Impact of COVID-19 Pandemic on Post-Graduate Medical Education and Training in India: Lessons Learned and Opportunities Offered

Hands-on or practice-based learning is the foundational objective of postgraduate teaching and training. A skilled and competent postgraduate resident is critical to the country's health needs and is more relevant in the ongoing COVID-19 pandemic. The postgraduate medical training in India is speciality-specific and based on a structured curriculum and syllabus to achieve precise educational goals and objectives. The impact of this pandemic on postgraduate medical education and training is controversial, challenging, unknown, and far-reaching. The exceptional contagious nature of the virus and country-wide lockdowns have tremendously decreased hospital visiting patients. Abolition of outpatient and inpatient services, disruptions in clinical postings, curtailment of elective operations and procedures have adversely affected the training of residents and fellowship students in India and abroad. Apart from this, research work, mentoring, academic conferences, and workshops that offer learning experiences to these residents have been cancelled or suspended, thus denying them a chance to achieve domain knowledge and enhance their skills. Although this pandemic has offered new learning modes like teleconsultation, videoconferencing, virtual simulations, digital podcasts, etc., how much actual knowledge transfer and skill gain will be achieved is unanswered. Despite this disruption, this pandemic has offered a golden opportunity to relook at the current PG resident education and training programme. The lessons learned from this adversity offer medical universities, medical educators, and regulatory authorities many opportunities to develop a novel and innovative curriculum that enables the current and future residents to achieve the necessary proficiency and competency.

Measuring nonhomologous end-joining, homologous recombination and alternative end-joining simultaneously at an endogenous locus in any transfectable human cell

Double strand break (DSB) repair primarily occurs through 3 pathways: non-homologous end-joining (NHEJ), alternative end-joining (Alt-EJ), and homologous recombination (HR). Typical methods to measure pathway usage include integrated cassette reporter assays or visualization of DNA damage induced nuclear foci. It is now well understood that repair of Cas9-induced breaks also involves NHEJ, Alt-EJ, and HR pathways, providing a new format to measure pathway usage. Here, we have developed a simple Cas9-based system with validated repair outcomes that accurately represent each pathway and then converted it to a droplet digital PCR (ddPCR) readout, thus obviating the need for Next Generation Sequencing and bioinformatic analysis with the goal to make Cas9-based system accessible to more laboratories. The assay system has reproduced several important insights. First, absence of the key Alt-EJ factor Pol θ only abrogates ∼50% of total Alt-EJ. Second, single-strand templated repair (SSTR) requires BRCA1 and MRE11 activity, but not BRCA2, establishing that SSTR commonly used in genome editing is not conventional HR. Third, BRCA1 promotes Alt-EJ usage at two-ended DSBs in contrast to BRCA2. This assay can be used in any system, which permits Cas9 delivery and, importantly, allows rapid genotype-to-phenotype correlation in isogenic cell line pairs.

Effect of proton and gamma irradiation on human lung carcinoma cells: Gene expression, cell cycle, cell death, epithelial-mesenchymal transition and cancer-stem cell trait as biological end points

Proton beam therapy is a cutting edge modality over conventional gamma radiotherapy because of its physical dose deposition advantage. However, not much is known about its biological effects vis-a-vis gamma irradiation. Here we investigated the effect of proton- and gamma- irradiation on cell cycle, death, epithelial-mesenchymal transition (EMT) and "stemness" in human non-small cell lung carcinoma cells (A549). Proton beam (3MeV) was two times more cytotoxic than gamma radiation and induced higher and longer cell cycle arrest. At equivalent doses, numbers of genes responsive to proton irradiation were ten times higher than those responsive to gamma irradiation. At equitoxic doses, the proton-irradiated cells had reduced cell adhesion and migration ability as compared to the gamma-irradiated cells. It was also more effective in reducing population of Cancer Stem Cell (CSC) like cells as revealed by aldehyde dehydrogenase activity and surface phenotyping by CD44(+), a CSC marker. These results can have significant implications for proton therapy in the context of suppression of molecular and cellular processes that are fundamental to tumor expansion.

DNA damage response signaling in lung adenocarcinoma A549 cells following gamma and carbon beam irradiation

Carbon beams (5.16MeV/u, LET=290keV/μm) are high linear energy transfer (LET) radiation characterized by higher relative biological effectiveness than low LET radiation. The aim of the current study was to determine the signaling differences between γ-rays and carbon ion-irradiation. A549 cells were irradiated with 1Gy carbon or γ-rays. Carbon beam was found to be three times more cytotoxic than γ-rays despite the fact that the numbers of γ-H2AX foci were same. Percentage of cells showing ATM/ATR foci were more with γ-rays however number of foci per cell were more in case of carbon irradiation. Large BRCA1 foci were found in all carbon irradiated cells unlike γ-rays irradiated cells and prosurvival ERK pathway was activated after γ-rays irradiation but not carbon. The noteworthy finding of this study is the early phase apoptosis induction by carbon ions. In the present study in A549 lung adenocarcinoma, authors conclude that despite activation of same repair molecules such as ATM and BRCA1, differences in low and high LET damage responses might be due to their distinct macromolecular complexes rather than their individual activation and the activation of cytoplasmic pathways such as ERK, whether it applies to all the cell lines need to be further explored.

The complexity of mitogen-activated protein kinases (MAPKs) made simple

The mitogen-activated protein kinase (MAPK) pathways are known to be involved in various processes of growth, differentiation and cell death. In spite of their ubiquitous presence and seemingly enormous cross-talk with each other, their action is very specific. This review deals with various aspects of the three different MAPK pathways (ERK, p38 and JNK) and how their specificity is brought about.

Effect of nitric oxide donor and gamma irradiation on MAPK signaling in murine peritoneal macrophages

Irradiation (IR) of cells is known to activate enzymes of mitogen activated protein kinase (MAPK) family. These are known to be involved in cellular response to stress and are determinants of cell death or survival. When radiotherapy is delivered to malignant cells, macrophages, being radioresistant, survive, get activated, and produce large amounts of nitric oxide. As a result of activation they recognize and phagocytose tumor and normal cell apoptotic bodies leading to tumor regression. In this study, the MAPK signaling in peritoneal macrophages was investigated which plays an important role in its various functions, in an environment which is predominantly nitric oxide, as is after IR. The behavior of macrophages in such an environment was also looked at. The three MAPK (ERK1/2, p38, and JNK) respond differently to Sodium nitroprusside (SNP) alone or IR alone. All the three were activated following IR but only JNK was activated following SNP treatment. Surprisingly, when both the stresses were given simultaneously or one after the other, this differential response was lost and there was a complete inhibition of phosphorylation of all the three MAPKs, irrespective of the order of the two insults (IR and SNP). The noteworthy observation was that despite the complete inhibition of MAPK signaling there was no effect on either the viability or the phagocytic efficiency of peritoneal macrophages.

Delayed activation of PKCdelta and NFkappaB and higher radioprotection in splenic lymphocytes by copper (II)-Curcumin (1:1) complex as compared to curcumin

A mononuclear 1:1 copper complex of curcumin had been found to be superior to curcumin in its anti-oxidant properties. This paper describes the radio-protective effects of the complex in splenic lymphocytes from swiss mice. The complex was found to be very effective in protecting the cells against radiation-induced suppression of glutathione peroxidase, catalase and superoxide dismutase (SOD) activities. Both curcumin and the complex protected radiation-induced protein carbonylation and lipid peroxidation in lymphocytes with the complex showing better protection than curcumin. It also showed better overall protection by decreasing the radiation-induced apoptosis. The kinetics of activation of PKCdelta and NFkappaB after irradiation in presence or absence of these compounds was looked at to identify the molecular mechanism involved. The modulation of irradiation-induced activation of PKCdelta and NFkappaB by curcumin and the complex was found different at later time periods although the initial response was similar. The early responses could be mere stress responses and the activation of crucial signaling factors at later time periods may be the determinants of the fate of the cell. In this study this delayed effect was observed in case of complex but not in case of curcumin. The delayed effect of the complex along with the fact that it is a better free radical scavenger must be the reason for its better efficacy. The complex was also found to be less cytotoxic then curcumin at similar concentration.

Inhibition of radiation induced nitration by curcumin and nicotinamide in mouse macrophages

Nitric oxide plays an important role in inflammation and carcinogenesis and has now been implicated as an important signaling molecule under normal physiological conditions also. Increased nitric oxide (NO) results in increased nitration of proteins at tyrosine, which can cause protein dysfunction or alterations in signal transduction pathways. Irradiation of Lipopolysaccharide (LPS) activated mouse peritoneal macrophages was found to increase NO production, inducible nitric oxide synthase (iNOS) expression and nitration of proteins. The increase in iNOS expression was very less when compared to increase in NO production, indicating the possibility of post-translational activation of iNOS by LPS and ionising radiation. The addition of curcumin, nicotinamide and Jun N-terminal kinase (JNK) inhibitor, SP 600125, reduced the levels of NO, iNOS expression and nitration of proteins in macrophages. Closer scrutiny of the inhibition pattern of these modulators revealed that although the JNK inhibitor did not result in significant decrease in iNOS expression it led to a significant decrease in NO production, implying the possible involvement of JNK in the regulation of iNOS activity. Curcumin and JNK inhibitor directly inhibited the nitration of proteins and JNK inhibitor and curcumin, when added together, did not show synergistic effect.

Mitogen-activated protein kinases: specificity of response to dose of ionizing radiation in liver

Ionizing radiation is known to activate both the cytotoxic stress-activated kinases (SAPK/JNK, p38) and the cytoprotective mitogen-activated protein kinases (MAPKs, ERKs), which send divergent signals to the nucleus. However, all these kinases could not be activated simultaneously and at all the doses. An attempt has been made in this study to establish the dose and temporal response of these kinases with a view to establish the identity of the transcription factors that remain activated because only these will be translated into an effect. The study indicates that the stress-activated kinases (SAPK/JNK and p38) are activated by very low doses (0.1 Gy) of ionizing radiation. An induction of expression of MKK4, precursor to SAPK and p38, was found at lower doses (0.1-0.5 Gy). However, the cytoprotective ERK2 showed a progressive increase in expression with dose, except at 3 Gy where it shows a marginal decline. The stress-activated kinases show an increased expression or activation at early periods, unlike ERK2, which shows a prolonged response to stimuli. This study reveals that in the in vivo condition there is a chronological order of activation of the kinases and a dose-dependent activation. The activations of the cytoplasmic kinases and the transcription factors, Elk-1 and c-Jun, both show prolonged activation and maximum response at high doses.

Poly (ADP-ribose) polymerase and DNA-dependent protein kinase: differential activation in vivo

DNA damage-activated homodimer of PARP-1 binds to single-strand breaks and catalyzes the synthesis and transfer of negatively charged ADP-ribose polymers to nuclear protein acceptors, including itself. It also undergoes site-specific proteolysis during apoptosis. On the other hand, DNA-PK is a heterotrimeric enzyme that specifically binds to double-strand breaks and phosphorylates its target proteins. Because both DNA breaks and apoptosis are known to occur following irradiation, whole-body irradiation was administered to find out the temporal pattern and dose-response of PARP expression and the activity pattern of DNA-PK. To assess the temporal response, male Wistar rats were subjected to a radiation dose of 3Gy and killed at various time intervals (1-24 hours). Both the PARP activity and expression were enhanced 4 hours after irradiation. Fragmented PARP was not observed until 24 hours after irradiation. The differential expression at DNA-PK various doses (0.1-5.0 Gy) was examined. The maximum expression of PARP was noted at 1 Gy, whereas the activation of DNA-PK was maximally observed at 3 Gy. We did not observe any increase in the expression of PARP until the dose of 3Gy was reached, which contradicted the findings in previous in vitro reports of PARP activation at high radiation doses. DNA-PK, however, showed a dose-dependent increase. Our results indicate that although both the PARP and the DNA-PK are nuclear enzymes with similar roles, the activation of these enzymes is dependent on the dose, and any extrapolation of data from in vitro observations can lead to misinterpretation.

The nature of the scrapie agent: the virus theory

All spongiform encephalopathies (SEs) are slow virus-transmissible infectious disorders of the brain. Tubulofilamentous particles/scrapie-associated fibrils (SAF) are ultrastructural markers, while protease-resistant protein (PrP) is a protein marker. The PrP molecules aggregate to form SAF, which occurs as an internal part of the tubulofilamentous particle termed nemavirus (NVP). Each NVP consists of three layers: (i) an outer protein coat, (ii) an intermediate ssDNA layer, and (iii) inner PrP/SAF. A chronological study of scrapie-infected hamster brain revealed that NVP and SAF are seen 10 days postinoculation from the inoculated right side of the brain and from 18 days postinoculation from both sides of the brain. The existence of at least 20 stable strains of SEs implies that a nucleic acid molecule serves as the information molecule. This is incompatible with the hypothesis that PrP by itself or a specific point mutation is the agent. It appears that an "accessory protein" coded by the ssDNA of the nemavirus interacts with normal PrPc molecules, resulting in their conversion to PrPsc/SAF. The pathogenesis process in infected animals with increasing incubation periods reveals that larger amounts of normal PrP molecules are modified to form SAF. This interferes with the normal supply of PrP to cell membranes, which become disrupted and eventually fragment, resulting in the vacuoles typical of those found in the SEs.

Origin and implications of bovine spongiform encephalopathy

All spongiform encephalopathies in animals, including humans, are slow developing infectious diseases. The current working theory links the origin of bovine spongiform encephalopathy (BSE) to the feeding of cattle with meat and bone meal prepared from scrapie-infected sheep remains. Recycling of cattle meat and bones (MBM) essentially resulted in the selection of a single strain from the "wild type", a mixture of 20 strains. The BSE agent is easily transmitted through ingestion, with some evidence of vertical transmission. Paradoxically, cattle have selected a major new strain which appears to be more virulent than an unselected strain found in scrapie sheep. The same strain of BSE agent is implicated in the occurrence of spongiform encephalopathy in domestic cats, tiger, and some exotic species of ruminants in zoos. The properties of BSE and its spread into cattle are still disputed. Since our understanding of the disease and its transmissibility in humans must await observations that will be made over some years to come, it is important to keep a reasonable perspective and ensure that any speculative comment is consistent with fact. In risk assessment in such circumstances, it is tempting give too much credence to persuasive parallels when direct relevant information is not available. On the other hand, it would also not be wise to assume that the disease will die by itself and will have no effect on humans.