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Iulian Alecu, Tsveta Milenkova, Simon R Turner Research and Development, AstraZeneca UK Limited, Cambridge, UKThe tolerability profile of PARP inhibitors often includes hematologic toxicities, and the characterization of these adverse events is important to allow effective management by clinicians. Zhou et al1 recently carried out a meta-analysis of the incidence and relative risks of severe neutropenia, thrombocytopenia, and anemia events in 12 randomized controlled trials of PARP inhibitors, either as monotherapy or in combination with chemotherapy or radiotherapy. The authors concluded that olaparib resulted in a higher incidence of severe (common terminology criteria for adverse events [CTCAE] grade $3) neutropenia when compared with niraparib and veliparib; however, these conclusions are based on inappropriate and incomplete comparisons of hematologic toxicity with olaparib or veliparib in combination with myelotoxic chemotherapy versus niraparib monotherapy. While both monotherapy and combination therapy olaparib studies are discussed in the paper, the neutropenia analysis is based on olaparib data solely from studies in combination with paclitaxel or paclitaxel plus carboplatin. In order to inform the practicing clinician of the relative risk of hematologic toxicity associated with different PARP inhibitors, direct comparison needs to be conducted based on monotherapy, where applicable, as per the approved drug indication, otherwise the reader is given misleading information.View the original paper by Zhou et al.

Studies the psychological aspects of cleft lip and palate (CLP). Psychological factors in the rehabilitation of CLP affected individuals; Stigma experienced by CLP affected individuals; Problems experienced by CLP patients in social interactions and speech.

Objective: There is concern that current surgical residents are suboptimally prepared for autonomous practice. This qualitative study aimed to clarify perceptions of competency, autonomy and surgical training goals by Canadian cardiac surgery programs and trainees., Design: This was a qualitative study using semistructured interviews. These were audio recorded and transcribed verbatim. We used thematic analysis and content analysis to deductively analyze interview transcripts. From this, we identified major themes describing competency, autonomy, and goals of surgical training., Setting: All interviews were conducted online over Zoom., Participants: We interviewed 16 individuals (7 trainees and 9 program directors) from 10 Canadian cardiac surgery training programs., Results: Both trainees and staff agreed that the goal of surgical residency is to produce competent, not autonomous, surgeons. When defining competency, both faculty and trainees identified the importance of technical skills and nontechnical skills, such as surgical decision-making. Both groups believed autonomy and competency to be different, wherein autonomy assumes competency and is distinguished by the ability to make decisions independently. Importantly, 81% (n=13) believed that nontechnical skills were more important for independent practice than technical skills. Only 57% (n=4) of trainees and 33% (n=3) of staff surgeons felt that the current RCPSC competencies were reasonable to achieve during residency training., Conclusion: We have identified several important discrepancies in the perceptions of competency, autonomy, and surgical training goals. The RCPSC (Royal College of Physicians and Surgeons of Canada) stated goal of producing trainees who are ready for independent practice is discordant with the perspective of Canadian cardiac surgery programs. Many staff and trainees do not feel that the currently espoused competencies are feasible to achieve by graduation. The results of our study will allow us to identify the barriers during training to produce trainees ready for independent practice., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment., Methods: Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity., Results: The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043)., Conclusions: Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room., Competing Interests: The author declares no conflict of interest., (Copyright © 2023 Society for Simulation in Healthcare.)

Background: Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication., Methods: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test., Results: A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95% CI 1.18-1.76, I 2  = 44%, p < 0.001. Meta-analysis of six studies comparing active smokers alone to never smokers identified a significant increased odds of anastomotic leak (OR 1.80, 95% CI 1.25-2.59, p = 0.002, I 2  = 0%). Meta-analysis of five studies comparing ex-smokers to never smokers identified a significant increased odds of anastomotic leak (OR 1.36, 95% CI 1.02-1.82, p = 0.04, I 2  = 0%). The odds of anastomotic leak decreased among ex-smokers compared to active smokers., Conclusion: The findings of this systematic review and meta-analysis support the association between positive-smoking status and the risk of anastomotic leak after esophagectomy. Results further emphasize the importance of preoperative smoking cessation to reduce post-operative morbidity., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non-small cell lung cancer (NSCLC)., Methods: Patients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05., Results: Between November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, -0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS., Conclusions: In high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients., Competing Interests: Conflict of Interest Statement Dr Turner serves on an advisory board and has received speaker honoraria from Astra Zeneca. Dr Yasufuku has received unrestricted grants from Olympus Medical Systems for continuing medical education. Dr Hanna serves on an advisory board for AstraZeneca, data safety committee for Roche/Genentech, and speaker’s bureau for Minogue Medical. Dr Nayak has received speaker honoraria from Merck and Co. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It is vital for national professional surgical societies to embrace diversity, inclusion, and equity. This study examines race and sex diversity in two Canadian surgical societies., Methods: Websites of the Canadian Society of Cardiac Surgeons (CSCS) and the Canadian Association of General Surgeons (CAGS) and previous programs of their annual meetings were reviewed. Leadership positions, conference speakers, and award winners were categorized by race and sex., Results: White males made up the largest category of Cardiac Surgery meeting speakers (73/142 [51%]), CAGS committee members (89/198 [45%]), CAGS past presidents (38/43 [88%]), and General Surgery meeting speakers (841/1472 [57%]). Of the 17 members that made up the CSCS board of directors and officers, 8 were White males (47%), 5 were BIPOC males (29%), 3 were White females (18%), and 1 was a BIPOC female (6%). Of the 42 members of the CAGS board of directors and advisory committee, 16 were White males (38%), 5 were BIPOC males (12%), 17 were White females (40%), and 4 were BIPOC females (10%)., Conclusions: BIPOC individuals and females are underrepresented in both societies compared to White males. However, in CAGS, improvements in representation can be seen in recent years. It is important that both of these organizations continue to embrace diversity., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Cohesion between team members is critical for surgical performance. Our previous study has shown that the experience of working together (measured by Team Familiarity Score, TFS) helps reduce procedure time (PT). However, that conclusion was found in a relatively small sample size. With a large dataset including mixed general surgical procedures, we hypothesize that team familiarity makes a significant contribution to the improvement of team performance in complex cases, rather than in medium or basic surgical cases, measured by the procedure time, length of hospital stays (LOS), and surgical cost (COST)., Study Design: Patient demographics, operation, and patient outcome data of 922 general surgery cases were included. The cases were divided into three subgroups, including basic, medium, and complex surgical procedures. TFS and an Index of Difficulty of Surgery (IDS) were calculated for each procedure. Simple linear regression and random forest regressions were performed to analyze the association between surgical outcomes and all included independent variables (TFS, IDS, patient age, patient weight, and team size)., Results: When applied to complex cases, procedure time (r = -0.21) and cost (r = -0.23) dropped as TFS increases. In basic and medium surgical cases, increasing team familiarity failed to shorten the procedure time on average., Conclusion: Team familiarity is more important in complex cases because there is greater potential for improvement through team collaboration compared to basic and medium cases. Caution will be needed when applying team familiarity scores for examining surgical team performance in large databases with skewed to basic surgical cases., Competing Interests: Declaration of competing interest Dr. Simon Turner discloses financial relationships with Astra Zeneca and Ethicon. All remaining authors have declared no conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Surgeon-industry collaboration is a key driver of advancement in surgical technology and practice. Disclosures of financial relationships between investigators and industries are important to ensure transparent and critical evaluation of literature., Methods: All American cardiothoracic (CT) surgeons who published in three major CT surgery journals in 2019 were identified. Whether these surgeons disclosed any conflicts of interest was recorded and compared to actual payments received within 5 years of publication as reported by the Centers for Medicare and Medicaid Services data., Results: In the study period, there were 1079 unique manuscripts involving 885 American CT surgeons as authors, which combined for 2719 author instances. Of these, 96.2% of authors (851 of 885) received payments from companies. The authors who received payments produced 2651 author instances (97.4%). Financial disclosure was reported in only 11.4% (301 of 2651) of these instances. In total, 851 surgeons received more than $187 million over 5 years, with the highest-paid surgeon receiving an average of over $5.9 million per year. The largest individual payments were from "Associated Research Funding," with over $115 million being paid to 277 surgeons over 5 years. The top paying company issued over $96.5 million to American CT surgeons over 5 years., Conclusions: Nearly all the reviewed publications in three top CT surgery journals were by surgeons who received payments from companies, but very few of these payments were recorded as potential conflicts of interest. A more consistent and robust policy of COI disclosure is needed to reduce perceptions of bias., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Seed germination responses for most narrow-range endemic species are poorly understood, imperilling their conservation management in the face of warming and drying terrestrial ecosystems. We quantified the realized microclimatic niches and the hydrothermal germination thresholds in four threatened taxa ( Tetratheca erubescens, Tetratheca harperi , Tetratheca paynterae subsp. paynterae and Tetratheca aphylla subsp. aphylla ) that are restricted to individual Banded Ironstone Formations in Western Australia. While T. aphylla subsp. aphylla largely failed to germinate in our trials, all other species demonstrated extended hydrothermal time accumulation (186-500°C MPa days), cool minimum temperatures (7.8-8.5°C), but broad base water potential thresholds (-2.46 to -5.41 MPa) under which germination occurred. These slow germination dynamics are suggestive of cool and wet winter months, where soil moisture is retained to a greater capacity in local microsites where these species occur, rather than the warmer and drier conditions in the surrounding arid environment. Hydrothermal time-to-event modelling showed that each species occupied unique hydrothermal germination niches, which correspond with the microclimatic differences the species are exposed to. Our results provide a baseline understanding for environmental and germination thresholds that govern the recruitment, and ultimately the population structure and persistence, of these short-range endemic plants. In addition, our results can aid future conservation, as well as restoration actions such as translocation to bolster population numbers and to mitigate against losses due to anthropogenic disturbance and global environmental change., Competing Interests: The authors have no conflicts of interest to declare., (© The Author(s) 2024. Published by Oxford University Press and the Society for Experimental Biology.)

Introduction: Competency-based training requires frequent assessment of residents' skills to determine clinical competence. This study reviews existing literature on procedure-specific competence assessment tools in orthopaedic surgery., Methods: A systematic search of eight databases up to May 2023 was conducted. Two reviewers independently assessed validity evidence and educational utility of each assessment tool and evaluated studies' methodological quality., Results: Database searching identified 2,556 unique studies for title and abstract screening. Full texts of 290 studies were reviewed; 17 studies met the inclusion criteria. Bibliography review identified another five studies, totaling 22 studies examining 24 assessment tools included in the analysis. These tools assessed various orthopaedic surgery procedures within trauma, sports medicine, spine, and upper extremity. Overall validity evidence was low across all studies, and was lowest for consequences and highest for content. Methodological quality of studies was moderate. Educational utility assessment was not explicitly done for most tools., Discussion: The paucity of current procedure-specific assessment tools in orthopaedic surgery lacks the validity evidence required to be used reliably in high-stake summative assessments. Study strengths include robust methodology and use of an evidence-based validity evidence framework. Poor-quality existing evidence is a limitation and highlights the need for evidence-based tools across more subspecialties., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

In this study, we focused on understanding key storage traits of seeds from Macrozamia fraseri , an unusual though important species that is impacted by mining. To support current restoration activities, large amounts of seed from M. fraseri have been regularly collected and stored for up to 8 years under standard seed banking conditions (5°C and 20% relative humidity), though in situ recruitment from directly sown seed is poor. To investigate the underlying constraints to germination on demand, we set out to assess the viability of M. fraseri seeds that had been stored in a restoration seed bank from 6 to 66 months. Seed moisture content (MC) (fresh weight basis) was also determined for seeds with different storage histories to ascertain whether M. fraseri seeds display traits (i.e. high MC) that might suggest non-orthodox seed storage behaviour. The youngest seed accession (6 months old) was found to have a high MC (45.8 ± 5.4%-fresh weight basis), and >50% viability. In comparison, older (>30 months old) accessions were observed to have a marked reduction in both seed MC (10-35% MC) and viability (0-29.4%). While preliminary, we conclude that M. fraseri seeds appear to lose viability during conventional storage with younger accessions displaying both a higher seed MC and viability, compared to accessions stored for longer. Given the significance of these results, future research activities are recommended to better understand the interplay between seed MC and storage environment and how this relates to the seasonally dry Mediterranean climate where this species naturally occurs. As well, storage and propagation approaches are proposed to increase success when using M. fraseri for conservation and restorative activities., Competing Interests: All authors acknowledge that regarding this manuscript there is no conflict of interest to declare., (© The Author(s) 2023. Published by Oxford University Press and the Society for Experimental Biology.)

Background: Sarcopenia is a predictor of survival in patients with esophageal cancer. The objective of this research was to obtain insight into how changes in sarcopenia influence survival in resectable esophageal cancer., Patients and Methods: A retrospective cohort of patients with esophageal cancer undergoing tri-modality therapy was selected. Body composition parameters from the staging, post-neoadjuvant, and 1-year surveillance computed tomography (CT) scans were calculated. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank test, as well as multivariable Cox-proportional hazards models., Results: Of 141 patients, 118 had images at all three timepoints. The median DFS and OS were 33.2 [95% confidence interval (CI) 19.1-73.7] and 34.5 (95% CI 23.1-57.6) months, respectively. Sarcopenia classified by the staging CT was present in 20 (17.0%) patients. This changed to 45 (38.1%) patients by the post-neoadjuvant scan, and 44 (37.3%) by the surveillance scan. In multivariable analysis, sarcopenia at the post-neoadjuvant scan was significantly associated with OS [hazards ratio (HR) 2.65, 95% CI 1.59-4.40; p < 0.001] and DFS (HR 1.80, 95% CI 1.03-3.13; p = 0.038). The net change in skeletal muscle index was associated with OS (HR 0.93, 95% CI 0.90-0.97; p < 0.001) and DFS (HR 0.94, 95% CI 0.91-0.98; p = 0.001)., Conclusions: Patients who develop sarcopenia as a consequence of skeletal muscle wasting during neoadjuvant therapy are at risk for worse DFS and OS. Patients who have a net loss of muscle over time may be at high risk for early disease recurrence., (© 2023. Society of Surgical Oncology.)

To ensure equitable representation of women and BIPOC (Black, Indigenous, person of colour) individuals in surgical specialties, it is first necessary to understand the presence and extent of the disparities that exist. We explored the websites of the 17 Canadian faculties of medicine to examine sex and racial diversity in surgical specialties and in surgical leadership positions in Canada. We categorized faculty members of each department of surgery as either male or female and White or BIPOC. The relative percentage of female academic surgeons was very low compared with Canadian demographic data, and the relative percentage of BIPOC academic surgeons was similar to Canadian demographic data. Our observations suggest that actions must be taken to improve diversity and inclusion in surgery., Competing Interests: Competing interests: S. Turner has participated on an advisory board for AstraZeneca and has receive honoraria from AstraZeneca for lectures, presentations, manuscript writing or educational events. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Enhanced recovery after surgery (ERAS) guidelines have been incorporated across surgical specialties supported by the publication of evidence-based guidelines. The purpose of this research was to explore adherence to such guidelines among Canadian thoracic surgeons with respect to esophagectomy. A standardized questionnaire was developed comprising 43 validated ERAS recommendations. Additional questions such as the number of annual esophagectomies per institution, the clinical practice environment of the survey responder, preferred operative approach, and responder demographics were included. The survey was circulated to all Canadian Association of Thoracic Surgery (CATS) members and remained open for a four month period. Of the 136 CATS members, 74 (54.4%) completed the survey. Among responders, 29 (40.3%) did have a standard ERAS protocol at their institution. The majority of the responders practiced at an academic center (50, 88.3%). A self-reported adherence rate greater than 80% was observed in six out of 12 of the pre-operative ERAS recommendations, two out of eight of the intraoperative, and seven out of 23 of the post-operative ERAS recommendations. Among the five recommendations associated with high levels of evidence, two had been incorporated into practice by the majority of responders. Out of the 29 strong recommendations, 24 were incorporated into practice by the majority of responders. Canadian thoracic surgeons' express practices that are largely consistent with strongly recommended ERAS guidelines in patients undergoing esophagectomy. ERAS guidelines continue to be instrumental in the improvement of perioperative care; however, high adherence is ultimately necessary for optimal patient outcomes., (© 2023. Italian Society of Surgery (SIC).)

New Findings: What is the central question of this study? DAPK3 contributes to the Ca 2+ -sensitization of vascular smooth muscle contraction: does this protein kinase participate in the myogenic response of cerebral arteries? What is the main finding and its importance? Small molecule inhibitors of DAPK3 effectively block the myogenic responses of cerebral arteries. HS38-dependent changes to vessel constriction occur independent of LC20 phosphorylation, and therefore DAPK3 appears to operate via the actin cytoskeleton. A role for DAPK3 in the myogenic response was not previously reported, and the results support a potential new therapeutic target in the cerebrovascular system., Abstract: The vascular smooth muscle (VSM) of resistance blood vessels is a target of intrinsic autoregulatory responses to increased intraluminal pressure, the myogenic response. In the brain, the myogenic reactivity of cerebral arteries is critical to homeostatic blood flow regulation. Here we provide the first evidence to link the death-associated protein kinase 3 (DAPK3) to the myogenic response of rat and human cerebral arteries. DAPK3 is a Ser/Thr kinase involved in Ca 2+ -sensitization mechanisms of smooth muscle contraction. Ex vivo administration of a specific DAPK3 inhibitor (i.e., HS38) could attenuate vessel constrictions invoked by serotonin as well as intraluminal pressure elevation. The HS38-dependent dilatation was not associated with any change in myosin light chain (LC20) phosphorylation. The results suggest that DAPK3 does not regulate Ca 2+ sensitization pathways during the myogenic response of cerebral vessels but rather operates to control the actin cytoskeleton. A slow return of myogenic tone was observed during the sustained ex vivo exposure of cerebral arteries to HS38. Recovery of tone was associated with greater LC20 phosphorylation that suggests intrinsic signalling compensation in response to attenuation of DAPK3 activity. Additional experiments with VSM cells revealed HS38- and siDAPK-dependent effects on the actin cytoskeleton and focal adhesion kinase phosphorylation status. The translational importance of DAPK3 to the human cerebral vasculature was noted, with robust expression of the protein kinase and significant HS38-dependent attenuation of myogenic reactivity found for human pial vessels., (© 2023 The Authors. Experimental Physiology published by John Wiley & Sons Ltd on behalf of The Physiological Society.)

Background: The Canada Lymph Node Score (CLNS) uses 4 sonographic criteria to predict the risk of malignancy in lymph nodes during endobronchial ultrasound. The CLNS may play a role in identifying targets for biopsy or rebiopsy during invasive mediastinal staging for lung cancer. However the CLNS has not yet been prospectively validated in routine clinical practice., Methods: CLNSs for each lymph node biopsied during endobronchial ultrasound were prospectively captured for 1 year (2019). The CLNS and the presence of malignancy in each node were compared. Univariate binary logistic regression was completed for each ultrasonographic feature and multivariate logistic regression model., Results: CLNSs and diagnostic pathology results were available for 367 lymph nodes. Incidence of malignancy increased with higher scores. Scores ≥ 3 were significantly associated with malignancy (specificity, 84.4%; positive likelihood ratio, 4.0). Area under the curve was 0.76, indicating a good ability of the model to predict presence or absence of malignancy. Nodes scoring < 2 and negative on computed tomography and positron emission tomography were malignant in 10.1%., Conclusions: The CLNS correlates with the presence or absence of malignancy in thoracic lymph nodes and may serve as an adjunct to currently available methods of invasive and noninvasive mediastinal staging. The CLNS may be most helpful in selecting which nondiagnostic lymph nodes require rebiopsy. There is a significant risk of a false-negative result even with a score of 0, and using a combination of low CLNSs and negative conventional radiology to obviate the need for any initial biopsy remains to be studied in prospective trials., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy., Methods: A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model., Results: A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I 2 = 49%)., Conclusion: Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The Continuing Professional Development (CPD) (Education) Committee of the Canadian Association of Thoracic Surgeons (CATS) has established a goal of describing the essential knowledge of thoracic surgery. We aimed to develop a national standardized set of undergraduate learning objectives for thoracic surgery., Methods: We obtained these learning objectives from 4 medical schools in Canada. These 4 institutions were selected to provide a broad geographical representation of medical schools of varying sizes and of both official languages. The resulting list of learning objectives underwent critical review by the CPD (Education) Committee, made up of 5 Canadian community and academic thoracic surgeons, 1 thoracic surgery fellow and 2 general surgery residents. A national survey was developed and circulated to all CATS members ( n = 209). Respondents were asked to indicate on a 5-point Likert scale whether each objective should be a priority for all medical students., Results: Among 209 CATS members, 56 responded (response rate 27%). The mean length of experience in clinical practice among survey respondents was 10.6 (standard deviation 10.0) years. Respondents most commonly reported teaching or supervising medical students monthly (37.0%), followed by daily (29.6%). Eight of the 10 proposed objectives received a mean Likert score of 4/5 or higher and were selected for inclusion in the final list. A finalized list of 8 learning objectives was created, following a final review from the CATS Executive Committee., Conclusion: We developed a standardized set of learning objectives for medical students that was reflective of the core concepts within thoracic surgery., Competing Interests: Competing interests: Julius Poon received travel support from Intuitive Surgical and participated on an AstraZeneca Advisory Board. Nazgol Seyednejad received honoraria from Bristol Myers Squibb for a lecture given on neoadjuvant treatment in stage IIIA lung cancer. Simon Turner received institutional funding from Ethicon and advisory board consulting fees from AstraZeneca. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Objective: Better understanding the research productivity of Canadian general surgery residents and factors associated with success would provide a valuable reference and help inform actions to enable success. We aimed to characterize the research productivity of Canadian general surgery residents and to evaluate factors associated with residents' research quantity and impact., Design: A cross-sectional, observational study was performed using publicly available data evaluating Canadian General Surgery resident research productivity. Research productivity was characterized using measures including publications per postgraduate year (PGY) and CiteScore among others. Residency programs were then comparatively assessed using a multivariable logistic regression to evaluate program and resident factors associated with achieving >50th percentile research productivity., Setting and Participants: All General Surgery residents from English speaking Canadian training programs were included in this study, which was completed at the University of Alberta, a tertiary level academic center in Edmonton, Canada., Results: A wide range of resident research productivity was observed across Canada with the median publications per PGY of 0.29, and the median sum of a resident's publication CiteScores of 2.05. The median h-index was 0.90. Graduate degree completion and publication experience prior to residency were significantly associated with higher publications per PGY (OR 2.94 and OR 2.10, respectively), as well as higher mean CiteScore (OR 3.42 and 2.24). The program factors that were assessed, including program size, research blocks, mandatory projects, or higher staff research productivity, did not show significant association with increased research output., Conclusions: There is a wide range in research output by general surgery residents across the country. Successful completion of graduate degrees and the experience of publication prior to residency are associated with higher research productivity and impact., Competing Interests: COMPETING INTERESTS There is no funding or grant support associated with this study, and there are no competing interests to declare., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Cellulose is known to interact well with water, but is insoluble in it. Many polysaccharides such as cellulose are known to have significant hydrogen bond networks joining the molecular chains, and yet they are recalcitrant to aqueous solvents. This review charts the interaction of cellulose with water but with emphasis on the formation of both natural and synthetic fiber composites. Covering studies concerning the interaction of water with wood, the biosynthesis of cellulose in the cell wall, to its dispersion in aqueous suspensions and ultimately in water filtration and fiber-based composite materials this review explores water-cellulose interactions and how they can be exploited for synthetic and natural composites. The suggestion that cellulose is amphiphilic is critically reviewed, with relevance to its processing. Building on this, progress made in using various charged and modified forms of nanocellulose to stabilize oil-water emulsions is addressed. The role of water in the aqueous formation of chiral nematic liquid crystals, and subsequently when dried into composite films is covered. The review will also address the use of cellulose as an aid to water filtration as one area where interactions can be used effectively to prosper human life.

Purpose of Review: This article aims at describing the role of neoadjuvant chemotherapy, radiation therapy as well the novel immunotherapy and targeted therapy in thoracic oncology with focus on anesthetic considerations of such treatments for the surgical patient., Recent Findings: In recent years, immune check point inhibitors have changed the landscape of thoracic oncology treatment. In this review, we summarize the key studies that have been fundamental in this change., Summary: Rather than a comprehensive review, the purpose of this work is to provide the reader with an overview of the most common neoadjuvant regimens used in current practice, with the corresponding most prevalent adverse effects as it pertains for patients with esophageal and lung cancer, malignant pleural mesothelioma and mediastinal tumors. Considerations relevant to the anesthesiologist, including specific toxicities related to each treatment type, and the impact of each treatment type on perioperative outcomes and complications will be discussed., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

It has been over 10 years since the relationship between sarcopenia and lung cancer was first explored. Since then, sarcopenia research has progressed substantially, and the prognostic value of this condition is becoming increasingly apparent. Prior systematic reviews and meta-analyses have established sarcopenia to be negatively associated with disease-free and overall-survival, as well as a major risk factor for post-operative complications. The bulk of the literature has explored sarcopenia in the resectable setting, with less emphasis placed on studies evaluating this condition in advanced disease. In this up-to-date review, an examination of the literature exploring the association between sarcopenia and long-term outcomes in advanced lung cancer is provided. We further explore the association between adverse events of medical therapy and the role of sarcopenia as a predictor of tumor response. Finally, the interventions on sarcopenia and cancer cachexia are reviewed, with an emphasis placed on prospective studies.

Smoothelin-like 1 (SMTNL1) modulates the contractile performance of smooth muscle and thus has a key role in vascular homeostasis. Elevated vascular tone, recognized as a contributor to the development of progressive cardiac dysfunction, was previously found with SMTNL1 deletion. In this study, we assessed cardiac morphology and function of male and female, wild-type ( Smtnl1 +/+ ) and global SMTNL1 knockout ( Smtnl1 -/- ) mice at 10 weeks of age. Gross dissection revealed distinct cardiac morphology only in males; Smtnl1 -/- hearts were significantly smaller than Smtnl1 +/+ , but the left ventricle (LV) proportion of heart mass was greater. Male Smtnl1 -/- mice also displayed increased ejection fraction and fractional shortening, as well as elevated aortic and pulmonary flow velocities. The impact of cardiac stress with pressure overload by transverse aortic constriction (TAC) was examined in male mice. With TAC banding, systolic function was preserved, but the LV filling pressure was selectively elevated due to relaxation impairment. Smtnl1 -/- mice displayed higher early/passive filling velocity of LV/early mitral annulus velocity ratio (E/E' ratio) and myocardial performance index along with a prolonged isovolumetric relaxation time. Taken together, the findings support a novel, sex-dimorphic role for SMTNL1 in modulating cardiac structure and function of mice.

High-Entropy Alloys (HEAs) are a new family of crystalline random alloys with four or more elements in a simple unit cell, at the forefront of materials research for their exceptional mechanical properties. Their strong chemical disorder leads to mass and force-constant fluctuations which are expected to strongly reduce phonon lifetime, responsible for thermal transport, similarly to glasses. Still, the long range order would associate HEAs to crystals with a complex disordered unit cell. These two families of materials, however, exhibit very different phonon dynamics, still leading to similar thermal properties. The question arises on the positioning of HEAs in this context. Here we present an exhaustive experimental investigation of the lattice dynamics in a HEA, Fe 20 Co 20 Cr 20 Mn 20 Ni 20 , using inelastic neutron and X-ray scattering. We demonstrate that HEAs present unique phonon dynamics at the frontier between fully disordered and ordered materials, characterized by long-propagating acoustic phonons in the whole Brillouin zone., (© 2022. The Author(s).)

Sarcopenia measured through body composition analysis is emerging as an important prognosticator among various malignancies, including oesophageal cancer. Skeletal muscle index (SMI) as determined by the third lumbar vertebrae on cross-sectional CT images has been demonstrated as a predictor of overall survival in oesophageal cancer, using pre-defined cut off values for sarcopenia. However, this is largely within the setting of resectable disease. The primary objective of this systematic review and meta-analysis was to determine the effect of sarcopenia defined by SMI on overall-survival in patients with unresectable oesophageal cancer. On 30 January 2021, a systematic search of the literature was conducted to identify the role of SMI among patients with unresectable oesophageal cancer, with overall survival as the primary outcome. Databases included MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library. Inclusion criteria included age >18, diagnosis of oesophageal cancer, and non-operative management. A meta-analysis was conducted using RevMan 5.4.1 using an inverse variance, random effects model. After the removal of duplicates, 2755 unique search results were obtained. Manual screening of titles and abstracts resulted in 287 full text articles that were reviewed. Of these, five studies met the inclusion criteria with data evaluating the effect of sarcopenia defined by SMI on overall survival. A total of 783 patients, the majority of which were male (n = 638, 81%), with a mean age of 68 ± 2.3 years were included. 641 (82%) patients were diagnosed with squamous cell carcinoma. Sarcopenia, as determined by SMI using pre-defined cut-off values, was reported in 517 patients (66%). Meta-analysis demonstrated decreased overall survival in the sarcopenia group compared with the non-sarcopenia group (HR = 1.51; 95% CI 1.21-1.89; P = 0.0003; I 2  = 0%; Figure 1). No significant publication bias was noted on assessment of funnel plot and Egger's test (P = 0.295). Sarcopenia as defined by SMI is predictive of overall survival among patients with nonoperative oesophageal cancer. Further analysis on the effect of sarcopenia on treatment related adverse effects and complications, particularly related to chemotherapy, radiotherapy, and oesophageal stenting, is needed to identify the degree of prognostication offered by body composition analysis. Studies on the modifiability of sarcopenia will help determine the utility of nutritional interventions., (© 2022 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of Society on Sarcopenia, Cachexia and Wasting Disorders.)

Background: The phenomenon of lung cancer stigma has been firmly established in the literature. However, studies have predominantly focused on patients with advanced disease, whose experiences may differ from patients with earlier stage, surgically resectable lung cancer and an improved prognosis., Purpose: The objective of the study was to examine the stigma experienced in a Canadian population with early-stage, resectable lung cancer., Methods: Patients with newly diagnosed lung cancer were enrolled at a tertiary thoracic surgery clinic. The 25-item Lung Cancer Stigma Inventory (LCSI) was self-administered by patients to quantitatively measure experiences of lung cancer stigma. LCSI results informed the development of a semi-structured focus group and individual interviews., Results: Of the 53 participants completing the survey, 38 (72%) met established LCSI score threshold, indicating a clinically meaningful level of stigma. No significant relationship was found between total LCSI scores and any demographic variable. Analysis of qualitative data revealed multiple themes related to experiences of lung cancer stigma. The major themes were classified into four categories: impact of the association between lung cancer and smoking, societal attitudes and assumptions, personal choices in relation to diagnosis, and experiences related to care., Conclusions: A surgical population of patients with predominantly early-stage lung cancer experienced lung cancer stigma at a high incidence and a level similar to previously studied populations with more advanced disease. The qualitative results support the quantitative findings that respondents experienced more internal stigma than either perceived stigma from others or constrained disclosure related to their diagnosis., (© Society of Behavioral Medicine 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Sarcopenia has been identified as a prognostic factor among certain types of cancer. In esophageal cancer, patients are at increased risk of malnutrition and sarcopenia, ultimately contributing to poor outcomes. A systematic review was conducted to determine whether sarcopenia, defined by the skeletal muscle index, is predictive of overall survival, disease-free survival, and postoperative complications in resectable esophageal cancer., Materials and Methods: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines up until January 2021. The primary outcome was overall survival; secondary outcomes included disease-free survival, pulmonary complications, and anastomotic leak., Results: Twenty-one studies (4 prospective; 17 retrospective; 3966 patients) were included. Sarcopenia was present in 1940 (48.1%) patients and was associated with lower overall survival [hazard ratio (HR): 1.56; 95% confidence interval (CI): 1.25-1.95; P <0.00001; I2 =71%] and disease-free survival (HR: 1.73; 95% CI: 1.04-2.87; P =0.03; I2 =51%). A decrease in skeletal muscle index, independent of sarcopenia status, was associated with lower overall survival (HR: 1.81; 95% CI: 1.20-2.73; P =0.005; I2 =92%). Sarcopenia was associated with increased odds of pulmonary complications (odds ratio: 1.86; 95% CI: 1.29-2.66; P =0.0008; I2 =41%) and increased odds of anastomotic leak (odds ratio: 1.46; 95% CI: 1.11-1.93; P =0.008; I2 =0%)., Conclusions: Sarcopenia is a predictor of overall survival, disease-free survival, and postoperative complications in patients with resectable esophageal cancer. Studies on the modifiability of sarcopenia in the preoperative period will help determine the utility of nutritional interventions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Woody plant material represents a vast renewable resource that has the potential to produce biofuels and other bio-based products with favorable net CO 2 emissions. 1 , 2 Its potential has been demonstrated in a recent study that generated novel structural materials from flexible moldable wood. 3 Apple rubbery wood (ARW) disease is the result of a viral infection that causes woody stems to exhibit increased flexibility. 4 Although ARW disease is associated with the presence of an RNA virus 5 known as apple rubbery wood virus (ARWV), how the unique symptoms develop is unknown. We demonstrate that the symptoms of ARWV infections arise from reduced lignification within the secondary cell wall of xylem fibers and result in increased wood digestibility. In contrast, the mid-lamellae region and xylem ray cells are largely unaffected by the infection. Gene expression and proteomic data from symptomatic xylem clearly show the downregulation of phenylalanine ammonia lyase (PAL), the enzyme catalyzing the first committed step in the phenylpropanoid pathway leading to lignin biosynthesis. A large increase in soluble phenolics in symptomatic xylem, including the lignin precursor phenylalanine, is also consistent with PAL downregulation. ARWV infection results in the accumulation of many host-derived virus-activated small interfering RNAs (vasiRNAs). PAL-derived vasiRNAs are among the most abundant vasiRNAs in symptomatic xylem and are likely the cause of reduced PAL activity. Apparently, the mechanism used by the virus to alter lignin exhibits similarities to the RNAi strategy used to alter lignin in genetically modified trees to generate comparable improvements in wood properties. 6-8 ., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Women and people of color are often underrepresented in medicine. This study examined the inclusivity and diversity of the recent history of the Canadian Association of Thoracic Surgeons (CATS) in both its executive committees and invited participation at its annual meeting., Methods: CATS internal records and previous programs of CATS annual meetings were reviewed from 1997 to 2020. Leadership positions, invited speakers, and award recipients were categorized by sex and race., Results: Of 199 CATS members in 2020, 93 (47%) were White men, 64 (32%) were men of color, 24 (12%) were White women, and 18 (9%) were women of color. The majority of CATS presidents (86%), committee chairs (57%), named lecturers (88%), other invited speakers (67%), and major award winners (90%) were White men. Women and people of color were underrepresented. The Resident Research Award was the most diverse: of 23 awards, 10 (44%) have been to men of color, 6 (26%) to White men, 4 (15%) to women of color, and 2 (8%) to White women., Conclusions: There is a need for more representation and inclusion of both women and people of color at multiple levels in CATS. This includes opportunities for improvement in the make-up of its executive committees, the speakers at its annual conference, and the recipients of its awards. CATS has established an Equity, Diversity and Inclusion Task Force to address this critical issue., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical education has shifted from a time-based approach to the achievement and demonstration of procedural competency. High quality, objective assessment instruments are required to support this new approach. This study comprehensively reviewed the literature to identify and evaluate available procedure-specific assessment instruments in cardiothoracic and vascular surgery., Design: A systematic search of 8 databases identified studies containing procedure-specific operative assessment instruments in cardiothoracic and vascular surgery. Generic global rating scales were excluded, unless modified to be procedure-specific. Two reviewers independently evaluated the validity evidence, methodological rigour and educational utility of each instrument using objective scoring criteria. Validity evidence was evaluated with a scoring tool aligned with the contemporary framework of validity. Methodological rigour was evaluated using the Medical Education Research Study Quality Instrument. Educational utility was evaluated according to the Accreditation Council for Graduate Medical Education (ACGME) framework., Results: There were 2130 unique studies describing procedure-specific assessment in surgery. Of these, 9 studies evaluating 8 procedure-specific assessment instruments met inclusion criteria for cardiothoracic and vascular surgery. Four instruments were identified in thoracic surgery, 2 in cardiac surgery, and 2 in vascular surgery. Only 1 instrument was designed to evaluate surgeon performance, with the remainder designed to evaluate residents. No single instrument scored the maximum score of 15 for validity evidence. The highest score was 11, with 62.5% (n = 5) of instruments scoring greater than 10. All tools attained high scores in content validity, with minimal evidence generally presented regarding the consequences of assessment using a particular instrument. All but 1 instrument scored greater than 11 out of a maximum 16.5 points for methodological rigour. Very few studies reported on the ACGME domains of educational utility., Conclusions: In an era where surgical education is shifting towards the demonstration of procedural competency, objective procedure-specific assessment is critical. This review identified that few procedure-specific assessment instruments in cardiothoracic and vascular surgery exist, emphasizing the need for such instruments to ensure the success of competency-based education models., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Triple normal lymph nodes, appearing benign on computed tomography, positron emission tomography, and endobronchial ultrasound, have less than a 6% probability of malignancy. We hypothesized that targeted sampling (TS), which omits biopsy of triple normal lymph nodes during endobronchial ultrasound, is not an inferior staging strategy to systematic sampling (SS) of all lymph nodes., Methods: A prospective randomized feasibility trial was conducted to decide on the progression to a pan-Canadian trial comparing TS with SS. Patients with cN0-N1 non-small cell lung cancer undergoing endobronchial ultrasound were randomized to TS or SS. Lymph nodes in the TS arm crossed over to receive SS. Progression criteria included recruitment rate (70% minimum), procedure length (no significant increase for TS), and incidence of missed nodal metastasis (<6%). Mann-Whitney U test and McNemar's test on paired proportions were used for statistical comparisons., Results: The progression criterion of 70% recruitment rate was achieved early, triggering a planned early stoppage of the trial. Nineteen patients were allocated to each arm. The median procedure length for TS was significantly shorter than SS (3.07 vs 19.07 minutes; P < .001). After crossover analysis, 5.45% (95% confidence interval, 1.87-14.85) of lymph nodes in the TS arm were upstaged from N0 to N2, but this incidence of missed nodal metastasis was below the 6% threshold. During surgical resection, the nodal upstaging incidence from N0 to N2 was 0% for 15 lymph nodes in each arm., Conclusions: Progression criteria to a pan-Canadian, noninferiority crossover trial comparing TS with SS have been met, and such a trial is warranted., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastric ischemic conditioning (GIC) is a strategy to promote neovascularization of the gastric conduit to reduce the risk of anastomotic complications following esophagectomy. Despite a number of studies and reviews published on the concept of ischemic conditioning, there remains no clear consensus regarding its utility. We performed an updated systematic review and meta-analysis to determine the impact of GIC, particularly on anastomotic leaks, conduit ischemia, and strictures., Methods: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was performed on February 5th, 2020 by a university librarian after selection of key search terms with the research team. Inclusion criteria included human participants undergoing esophagectomy with gastric conduit reconstruction, age ≥ 18, N ≥ 5, and GIC performed prior to esophagectomy. Our primary outcome of interest was anastomotic leaks. Our secondary outcome was gastric conduit ischemia, anastomotic strictures, and overall survival. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel fixed-effects model., Results: A total of 1712 preliminary studies were identified and 23 studies included for final review. GIC was performed in 1178 (53.5%) patients. Meta-analysis revealed reduced odds of anastomotic leaks (OR 0.67; 95% CI 0.46-0.97; I 2  = 5%; p = 0.03) and anastomotic strictures (OR 0.48; 95% CI 0.29-0.80; I 2  = 65%; p = 0.005). Meta-analysis revealed no difference in odds of conduit ischemia (OR 0.40; 95% CI 0.13-1.23; I 2  = 0%; p = 0.11) and no difference in odds of overall survival (OR 0.54; 95% CI 0.29-1.02; I 2  = 22%; p = 0.06)., Conclusion: GIC is associated with reduced odds of anastomotic leaks and anastomotic strictures and may decrease morbidity in patients undergoing esophagectomy. Further prospective randomized trials are needed to better identify the optimal patient population, timing, and techniques used to best achieve GIC., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

S-acylation is the addition of a fatty acid to a cysteine residue of a protein. While this modification may profoundly alter protein behaviour, its effects on the function of plant proteins remains poorly characterized, largely as a result of the lack of basic information regarding which proteins are S-acylated and where in the proteins the modification occurs. To address this gap in our knowledge, we used an optimized acyl-resin-assisted capture assay to perform a comprehensive analysis of plant protein S-acylation from six separate tissues. In our high- and medium-confidence groups, we identified 1,849 cysteines modified by S-acylation, which were located in 1,640 unique peptides from 1,094 different proteins. This represents around 6% of the detectable Arabidopsis proteome and suggests an important role for S-acylation in many essential cellular functions including trafficking, signalling and metabolism. To illustrate the potential of this dataset, we focus on cellulose synthesis and confirm the S-acylation of a number of proteins known to be involved in cellulose synthesis and trafficking of the cellulose synthase complex. In the secondary cell walls, cellulose synthesis requires three different catalytic subunits (CESA4, CESA7 and CESA8) that all exhibit striking sequence similarity and are all predicted to possess a RING-type zinc finger at their amino terminus composed of eight cysteines. For CESA8, we find evidence for S-acylation of these cysteines that is incompatible with any role in coordinating metal ions. We show that while CESA7 may possess a RING-type domain, the same region of CESA8 appears to have evolved a very different structure. Together, the data suggest that this study represents an atlas of S-acylation in Arabidopsis that will facilitate the broader study of this elusive post-translational modification in plants as well as demonstrating the importance of further work in this area., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Approximately 38 million people were living with human immunodeficiency virus (HIV) in 2020 and 53% of those infected were female. A variety of virological and immunological sex-associated differences (sexual dimorphism) in HIV infection have been recognized in males versus females. Social, behavioral, and societal influences play an important role in how the HIV pandemic has affected men and women differently. However, biological factors including anatomical, physiologic, hormonal, and genetic differences in sex chromosomes can each contribute to the distinct characteristics of HIV infection observed in males versus females. One striking example of this is the tendency for women to have lower HIV plasma viral loads than their male counterparts early in infection, though both progress to AIDS at similar rates. Sex differences in acquisition of HIV, innate and adaptive anti-HIV immune responses, efficacy/suitability of specific antiretroviral drugs, and viral pathogenesis have all been identified. Sex differences also have the potential to affect viral persistence, latency, and cure approaches. In this brief review, we summarize the major biological male/female sex differences in HIV infection and their importance to viral acquisition, pathogenesis, treatment, and cure efforts., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Moran, Turner and Marsden.)

Background: Despite guidelines recommending diagnostic laparoscopy in patients with gastric cancer, implementation is low. We aimed to explore trends in the use of laparoscopy for staging of gastric cancer in Alberta, Canada, determine the rate of positive findings and identify factors predictive of positive staging laparoscopy (SL) findings in this patient population., Methods: In August 2018, we sent a survey to all general surgeons in Alberta who were members of the Alberta Association of General Surgeons to identify those treating gastric cancer. The survey inquired about type of practice (academic or community), gastric cancer case volume, routine versus selective use of SL and, if selective use of SL, criteria used to select cases. Participants were also asked to provide data from their SL cases from July 2007 to February 2019. We double-checked surgeon records with chart review. The primary outcome was evidence of metastatic disease on SL or cytologic examination or both. We performed logistic regression analysis to identify factors predictive of positive laparoscopy findings., Results: The survey was completed by 41 of 127 surgeons (response rate 32.3%). We reviewed 116 cases from 5 surgeons at 4 centres. Gross metastatic disease or positive findings on cytologic examination or both were identified in 37 patients (31.9%). On univariate analysis, the following were associated with an increased risk of identification of metastatic disease at laparoscopy: visualization of the primary tumour on computed tomography (CT) (odds ratio [OR] 9.8, 95% confidence interval [CI] 1.2-76.5), presence of abdominal lymphadenopathy greater than 1 cm (OR 2.4, 95% CI 1.1-5.4) and presence of ascites (OR 19.1, 95% CI 2.2-161.8). Visualization of the primary tumour on CT (OR 8.4, 95% CI 1.0-68.3) and the presence of ascites (OR 15.9, 95% CI 1.8-137.0) remained statistically significant predictors on multivariate analysis., Conclusion: Metastatic disease was identified at SL in almost one-third of cases, which suggests that SL should still be used routinely in gastric cancer staging in Canadian centres. Our study identified several preoperative imaging findings associated with evidence of metastatic disease on laparoscopy; however, further studies are needed to establish robust predictors of positive findings before advocating for a selective SL approach., Competing Interests: Competing interests: None declared., (© 2022 CMA Impact Inc. or its licensors.)

Objective: Pulmonary complications in patients with obesity carry a high morbidity and mortality. An analysis of the MBSAQIP database was performed to determine the effect of post-operative pulmonary complications on patients undergoing elective bariatric surgery, with the primary outcome of 30-day mortality., Methods: We extracted data from the MBSAQIP database from 2015 to 2019 on patients who underwent elective Roux-en-Y gastric bypass or sleeve gastrectomy. Pulmonary complications were defined as prolonged ventilation, pneumonia, unplanned intubation, pulmonary embolism, and coma past 24 h (with the assumption of this being due to hypercapnia). Data on post-operative complications and 30-day mortality was extracted. To determine the effect of pulmonary complications on 30-day mortality, a multivariable logistic regression model was developed., Results: Pulmonary complications were associated with a near 50-fold increased odds of 30-day mortality (OR 47.1; 95%, 38.6-57.5; p < 0.0001). Pulmonary complications were also associated with higher rates of anastomotic leaks (9.5% vs. 0.3%; p < 0.0001), post-operative bleeding (13.7% vs. 0.9%; p < 0.0001), cardiac complications (6.6% vs. 0.0%; p < 0.0001), post-operative AKIs (9.6% vs. 0.1%; p < 0.0001), incidence of deep SSI (9.4% vs. 0.2%; p < 0.0001), incidence of post-operative sepsis (6.2% vs. 0.1%; p < 0.0001), and incidence of Clostridioides difficile (2.0% vs. 0.1%; p < 0.0001)., Conclusion: Pulmonary complications after elective bariatric surgery are a strong predictor of 30-day mortality. Patients who experience pulmonary complications have a higher incidence of co-morbidities and unfavorable baseline patient characteristics, and thus, likely form a unique subset of the bariatric patient population., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery., Summary of Background Data: Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences., Methods: A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework., Results: There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited., Conclusions: This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation., Competing Interests: Conflicts of Interest and Sources of Funding: ST has received speaker fees and serves on the advisory board for Astra Zeneca. JR, BM, and ST hold Edmonton Civic Employees Charitable Assistance Fund research grants for other work. For the remaining authors, none were declared. This work did not receive any dedicated funding. The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)