A reflection on the role of anatomists in modern medical education: confronting meaning and mortality in the gross anatomy laboratory

Modes of anatomical instruction (especially the need to dissect cadavers) have been contested for generations. The present narrative provides an opportunity to re-approach this age-old debate and contemplate the state of anatomical sciences education through a narrative reflection of an encounter with a donor in the cadaveric anatomy laboratory.

Approach to hypercalcemia

Hypercalcemia is a presentation commonly encountered in the clinical setting. Due to its vast differential diagnosis, a systematic approach is necessary when approaching patients with hypercalcemia. This article presents a simple, yet thorough approach to help clinicians determine the etiology of their patient's hypercalcemia. The main components of history taking, physical examination, and laboratory investigations for patients with hypercalcemia are highlighted. Emphasis is put on the importance of determining whether the hypercalcemia is associated with elevated or inappropriately normal parathyroid hormone (PTH) or not. The main etiologies of PTH-dependent hypercalcemia and PTH-independent hypercalcemia are explored. Primary hyperparathyroidism and hypercalcemia secondary to malignancy are highlighted as together, they make up 90% of hypercalcemia cases. A presentation of the management principles of hypercalcemia is also provided.

Exercise-Induced Pulmonary Hypertension: How to Define, Diagnose, and Treat At-Risk Patients

Introduction Pulmonary hypertension is a devastating disease with a rapid progression of symptoms leading to high patient mortality. It is characterized by high blood pressure in the pulmonary vasculature and poor pulmonary perfusion, resulting in patient fatigue, dyspnea, and syncope, especially upon physical exertion. A sub-clinical form of pulmonary hypertension also exists which is referred to as exercise induced pulmonary hypertension, where patients display normal resting hemodynamic properties but abnormal pulmonary responses to exercise. Discussion Recent evidence suggests early intervention and treatment of pulmonary hypertension can improve patient outcomes. However, there is a lack of clinical evidence supporting effective treatments for exercise induced pulmonary hypertension (EIPH), arguably the earliest stage of pulmonary hypertension. This is due in part to the removal of EIPH from official guidelines such as the European Respiratory Society in 2008. EIPH was removed from clinical guidelines due to a lack of consensus on the definition and standardized testing procedures for diagnosing EIPH. Emerging evidence suggests that exercise testing following a standardized protocol of stress echocardiography or right heart catheterization of patients may allow for the classification of EIPH as a mean pulmonary artery pressure/cardiac output slope > 3 mmHg/L/min, and/or mean pulmonary artery pressure > 30 mmHg with a pulmonary vascular resistance > 3 Wood Units. Conclusion Providing evidence for a consensus definition of EIPH, along with a validated, standardized testing procedure, will hopefully foster the progression of research on EIPH and further the development of treatments and improve patient outcomes for people with pulmonary hypertension.

How should we present the epidemic curve for COVID-19?

Epidemic curves are used by decision makers and the public to infer the trajectory of the COVID-19 pandemic and to understand the appropriateness of response measures. Symptom onset date is commonly used to date incident cases on the epidemic curve in public health reports and dashboards; however, third-party trackers date cases by the date they were publicly reported by the public health authority. These two curves create very different impressions of epidemic progression. On April 1, 2020, the epidemic curve based on public reporting date for Ontario, Canada showed an accelerating epidemic, whereas the curve based on a proxy variable for symptom onset date showed a rapidly declining epidemic. This illusory downward trend is a feature of epidemic curves anchored using date variables earlier in time than the date a case was publicly reported, such as the symptom onset date. Delays between the onset of symptoms and the detection of a case by the public health authority mean that recent days will always have incomplete case data, creating a downward bias. Public reporting date is not subject to this bias and can be used to visualize real-time epidemic curves meant to inform the public and decision makers.

The Interplay Between COVID-19 and Cardiovascular Disease

Introduction: The emergence of the global COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus, SARS-CoV-2, has created a substantial burden on healthcare systems worldwide. The systemic impacts of COVID-19 infection are severe and broad in their implications, and the cardiovascular system is no exception. Discussion: Patients with a history of cardiovascular disease are at an increased risk for hospitalization and mortality, and COVID-19 infection has now been demonstrated to initiate acute, but serious, episodes of cardiovascular events such as stroke. Considering the rapid spread of COVID-19 across the globe and the inability of healthcare systems to address and adequately respond to the pandemic, therein lies an increased need for understanding the interplay between COVID-19 infection and cardiovascular disease. SARS-CoV-2 relies on binding the angiotensin-converting enzyme-2 (ACE2) receptor to infect host cells, with ACE2 representing a critical regulator of blood pressure homeostasis and proper cardiovascular functioning. Conclusion: Identifying the exact role of ACE2 in COVID-19 infection will have major implications for understanding the disease; therefore, here we have reviewed ACE2’s involvement in the pathogenesis of COVID-19 infection and the resulting end-organ damage. In addition, we have summarized how COVID-19 affects cardiovascular physiology, and how COVID-19 infection can manifest in acute cardiovascular events. Finally, we examine why patients with cardiovascular disease are at an increased risk of succumbing to COVID-19 and what the long-term cardiovascular implications of COVID-19 infection could mean. Relevance: This paper discusses the cardiovascular consequences of the global COVID-19 pandemic.

Can an Emergency Surgery Scheduling Software Improve Residents’ Time Management and Quality of Life?

Background: Operating room efficiency is invaluable. Particularly in public health systems, where resources are limited and patient loads are high, efficient systems underpin the continued delivery of high quality care. In addition to impacting patients, the implementation of efficient healthcare tools has the potential to improve staff quality of life. In the face of growing surgical resident attrition and healthcare worker burnout, developments in standard practice, such as the implementation of the 80-hour work week, are necessary to improve quality of life. Materials and methods: A new online scheduling software (ORNET.CA) was created, installed, and piloted in a Level I Trauma Center after instructing users (physicians and nurses) on its use. A 20-item survey was then distributed to all users to assess the effect implementation of the software had on their quality of life. Results: ORnet was shown to improve communication between hospital staff and physicians, reduce workflow interruptions, and improve the quality of the working environment. The survey showed that 60% of residents and 50% of attending staff believed that ORNET.CA improved their quality of life. Conclusions: We present data from a novel emergency operating room scheduling system that allowed surgical residents and attending physicians to better plan their on-call shifts. Staff (resident and physician) reported survey results suggest that implementation of this system resulted in an improved quality of life and a decrease in stress and anxiety levels.

Approach To: Delirium

Delirium is a common and serious geriatric syndrome with core features of acute onset and inattention. It is often underdiagnosed and is associated with many adverse outcomes, such as prolonged hospitalization, institutionalization, functional impairment and death. This review summarizes an approach to the recognition, work-up, management and prevention of delirium.

Epistemic and ethical considerations in the direct-to-consumer health and ancestry genetic testing process

Background: Direct-to-consumer genetic testing (DTC-GT) is a popular and fast-growing field within the healthcare industry. Consumers often pursue DTC-GT without a clear understanding of its epistemic and medical limitations. This report will present the current state of DTC-GT technology, and highlight the ethical, legal and social issues of DTC-GT. Methods: Quantitative methods such as systematic reviews were used to evaluate the field of DTC-GT. Experimental data was taken from randomized control trials and case studies of 23andMe. Qualitative methods such as newspaper articles and surveys were also used. Relevant policies and regulatory information were analyzed in the context of 23andMe. Broader ethical issues are analyzed from the social disability model and feminist ethics frameworks. Results: Several aspects of direct-to-consumer genetic testing are outlined: (i) regulatory and legal distinctions of DTC-GT that separate its use from conventional genetic testing, (ii) epistemic issues of the genetic testing process within the direct-to-consumer context, and (iii) ethical considerations of DTC-GT in regard to genetic health and genetic ancestry. Conclusion: This report does not take a position for or against the use of DTC-GT; rather, it highlights the key ethical issues often missed in the DTC-GT process. There is no perfect method for understanding genetic health and race. DTC-GT offer consumers the ease and power of taking genetic data ‘in their own hands’, at the cost of exacerbating geneticization and race essentialism. Until further work is done to address the epistemic, regulatory and legal issues, ethical implications of DTC-GT usage will continue to exist.

Congenital Cytomegalovirus Infection: Transmission, Diagnosis and Treatment.

Introduction: Cytomegalovirus (CMV) is a linear, dsDNA virus that is regarded as the prototype of the Betaherpesvirinae subfamily of viruses. It has an established endemic status in certain locations around the globe, and is also reported to be the most prevalently occurring congenital infection in humans. Furthermore, Cytomegalovirus is notorious for being a persistent lifelong pathogen that poses a threat of reactivation as well. Discussion: Congenital cytomegalovirus infection causes numerous ophthalmologic, and neurologic sequelae, and is also known for being the principal reason behind sensorineural hearing loss of non-genetic etiology in neonates. These symptoms, if present, may give rise to a premonition of congenital Cytomegalovirus disease, and so, a diagnosis can be established through serology, radiology, and PCR of salivary, urinary, or dried blood spot samples. Timely administration of ganciclovir or valganciclovir has proven to be effective in managing symptomatic cases of congenital CMV. Conclusion: A well-timed delivery of pharmacological and non-pharmacological interventions is necessary to achieve healthy developmental outcomes for the neonate. Moreover, there is still a need to study the role of antiviral therapy in silent cases since asymptomatic patients are at a risk of developing long-term clinical sequelae as well. Relevance: An estimated 60-90% of women of child-bearing age get infected with Cytomegalovirus, and Congenital CMV disease is reported in 0.2-2.4% of all live births. Therefore, in order to develop effective screening and management protocols, it is vital to educate healthcare professionals regarding the various aspects of this congenital infection.

Distal Radial Artery Ligation for Dialysis Access Steal Syndrome

Renal replacement therapy is the definitive treatment for end stage renal disease apart from transplant. Steal syndrome, which can lead to distal limb ischemia, is a rare but serious complication in patients who undergo hemodialysis with an arteriovenous fistula. We present a case of a 48-year-old female with limited options for dialysis access who presented with symptoms of steal syndrome. Given the need to keep her current fistula, we opted to treat her with distal radial artery ligation. This case report summarizes the various surgical techniques available for treating dialysis access-associated steal syndrome and why distal radial artery ligation should be considered a viable management strategy, especially in the context of our patient.