Streptococcus pneumoniae is a leading cause of invasive bacterial infections, with nasal colonization an important first step in disease. While cigarette smoking is a strong risk factor for invasive pneumococcal disease, the underlying mechanisms remain unknown. This is partly due to a lack of clinically relevant animal models investigating nasal pneumococcal colonization in the context of cigarette smoke exposure. We present a model of nasal pneumococcal colonization in cigarette smoke-exposed mice and document, for the first time, that cigarette smoke predisposes to invasive pneumococcal infection and mortality in an animal model. Cigarette smoke increased the risk of bacteremia and meningitis without prior lung infection. Mechanistically, deficiency in interleukin 1␣ (IL-1␣) or platelet-activating factor receptor (PAFR), an important host receptor thought to bind and facilitate pneumococcal invasiveness, did not rescue cigarette smoke-exposed mice from invasive pneumococcal disease. Importantly, we observed cigarette smoke to attenuate nasal inflammatory mediator expression, particularly that of neutrophil-recruiting chemokines, normally elicited by pneumococcal colonization. Smoking cessation during nasal pneumococcal colonization rescued nasal neutrophil recruitment and prevented invasive disease in mice. We propose that cigarette smoke predisposes to invasive pneumococcal disease by suppressing inflammatory processes of the upper respiratory tract. Given that smoking prevalence remains high worldwide, these findings are relevant to the continued efforts to reduce the invasive pneumococcal disease burden.

Introduction: We conducted a national survey to characterize current Canadian procedural skills training in Undergraduate Medical Education (UGME). The goals were to identify the most important procedures students should know upon graduation and assess clinician-educator perceptions regarding implementation of a pre-clerkship procedural program. Methods: We distributed the survey to physician-educators across Canada’s 17 medical schools. Respondents were directed to an individualized survey that collected demographic data, physician-educator responses on essential procedural skills, as well as physician-educator opinions on the value of a pre-clerkship procedural training program. Results: The response rate for this survey was 21% (42 out of 201 distributed surveys were completed). The top 10 most important procedures identified by physician-educators included IV Access, Airway Management, Local anesthesia/field block, Casting, Spontaneous Vaginal Delivery, Testing for STIs, Phlebotomy, Suturing of Lacerations, Nasogastric Tube Insertion, and Venipuncture. Physician-educators supported a pre-clerkship procedural program. Conclusions: Identifying the most crucial procedural skills is the first step in implementing a competency-based procedural skills training program for Canadian medical students. With the list of essential skills, and the support for physician-educators in developing a pre-clerkship procedural skills curriculum, hopefully there can be future development of formalized curricula.

Background Recent guidelines recommended judicious use of abdominal computed tomography (CT) in the emergency department (ED) for inflammatory bowel disease. Trends in CT utilization over the last decade, including since the implementation of these guidelines, remain unknown. Methods We performed a single-centre, retrospective study between 2009 and 2018 to assess trends in CT utilization within 72 h of an ED encounter. Changes in the annual rates of CT imaging among adults with IBD were estimated by Poisson regression and CT findings by Cochran-Armitage or Cochran-Mantel Haenszel tests. Results A total of 3000 abdominal CT studies were performed among 14,783 ED encounters. CT utilization increased annually by 2.7% in Crohn’s disease (CD) (95% confidence interval [CI], 1.2 to 4.3; P = 0.0004), 4.2% in ulcerative colitis (UC) (95% CI, 1.7 to 6.7; P = 0.0009) and 6.3% in IBD unclassifiable (95% CI, 2.5 to 10.0; P = 0.0011). Among encounters with gastrointestinal symptoms, 60% with CD and 33% with UC underwent CT imaging in the final year of the study. Urgent CT findings (obstruction, phlegmon, abscess or perforation) and urgent penetrating findings alone (phlegmon, abscess or perforation) comprised 34% and 11% of CD findings, and 25% and 6% of UC findings, respectively. The CT findings remained stable overtime for both CD (P = 0.13) and UC (P = 0.17). Conclusion Our study demonstrated persistently high rates of CT utilization among patients with IBD who presented to the ED over the last decade. Approximately one third of scans demonstrated urgent findings, with a minority demonstrating urgent penetrating findings. Future studies should aim to identify patients in whom CT imaging is most appropriate.

Introduction: Pre-clerkship procedural skills training is not yet a standard across Canadian medical school curricula, resulting in limited exposure to procedures upon entering clerkship. While simulated skills training has been documented in the literature to improve performance in technical ability, anxiety and confidence have yet to be investigated despite their documented impact on performance and learning. This study therefore aims to evaluate the effect of pre-clerkship procedural skills training on medical student anxiety and confidence. Methods: A procedural skills training program was designed based on an evidence-based near-peer, flipped classroom model of education. Ninety-two second-year medical students volunteered for the study. Fifty-six were randomized to the training group, and 36 were randomized to the control group. Students in the training group attended seven procedural skills tutorials over seven months. The control group represented the average medical school student without standardized procedural training. Student anxiety and confidence were assessed at the beginning and end of the program using the State Trait Anxiety Inventory and Confidence Questionnaires. Results: Students who participated in the procedural skills program demonstrated greater reductions in their state anxiety and greater improvements in confidence compared to the control group. Conclusion: Longitudinal procedural skills training in the simulation setting has demonstrated improvements in anxiety and confidence among pre-clerkship medical students. These added benefits to training have the potential to ease medical students’ transition into clerkship, while also contributing to a safer and more effective clinical experience. Therefore, future integration of standardized pre-clerkship procedural skills training within medical school curricula should be considered.

Introduction: Procedural skills training varies significantly across Canadian medical schools, and there is currently no standardized assessment tool to evaluate its benefits. This project aims to develop a curriculum that teaches 2nd-year medical students to perform and evaluate procedural skills. The goals of this program include decreasing anxiety, increasing confidence, and achieving competence for students and also allowing staff to judge the appropriate level of supervision when delegating learners to perform basic procedures in the team setting. Our curriculum incorporates, near-peer teaching as well as near peer formative assessment. Methods: Each of the twelve 2nd year participants completed a State Trait Anxiety Inventory and self-reported confidence questionnaire related to procedural skills. Students participated in four sessions taught by expert physicians over a five month period. A new skill was taught at each monthly workshop and an opportunity to practice previously taught skills was provided. Skills were assessed in a skills integration simulation OSCE, and the anxiety and confidence questionnaire was repeated. Results: Students who completed this pilot program showed a significant decrease in mean anxiety state (2.48 vs 1.74, p-value <0.001), while the control group did not (p-value = 0.408). When assessing confidence, students who completed this program showed increased self-assessed knowledge and confidence in each of the program's assessed skills. An increased level of competency was achieved in each skill by each student as assessed by the expert physicians. Conclusion: There is evidence to suggest that implementation of this procedural skills training model within the Canadian medical school curriculum may improve student anxiety, confidence, and competency for success in clerkship and could be the foundation for developing milestones for EPAs.