Selecting the best and brightest: A comparison of residency match processes in the United States and Canada

BACKGROUND:

Selecting candidates for plastic surgery residency training remains a challenge. In the United States, academic measures (United States Medical Licensing Exam Step I scores, medical school class rank and publications) are used as primary criteria for candidate selection for residency. In contrast, Canadian medical education de-emphasizes academic measures by using a pass-fail grading system. As a result, choosing residents from many qualified applicants may pose a challenge for Canadian programs without objective measures of academic success.

METHODS:

A 25-question online survey was distributed to program directors of Canadian plastic surgery residency-training programs. Program directors commented on number of yearly residents and applicants; application sections (ranked in importance using a Likert scale); interview invitation and rank-order list determination; and their satisfaction with the selection process.

RESULTS:

Ten Canadian plastic surgery program directors responded (90.9% response rate). The most important application components determining invitation to interview were letters of reference from a plastic surgeon (mean importance of 5.0 on the Likert scale), clinical electives in plastic surgery (mean 4.6) and electives with their program (mean 4.5). Applicants invited for interview were assessed on the quality of their responses to questions, maturity and personality. The majority of program directors agreed that a clinical elective with their program was important for consideration on their rank-order list. Program directors were neutral on their satisfaction with the selection process.

CONCLUSION:

Canadian plastic surgery residency programs emphasize clinical electives with their program and letters of reference from colleagues when selecting applicants for interviews. In contrast to their American counterparts, Canadian program directors rely on clinical interactions with prospective residents in the absence of objective academic measures.     

Predictors of renal replacement therapy and mortality in children with chronic kidney disease

Objectives:

To study the epidemiology of chronic kidney disease (CKD) in children, and to look for risk factors to predict renal replacement therapy (RRT) and mortality.

Methods:

This is a retrospective cohort study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between 2006 and 2014, where the files of 1,000 children with CKD were reviewed. We determined the effect of consanguinity and hypertension, and being a Saudi indigene on mortality and RRT. We compared children with congenital versus non-congenital causes of CKD.

Results:

The mean±standard deviation age at presentation was 4.9±4.3 years. The median duration of follow up was 1.5 (interquartile range [IQR]: 0.4-4.0) years. Only 9.7% of children received RRT, and 8.3% died. The underlying etiology for CKD was congenital in 537 children. The congenital CKD group presented at a younger age group (3.5±4.0 versus 6.6±3.9 years, p<0.0001), had more advanced stages of CKD (p<0.0001), higher rates of consanguinity (75.4% versus 47.1%, p<0.0001), and RRT (p<0.004) than children with non-congenital CKD. Risk factors for RRT among children with CKD include being a Saudi indigene (relative risk [RR]=1.49, 95% confidence interval (CI): 1.01-2.21), and hypertensive (RR=5.29, 95% CI: 3.54-7.91). The risk factor for mortality was hypertension (RR=2.46, 95% CI: 1.66-3.65).

Conclusion:

Congenital causes of CKD represent the main etiology of CKD in children living in the western province of Saudi Arabia. Significant risk factors for RRT include congenital CKD, Saudi nationality, and hypertension. Hypertension is also a predictor of mortality in children with CKD.Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for more than 3 months with implications for health.1 Children with CKD who are on renal replacement therapy (RRT) have higher mortality rate, which is at least 30-fold higher than their age-matched peers.2 Epidemiological information on the incidence and prevalence of pediatric CKD in children is currently limited,3 particularly in developing countries. Furthermore, most of the available epidemiological data are from end-stage kidney disease (ESKD) registries, and information on the earlier stages of pediatric CKD is still lacking.4 The early stages of CKD in the pediatric population are in most cases asymptomatic, and are therefore under-diagnosed and under-reported.4 Direct comparisons of the incidence and prevalence rate of pediatric CKD are complex since each pediatric CKD registries uses different definition; some depend on the estimated glomerular filtration rate (eGFR), while others use serum creatinine levels. The incidence in Europe was consistent between 11-12 per million of the age-related population (pmarp) for CKD stages 3-5, and 8 pmarp for CKD stages 4-5.4 Data available on the exact prevalence of various kidney diseases in the Arab world is very limited. Most of the data come from small studies and are of limited generalizability.5 In Kuwait, the mean incidence was found to be as high as 38 pmarp, while the prevalence was as also high at 329 pmarp in 2003.6 An incidence of 11 pmarp and a prevalence of 51 pmarp has been reported in Jordanian children.7 The epidemiological data of CKD in children is very scarce in Saudi Arabia. One study from Asir reported that the mean annual incidence of CRF of 15.6 per million children, the mean annual incidence of ESRF is 9.2 per million children, and congenital anomalies of the urinary system constitute the most common cause of chronic renal failure (CRF).8 Another study from Jeddah reported similar results.9 All these studies enrolled a small number of children (less that 100). In the light of a limited data available regarding the epidemiology of CKD in children in Saudi Arabia, we performed a retrospective study to examine the risk factors for RRT and mortality among children with CKD.     

Health care services provided to type 1 and type 2 diabetic patients in Saudi Arabia

Objectives:

To assess health care services provided to type 1 and type 2 diabetic patients and diabetes health care expenditure in the Kingdom of Saudi Arabia (KSA).

Methods:

This study was part of a nationwide, household, population based cross-sectional survey conducted at the University Diabetes Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia between January 2007 and December 2009 covering 13 administrative regions of the Kingdom. Using patients’ interview questionnaires, health care services data were collected by trained staff.

Results:

A total of 5,983 diabetic patients were chosen to assess health care services and expenditure. Approximately 92.2% of health services were governmental and the remaining 7.8% were in private services. The mean annual number of visits to physicians was 6.5±3.9 and laboratories was 5.1±3.9. Diabetic patients required one admission every 3 years with a mean admission duration of 13.3±28.3 days. General practitioners managed 85.9% of diabetic cases alone, or shared with internists and/or endocrinologists. Health care expenditure was governmental in 90% of cases, while it was personal in 7.7% or based on insurance payment in 2.3%.

Conclusion:

Health services and its expenditure provided to diabetic citizens in Saudi Arabia are mainly governmental. Empowerment of the role of both the private sector and health insurance system is badly needed, aside from implementing proper management guidelines to deliver good services at different levels.The health care system (HCS) in the Kingdom of Saudi Arabia (KSA) is growing at an annual rate of 2% to meet the increasing demand for health care services caused by increased population growth, and a surge in chronic non-communicable diseases.1 This has resulted in an increase in the total health care budget by more than 2 times; from 30 billion Saudi Riyals (SR) (US$8 billion) in 2008 to approximately SR69 billion (US$18.4 billion US dollars) in the year 2011 with a cumulative allocation of SR113 billion (U$30.13 billion) in 2010 and 2011; which accounted for 3.7% of the estimated country’s gross domestic product (GDP), which is one of the highest among Gulf Cooperation Council (GCC) countries.2 The Saudi health care system, which is ranked 26th among 190 countries by the World Health Organization (WHO),3 has a lower percentage of average expenditure in relation to the country’s GDP than many developed and developing countries.4 The government HCS in KSA is structured to deliver free health care services to Saudi citizens through various public hospitals and primary health care centers (PHCCs) including government health sectors, such as the Ministry of Health (MOH), Military Health Services and University Health Institutions. In addition to this, the private health care sector, through its clinics and hospitals, provided 31.1% of the total health care services in KSA in 2013.5 The real challenge facing the Kingdom’s HSC is the increased demands for hospital beds and medical personnel to meet international standards.6 The population ratio of physician and nurses in the Kingdom is lower than the global ratio being 9.4 physicians and 21 nurses per 10,000 of population versus 13 physicians and 28 nurses globally.7 This explains the current imbalance between the growth in HCS and the real medical needs of Saudi citizens.Diabetes mellitus, being the most prevalent chronic non-communicable disease in the Kingdom, has a significant effect on the country’s HCS and overall economy.8,9 This is proved by the fact that 25.4% of Saudi citizens older than 30 years of age have diabetes, which implies that there are approximately 1.5 million Saudi citizens suffering from this chronic disease.10 This is aside from the fact that more than 70% of known diabetic patients in the Middle Eastern countries have poorly controlled diabetes,11 associated with high rates of chronic complications that place greater pressure on health services and expenditure, where in 2013, it was estimated that the Middle East and North Africa (MENA) region spent US$13.6 billion on diabetes care with the spending per person with diabetes, where the spending in Saudi Arabia was US$934, which is far below other GCC such as United Arab Emirates (US$2,228), Qatar (US$2,199), and Kuwait (US$1,886),12 although we strongly believe that these figures are underestimated.Diabetic patients are currently managed at all health care levels, from primary to secondary and tertiary levels by general practitioners (GPs), internists, and endocrinologists.13 Since diabetes care involves many medical disciplines, such as ophthalmology, cardiology, nephrology and so forth, specialized diabetes clinics, and diabetes centers are needed to function as liaising bodies. Although health care needs for diabetic patients’ management at a global level have witnessed a clear shift to the primary from secondary and tertiary health care levels,14 diabetic patients in the Kingdom are still receiving services at secondary or even tertiary levels. Since there are no studies so far that have looked into the health care services provided to diabetic patients in KSA, the current study, as a part of the Saudi Abnormal Glucose Metabolism and Diabetes Impact (SAUDI-DM) survey,10 has investigated the current status of health care services provided to diabetic patients. This study aimed to assess the medical system providing care to diabetic patients, and methods of payment through a randomly selected cohort of diabetic patients at a country level.     

Role of endoscopic ultrasound in pediatric patients: A single tertiary center experience and review of the literature

BACKGROUND Although endoscopic ultrasound(EUS) is now widely available and has an established role in adults, the utility of EUS and EUS-guided fine needle aspiration(EUS-FNA) in pediatrics is insufficiently described compared to adults and is supported by only a few studies.AIM To report the experience of a single tertiary center in the use of EUS and EUS-FNA in a pediatric population and to further assess its safety, feasibility, and clinical impact on management.METHODS A retrospective study of 13 children(aged 18 years or younger) identified from our medical database was conducted. A retrospective review of demographic data, procedure indications, EUS findings, and the clinical impact of EUS on the subsequent management of these patients was performed.RESULTS During the 4-year study period, a total of 13(1.7%) pediatric EUS examinations out of 749 EUS procedures were performed in our unit. The mean age of these 8 females and 5 males was 15.6 years(range: 6-18). Six of the 13 EUS examinations were pancreatobiliary(46.1%), followed by mediastinal 2/13(15.4%), peri-gastric 2/13(15.4%), abdominal lymphadenopathy 1/13(7.7%), tracheal 1/13(7.7%) and rectal 1/13(7.7%). Overall, EUS-FNA was performed in 7 patients(53.8%) with a diagnostic yield of 100%. The EUS results had a significant impact on clinical care in 10/13(77%) cases. No complications occurred in these patients during or after any of the procedures.CONCLUSION EUS and EUS-FNA in the pediatric population are safe, feasible, and have a significant clinical impact on the subsequent management; thus avoiding invasive and unnecessary procedures.     

Modelling,Analysis, and Optimization of the Effects of Pulsed Electrophoretic Deposition Parameters on TiO2 Films Properties Using Desirability Optimization Methodology

Titanium dioxide thin films immobilized over treated stainless steel were prepared using the pulsed electrophoretic deposition technique. The effects of process parameters (deposition time, applied voltage, initial concentration, and duty cycle) on photocatalytic efficiency and adhesion properties were investigated. To optimize the multiple properties of the thin film, a response surface methodology was combined with a desirability optimization methodology. Additionally, a quadratic model was established based on response surface analysis. The precision of the models was defined based on the analysis of variance (ANOVA), R², and the normal plot of residuals. Then, a desirability function was used to optimize the multiple responses of the TiO₂ thin film. The optimum values of applied voltage, catalyst concentration, duty cycle, and deposition time were 4 V, 16.34 g/L, 90% DC, and 150 s, respectively. Under these conditions, the decolorization efficiency of tested dye solution reached 82.75%. The values of critical charges L_C1, L_C2, and L_C3 were 5.9 N, 12.5 N, and 16.7 N, respectively.     

Respiratory symptoms in rheumatoid arthritis: relation to pulmonary abnormalities detected by high-resolution CT and pulmonary functional testing

Pulmonary disease is the most frequent and among the most severe extra-articular manifestation of rheumatoid arthritis (RA). However, this issue has not been sufficiently studied in Egyptian patients. The objectives of the present study are to investigate the prevalence and types of pulmonary involvement using high-resolution computed tomography scan (HRCT) and pulmonary function tests (PFT) and evaluate the association between respiratory symptoms and RA-lung disease in a group of Egyptian RA patients. Thirty-six RA patients were recruited; 34 females (94.4%) and 2 males (5.6%) with median age of 48.5?years, and none of them was smoker. Detailed medical and drug histories were obtained. PFT, plain X-ray of the chest, and HRCT were performed to all subjects involved. Nearly 64% of RA patients demonstrated abnormalities in PFT and 47% in HRCT. Mixed restrictive and obstructive pattern was the commonest. Nearly two-thirds of our patients reported one or more pulmonary symptom whether dyspnea, cough, wheezing, or phlegm. Dyspnea was the most frequent symptom. Respiratory symptoms were statistically more common in patients with lung disease. The advanced age, high radiological score, and severity of rheumatoid disease were found to be predictive of lung involvement. Among respiratory symptoms, dyspnea and cough were associated with any pulmonary abnormalities. When specific pulmonary abnormalities were considered, only dyspnea was identified as predictor for restriction. For obstructive abnormality, both cough and wheezing provided valid prediction. We conclude that pulmonary involvement is a common manifestation in Egyptian RA patients, and the pattern of involvement is generally consistent with other studies that were performed worldwide. Specific respiratory symptoms could be used as practical, easy, and cost-effective method, especially in older and with more severe RA patients, to discriminate patients in need of subsequent PFT and HRCT imaging.     

The end point of the ventral visual stream: face and non-face perceptual deficits following unilateral anterior temporal lobe damage

While it has been claimed that the ventral visual stream ends in the inferior aspects of the anterior temporal lobe (ATL), little is known about whether this region is important for visual perception. Here the performance of two patients with unilateral ATL damage was assessed across four visual perception tasks that parametrically varied stimulus similarity. Patients performed normally on difficult judgments of circle size or face age but were impaired on face identity and dot pattern matching tasks. Portions of the ATL, most likely the ventral surface, may have a functional role in visual perception tasks requiring detailed configural processing, most commonly used to discern facial identity.     

Immunogenicity of Recombinant Proteins Consisting of Plasmodium vivax Circumsporozoite Protein Allelic Variant-Derived Epitopes Fused with Salmonella enterica Serovar Typhimurium Flagellin

A Plasmodium falciparum circumsporozoite protein (CSP)-based recombinant fusion vaccine is the first malaria vaccine to reach phase III clinical trials. Resistance to infection correlated with the production of antibodies to the immunodominant central repeat region of the CSP. In contrast to P. falciparum, vaccine development against the CSP of Plasmodium vivax malaria is far behind. Based on this gap in our knowledge, we generated a recombinant chimeric protein containing the immunodominant central repeat regions of the P. vivax CSP fused to Salmonella enterica serovar Typhimurium-derived flagellin (FliC) to activate the innate immune system. The recombinant proteins that were generated contained repeat regions derived from each of the 3 different allelic variants of the P. vivax CSP or a fusion of regions derived from each of the 3 allelic forms. Mice were subcutaneously immunized with the fusion proteins alone or in combination with the Toll-like receptor 3 (TLR-3) agonist poly(I·C), and the anti-CSP serum IgG response was measured. Immunization with a mixture of the 3 recombinant proteins, each containing immunodominant epitopes derived from a single allelic variant, rather than a single recombinant protein carrying a fusion of regions derived from each of 3 allelic forms elicited a stronger immune response. This response was independent of TLR-4 but required TLR-5/MyD88 activation. Antibody titers significantly increased when poly(I·C) was used as an adjuvant with a mixture of the 3 recombinant proteins. These recombinant fusion proteins are novel candidates for the development of an effective malaria vaccine against P. vivax.