Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Original paper<br>The leukemogenic role of (iASPP) in acute leukemia

Introduction: The ASPP family (apoptosis – stimulating proteins of p53) comprises three proteins, ASPP1, ASPP2 and iASPP, that interact with and modulate the behavior of p53. ASPP1 and ASPP2 enhance the ability of p53 to induce apoptosis by causing p53 to up regulate the expression of proapoptotic genes specifically rather than genes involved in cell cycle arrest. Inhibitory member of the ASPP family (iASPP) acts as inhibitor for the p53, it was originally identified as a nuclear protein that interacts with and inhibits NFkb p56 RelA and inhibits p53-mediated cell death as well. Material and methods: To examine the role of iASPP in acute leukemic patients, we analyzed iASPP mRNA expression in acute leukemia by semi quantitative reverse transcriptase polymerase chain reaction (RT-PCR). Results: The results showed that the median level of iASPP in acute lymphoblastic leukemia and acute myeloid leukemia patients was significantly higher than those in cells from normal donors (p=0.04). The expression of iASPP in ALL and AML patients was not associated with age, gender, hemoglobin, platelets; blasts count in bone marrow, treatment outcome but was associated with blasts count in peripheral blood and total leucocytic count in AL patients. Conclusions: The results of the present study suggest that iASPP may play a role in leukemogenesis and/or disease progression of acute leukemia

ORIGINAL ARTICLES Detection Of Minimal Residual Disease In Breast Cancer Patients Undergoing Autologous Pbsct Using Flow Cytometry And Rt-Pcr 1

ABSTRACT Carcinoma of the breast is the most prevalent cancer among Egyptian women. Hematogenous distant metastasis is the leading cause of cancer-related deaths in breast cancer and other solid epithelial tumors. The present study was planned to evaluate CK-19 mRNA detection by nested RT-PCR assay as a detection marker of circulating breast cancer cells in the peripheral blood and disseminated tumor cells in bone marrow of patients with operable breast cancer before the initiation of any adjuvant therapy. Another aim was detection of minimal residual cancer cells contaminating the peripheral blood stem cell (PBSC) apheresis products of patients with advanced breast cancer undergoing high-dose chemotherapy (HDCT) and autologous PBSC transplantation, and to determine the impact of minimal residual disease (MRD) detection on the outcome of long-term follow up of these patients after transplantation. This present study included 64 breast cancer patients. Molecular and cellular approaches have been used in the detection of the occult tumor cells. RT-PCR targeting tissue-specific mRNA and flow cytometry using monoclonal antibodies against cytokeratin were applied on 14 bone marrow samples, 30 peripheral blood samples as well as 20 PBSC samples from high-risk primary and metastatic breast cancer patients who underwent high-dose chemotherapy and autologous transplantation. Flow cytometry detected minimal residual disease in 7 patients (35.0%) of group I (PBSC), while in group II bone marrow micrometastasis was detected in 3 (21.4%) patients. The nested RT-PCR assay for CK-19 mRNA detected minimal residual disease in 11(55.0%) patients of group I (PBSC) and 5 (36.0%) of group II (bone marrow micrometastasis) patients as well as 8 (27.3%) patients of group III (CTC). The concordance of flow cytometry and RT-PCR was 82.4%. There was a significant association between tumor stage and CK-19 mRNA by RT-PCR assay (p-value = 0.017) in group I (PBSC), while larger primary tumors &gt; 2 cm were significantly associated with a higher incidence in micrometastasis patients (group II) than were tumors that were 2 cm or less in diameter (p&lt;0.001). The presence of CK-19 mRNA positive tumor cells in the PBSC was significantly associated with a decreased DFS (p=0.04). Patients with bone marrow micrometastasis had a higher risk of relapse (p=0.007) and death (p=0.01) than patients without bone marrow micrometastasis. Measuring CTC counts can facilitate the early prediction of treatment response and thereby avoid unnecessary therapy. CTCs may also be a useful biomarker for molecular targeted agents, enabling the identification of patients most likely to respond to a given treatment and facilitating treatment selection

GLUL rs10911021 polymorphism and risk of coronary artery disease among Egyptian individuals

Abstract Background Genome-wide association studies have identified novel genes related to coronary artery disease (CAD). These studies have been replicated in distinct ethnic populations, returning inconsistent results. Our work aimed to study the frequency of C and T alleles of GLUL polymorphism genetic variant rs10911021 among Egyptians with coronary artery disease in comparison to apparently healthy subjects. Our study included 420 patients with CAD (180 CAD without T2DM, 240 CAD with T2DM patients) and 200 control subjects. All subjects were genotyped for rs10911021 by real-time polymerase chain reaction. Results For rs10911021, the frequency of (C/T + T/T) genotypes was significantly higher in CAD patients with and without T2DM than in controls (55(45 + 10) % vs. 22(19 + 3) %; p < 0.001) and (50(45 + 5) % vs. 22(19 + 3) %; p < 0.001 respectively). The genotype C/C was the most frequent among the controls (78%). The presence of GLUL polymorphism was associated with 4.4-fold increased risk to develop CAD in diabetic patients (OR = 4.4, 95% CI = (2.2–8.7); p < 0.001) and was associated with 2.3-fold increased risk to develop CAD (OR = 2.3, 95% CI = (1.1–4.6); p = 0.0213). Conclusion In conclusion, among Egyptians, the GLUL polymorphism susceptibility variant rs10911021 is associated with CAD, with and without T2DM

Peroxisome proliferator-activated receptor-γ polymorphism (rs1801282) is associated with obesity in Egyptian patients with coronary artery disease and type 2 diabetes mellitus

Objective: Peroxisome Proliferator-Activated Receptor-γ (PPAR-γ) gene is one of the possible genes linking diabetes mellitus (DM) with coronary artery disease (CAD). The aim of this study is to clarify whether PPAR-γ Pro12Ala polymorphism is associated with the development of CAD in type 2 diabetic patients and to evaluate PPAR-γ Pro12Ala polymorphism genetic distribution in type 2 DM (T2DM) Egyptian subjects. Methods: PPAR-γ Pro12Ala polymorphism was determined by Real-Time PCR in serum of 405 subjects classified into 4 groups; T2DM patients (n = 105), T2DM with CAD (n = 100), CAD patients (n = 100) and healthy controls (n = 100). Results: The PPAR-γ Pro12Ala polymorphism was associated significantly with T2DM with CAD (group2) (OR = 3, 95% CI = (1.5–6); p = 0.001). In this study, T2DM with CAD complications carrying the PPAR-γ Pro12Ala polymorphism had higher BMI than those without the PPAR-γ Pro12Ala polymorphism (p < 0.0001). CAD patients carrying PPAR-γ Pro12Ala polymorphism had considerable insulin resistance features. Plasma paraoxanase 1(PON1) level was considerably reduced among our 3 studied groups in comparison to control group (p < 0.001). Conclusions: PPAR-γ Pro12Ala polymorphism might represent a novel risk factor for CAD in T2DM

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation A Report From the GARFIELD-AF Registry

IMPORTANCE Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes