Perceived Impact of Coronavirus Disease 2019 on Surgical Training: A Brazilian Survey

INTRODUCTION

Recent studies revealed that coronavirus disease 2019 (COVID-19) negatively impacted residency programs worldwide, particularly procedure-based programs. However, most studies are from high-income countries, with scarce data from low- and middle-income countries. Pandemic effects on surgical training were likely worse in strictly apprenticeship models relying heavily on surgical volume as opposed to competency-based programs. Notably, training programs in Brazil and other low- and middle-income countries follow these strict apprenticeship style frameworks. In this study, we aimed to evaluate the trainees' perceptions of the impact of COVID-19 on their Brazilian surgical programs.

METHODS

A cross-sectional study was performed using an anonymous survey in Portuguese, distributed via social media platforms to surgical residents enrolled in Brazilian surgery programs. Data collection took place from August 2021 to May 2022. The survey contained 30 questions on the perception of the impact of COVID-19 on surgical training.

RESULTS

One-hundred sixty-two residents from 17 different surgical specialties and all five regions of Brazil responded to the survey. Of 162 residents, 145 (89%) believed the pandemic negatively impacted their surgical training. Furthermore, of 162 residents, 153 (94%) reported that elective surgical volume decreased during the pandemic and 91 (56%) were redeployed to assist with COVID-19 management. As a result, 102 of 162 (63%) residents believed their surgical skills were negatively impacted by COVID-19. Yet, 95 of 162 (59%) residents reported their residency programs did not offer resources to mitigate the pandemic's impact on training. Of 162 residents, 57 (35%) reported they did not feel on track for graduation, with no statistical difference between responses by year of residency (P = 0.083). Additionally, 124 of 162 (77%) residents reported that the pandemic negatively affected their mental health, most commonly related to stress at work, stress about transmitting COVID-19, and loss in surgical training.

CONCLUSIONS

Most of the surveyed Brazilian surgical residents felt the COVID-19 pandemic negatively impacted their training. This leads to believe that the detrimental impacts of the pandemic exposed preexisting weaknesses in the Brazilian surgical training model's dependence on a strict apprenticeship model. Our findings suggest a crucial need to redesign surgical education programs to make residency programs more prepared for changes in surgical volume, evolve the apprenticeship model to competency-based approaches, and unify surgical training standards in low- and middle-income countries.

The expression of the DeltaNp73beta isoform of p73 leads to tetraploidy

The p73 locus gene has a complex structure encoding a plethora of isoforms. The different DeltaN truncated isoforms of p73 may exert different activities depending on the cellular context. The beta isoform of DeltaNp73 seems to have a particular pattern of action even if its role in cell cycle and mitosis is still under investigation. To gain further knowledge of DeltaNp73beta's function, we investigated the effects of its over-expression in tumour cellular models, using the tetracycline-inducible expression system. In the human lung carcinoma cell line H1299, DeltaNp73beta over-expression resulted in suppression of cell growth and in cell death. Surprisingly stable over-expression of DeltaNp73beta impaired the genomic stability of tumour cells, leading to the formation of tetraploid cells. The cells become enlarged and multinucleate, with incorrect mitotic figures, and died by apoptotic-independent pathways. Our data suggest that DeltaNp73beta-induced aberrant mitosis evades the control of the mitotic spindle assay checkpoint, leading to tetraploidy and cell death through mitotic catastrophe rather than apoptosis. The various C-terminal regions of DeltaNp73 may influence the final cellular phenotype and we assume that the beta one in particular could be important in both cell growth control and regulation of mitosis.

DeltaNp63 expression is associated with poor survival in ovarian cancer

BACKGROUND

P63 belongs to the 'p53 family' whose role in cancer progression has been recently revisited in light of the plethora of splicing variants that are generated. We analyzed the expression of the full-length TAp63 gene and its dominant-negative form deltaNp63 in ovarian cancer biopsies to correlate their expression with clinical outcome.

MATERIALS AND METHODS

Real-time RT-PCR analysis was used to determine the levels of TAp63 and deltaNp63 in 83 stage I and in 86 stage III ovarian cancer biopsies and in seven human ovarian cancer cell.

RESULTS

TAp63 levels were comparable in stage I and stage III, but deltaNp63 levels increased 77-fold in stage III, independently of the p53 status. Patients with high deltaNp63 expression had the worst overall survival (OS); patients with a deltaNp63/TAp63 ratio >2 had a poor OS. Patients with a high deltaNp63/TAp63 ratio were those with a poor response to platinum-based therapy.

CONCLUSIONS

Data indicate a role for deltaNp63 as a potential biomarker to predict patient's outcome and tumor progression in ovarian cancer. This would have particularly clinical relevance in ovarian cancer where the high rate of mortality reflects our lack of knowledge of molecular mechanisms underlying cell progression toward malignancy.

Effects of inducible overexpression of DNp73alpha on cancer cell growth and response to treatment in vitro and in vivo

The p73 gene has a complex regulation, which leads to the expression of different isoforms, often with opposite biological effects. We have generated in the human colocarcinoma cell line HCT116, expressing a wild-type p53, an inducible DNp73alpha expressing system. Two clones (HCT116/DN3 and HCT116/DN14), upon doxycycline addition, show a strong expression of DNp73alpha. In vitro the two DNp73alpha overexpressing clones grow at similar rate of the control transfected clone (HCT116/8a) and similarly respond to DNA damage. When injected in mice, HCT116/DN3, HCT116/DN14, and HCT116/8a cells grew similarly in the absence or presence of tetracycline. In HCT116/DN3 and HCT116/DN14 tumors, tetracycline induced a strong expression of DNp73alpha both as mRNA and protein. These results indicate that in this system the overexpression of the DNp73alpha does not induce a more aggressive phenotype and does not seem to be associated with a reduced response of the cells to treatment with anticancer agents.

Molecular characterisation of two human cancer cell lines selected in vitro for their chemotherapeutic drug resistance to ET-743

ET-743 (Yondelis(TM), Trabectedin) isolated from the tunicate Ecteinascidia turbinata, is being tested in phase II clinical trials in Europe and the United States of America (USA). Studies with different solid tumours have shown antitumour activity in advanced, pre-treated sarcomas as well as in drug-resistant breast and ovarian cancer. The primary mechanism of action for ET-743 has not been fully elucidated and different models have been suggested to explain its molecular mechanism of action. ET-743 binds tightly to the minor groove of DNA and previous data have suggested that ET-743 acts by interfering with RNA transcription. To further investigate the mechanism of in vitro drug resistance, we evaluated the gene expression profile in ovarian and chondrosarcoma cell lines selected for resistance to ET-743. We found 70 genes whose expression was modulated in both drug-resistant cell lines when compared with their respective parental drug-sensitive cell lines. This pattern of gene expression seems to be selective for ET-743-resistant cells, since ovarian cancer cells resistant to paclitaxel did not share the same gene expression changes. Data presented in this study reveal different molecular pathways that could be involved in the cellular mechanism of ET-743 resistance.

Drug use by the elderly in Italy

OBJECTIVES

To evaluate drug consumption in the elderly aged 75 years or more living at home.

DESIGN

Cross-sectional study.

SETTING

Old-old (i.e., > or = 75 y) people living in central Turin, a city in northern Italy.

PARTICIPANTS

Thirty-four general practitioners (GPs), with 50 or more old-old people in their patient list, randomly chosen among the GPs working in the Unità Socio-Sanitaria Locale I (Local Health Unit I) of Turin; 261 old-old people (135 men and 126 women) randomly selected from the practice records.

METHODS

Data were collected by the GP through a structured questionnaire during an office visit and by a social worker in a home interview within 14 days of the GP visit. GPs were asked to record every diagnosis and drug currently taken by the patient; social workers were trained in the administration of a structured questionnaire exploring sociodemographic variables, drug use (following the medication inventory strategy), disability, cognitive functions, and depressive symptoms.

RESULTS

Nearly all subjects (95% of the women and 91% of the men) were taking at least 1 drug. The overall number of drugs recorded was 917 (47.1% for men and 52.9% for women), of which 172 (18.8%) were not reported by the GP but were recorded during the social worker's visit. The mean number of drugs was 3.2 for men and 3.8 for women, with a statistically significant difference (p = 0.02), while the mean number of diagnoses was 2.3 and 2.6, respectively. The study of correlates of drug consumption showed a strong association with number of diagnoses at univariate analysis (p < 0.0001, with a linear correlation coefficient of 0.64). No multivariate model showed a clear superiority over the simple one containing only the number of diagnoses in predicting the total number of drugs taken. Cardiovascular, nervous system, and alimentary tract drugs were the most frequently used. A total of 107 subjects (41%) were taking at least 1 unreported drug.

CONCLUSIONS

Our study shows high drug consumption among old-old people, with nearly 20% of drugs taken not reported by the GP. These results emphasize the need for an essential therapeutic approach in old-old people, prescribing only drugs of scientifically proven efficacy. Furthermore, the GP must make more effort when collecting a drug history from old-old patients.

Change in prescribing patterns of general practitioners in Italy before and after the Reform Drug Act. A case study of changes in the city of Turin

As of 1 January 1994, the introduction of a new classification of the drugs to be reimbursed by the National Health Service was approved by the Italian parliament in order to limit expenditure on pharmaceutical agents. This has set off a 'cultural revolution', unprecedented in Italy. The criteria that inspired the expert group charged with attributing drugs to different classes (Class A: essential, free of charge drugs; Class B: drugs to be paid for 50% by the patient; Class C: drugs to be paid entirely by the patient) were principally scientific rather than merely economic or administrative. Expectedly, the creation of Class C (drugs not reimbursed by the National Health Service on account of their insufficiently proven clinical effectiveness, or their unfavourable cost/benefit ratio with respect to therapeutically equivalent agents) has provoked remarkable changes in general practitioners' prescription options, particularly given the fact that many of these drugs were among the most prescribed in Italy. A database including the prescriptions of about 940 general practitioners, dispensed through the 280 community pharmacies of the city of Turin, has been analysed for a comparative sample of time periods in 1993 and 1994, in order to quantify the changes that occurred and to qualify them with respect to more relevant therapeutic groups and sentinel drugs.

[Health status of the very old at the USSL I in Turin. Epidemiological study in the area of the USSL I in Turin]

The aims of the study were: a. to describe the socioeconomic conditions of a randomized sample of over 75 years elderly of Torino USL; b. to evaluate the impact on doctors of a better knowledge of patients and c. to evaluate the feasibility and the results of a collaborative teamwork with doctors, nurses and social workers. Social workers or nurses evaluated the functional abilities of the elderly with the ADL and IADL scales, the cognitive function with the Mini Mental State and depressive symptoms with the Care Scale. 40 General Practitioners were randomized in two groups and each randomly selected 5 men and 5 women over 75 years, among their patients. Half of the doctors (experimental group) were offered a WHO textbook on drug prescription for the elderly and three monthly meetings with nurses and social workers, to globally evaluate the patients situation and define necessary interventions. 340 patients were recruited for the study (mean age 81 years). No differences were observed in the outcomes of the experimental and control group. An overall improvement of diagnostic skills and reduction of drug prescription was observed in both groups, but the impact of the latter was larger in the experimental group.