 70 à 80 % des accidents. Il est donc indispensable de mettre en place un système de sécurité qui prend en compte non seulement les erreurs techniques mais surtout les erreurs humaines. Le présent travail propose une nouvelle approche méthodologique d'analyse des risques maritime qui fait appel à plusieurs techniques et méthodes complémentaires inspirées d'autres secteurs à risques comme le transport ferroviaire, le secteur nucléaire, etc. En effet, la méthodologie proposée fait intervenir conjointement à la méthode d'Analyse Préliminaire du Risque (APR), le processus de Retour d'Expérience (REX), ainsi que les facteurs Humains.

International audience; Safety becomes gradually an important issue both internationally and nationally especially within a huge risky project such as maritime transport. In fact, this component’s extent is escalating over the years with the evolution of this kind of transport and particularly with appearance of seas’ motorways. The application of a method of safety and analysis of risk proves to be indispensable. This survey appears in this context and aims the development of a new methodological approach of analysis of the risk whose goal is the improvement of usual methods of risk analysis used in the maritime sector. The proposed methodology made intervene in a conjoined and complementary manner the method of Preliminary analysis of the Risk(PAR), the Return of Experience (ROX), and the Human factor.

International audience; The study is from a base of accident scenarii in rail transport (feedback) in order to develop a tool to share build and sustain knowledge and safety and secondly to exploit the knowledge stored to prevent the reproduction of accidents / incidents. This tool should ultimately lead to the proposal of prevention and protection measures to minimize the risk level of a new transport system and thus to improve safety. The approach to achieving this goal largely depends on the use of artificial intelligence techniques in order to develop a feasibility model of a Knowledge base system to exploit stored knowledge in order to create know-how that can help stimulate domain experts in the task of analysis, evaluation and certification of a new system.

International audience; The white book, revealed in 2001, governs and contains the main objectives that the European Union set on the horizon of 2010 in the domain of the railroad safety. The member States answered these impulses by taking the three packets of the white book as reference mark to the national regulation. This regulation, that is in perpetual evolution, gave birth not only to various actors who intervene in setting up safety of all railway system but also to a lot of files circulating between them. Nevertheless, in spite of the incontestable importance of this regulation, it collides with the absence of a tool that helps the experts of the domain to capitalize it and to exploit it in a rigorous manner. Our article aims at bringing an element of answer to this need by proposing a tool of help to the capitalization and the exploitation of the regulations in the railroad safety.

International audience; The growing increase in the volume of transportation system’s flows has entailed congestion problems of traffic. For railway transport as well as other transportation networks, the increase in traffic demand—without further investing in infrastructure—stands as a chief priority for operators. As a matter of fact they take special interest in improving the operating possibilities for some critical points of the rail network. In order to resolve the problems inherent in the operational management of rail transport traffic, optimization experts have operated mathematical optimization techniques and problem resolving methods that have been developed as part of operational research aimed at keeping a good level of availability. However, these optimization approaches have considerably contributed to balancing and stabilizing the flows of road and rail networks but still do not guarantee security at system, environmental and human levels. This work introduces a management and regulatory approach to rail traffic and takes into account the security component while chiefly aiming at improving and keeping a “good” level of security. To this end, we have set up a security modelling approach based on a hybrid risk analysis, both quantitative and qualitative. This approach seeks to develop a structured framework allowing the integration of the security component into an explicit generic optimization model in accordance with the operating constraints in use by rail optimization methods. On the one hand, this approach constitutes a formal checking process for the management and optimization of traffic even though they are subject to failures. On the other, it is a set of modelling tools and a methodological structure allowing managing and controlling risks at the level of a rail transport system.