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

Wnt/β-Catenin Signaling Regulates the Expression of the Ammonium Permease Gene RHBG in Human Cancer Cells.

Ammonium is a metabolic waste product mainly detoxified by the liver. Hepatic dysfunction can lead to cytotoxic accumulation of circulating ammonium and to subsequent encephalopathy. Transmembrane ammonium transport is a widely spread process ensured by the highly conserved proteins of the Mep-Amt-Rh superfamily, including the mammalian Rhesus (Rh) factors. The regulatory mechanisms involved in the control of RH genes expression remain poorly studied. Here we addressed the expression regulation of one of these factors, RHBG. We identify HepG2 hepatocellular carcinoma cells and SW480 colon adenocarcinoma cells as expressing RHBG and show that its expression relies on β-catenin signaling. siRNA-mediated β-catenin knockdown resulted in significant reduction of RHBG mRNA in both cell lines. Pharmaceutical inhibition of the TCF4/β-catenin interaction or knockdown of the transcription factor TCF4 also downregulated RHBG expression. We identify a minimal RHBG regulatory sequence displaying a promoter activity and show that β-catenin and TCF4 bind to this fragment in vivo. We finally characterize the role of potential TCF4 binding sites in RHBG regulation. Taken together, our results indicate RHBG expression as a direct target of β-catenin regulation, a pathway frequently deregulated in many cancers and associated with tumorigenesis

Impact of Obesity on Clinicopathologic Characteristics and Disease Prognosis in Pre- and Postmenopausal Breast Cancer Patients: A Retrospective Institutional Study

Purpose. To investigate the association between obesity and breast cancer clinicopathologic characteristics at presentation along with prognostic impact among Jordanian breast cancer patients. Such data are lacking in Arabian countries. Methods. In this retrospective study, 348 breast cancer patients were included. Analyses were conducted for associations between body mass index (BMI) and age at diagnosis, tumor clinicopathologic characteristics, and molecular subtypes. Eight prognostic factors were considered, and total prognostic scores were calculated. The analysis was stratified by menopausal status. Multivariate logistic stepwise regression analysis was conducted to identify predictors for breast cancer recurrence and death. Results. Mean age at diagnosis was 50.98 ± 10.96 years. Mean BMI at diagnosis was 29.52 ± 5.32 kg/m2. Mean age at diagnosis was significantly higher for overweight and obese patients compared to underweight/normal patients (P<0.001). A significant positive correlation was observed between patient age and BMI at diagnosis (r = 0.251, P<0.001). Grade of carcinoma was significantly correlated with BMI in the whole population examined (P=0.003). Obese breast cancer patients had significantly higher prognostic scores compared to nonobese cases, indicating worse prognostic features at presentation (P=0.034). Stratification of data analysis based on menopausal status revealed significant associations between obesity and each of tumor stage and grade among postmenopausal but not premenopausal patients (P=0.019 and P=0.031, respectively). Similarly, postmenopausal obese patients had significantly higher prognostic scores compared to nonobese counterparts (P=0.007), indicating worse prognosis, a finding which was also absent among premenopausal breast cancer patients. No significant association between BMI with expression status of hormone receptors, HER2, lymphovascular invasion, and molecular subtypes was found among patients. BMI was a significant predictor for disease recurrence in which obese breast cancer patients had greater odds (2-fold) to develop locoregional and distant recurrence compared to nonobese cases (P=0.011). Conclusions. Obesity was associated with advanced stage and grade of breast carcinoma at diagnosis. The impact of BMI on clinicopathologic characteristics and prognosis was confined to postmenopausal cases. Jordanian obese breast cancer patients are at greater risk of breast cancer recurrence and reduced survival compared to their nonobese counterparts

β-catenin knockdown decreases <i>RHBG</i> expression in SW480 colon cancer cells.

<p>A) Representative results of immunofluorescence of β-catenin localization in SW480 cells using β-catenin antibody. Nuclei were stained with DAPI. B-G) SW480 cells were reverse transfected with β-catenin or control (scramble) siRNAs. 72 hours after transfection, expression levels of <i>β-catenin</i> mRNA (B), β-catenin protein (C), <i>RHBG</i> mRNA (D), <i>Axin2</i> mRNA (E), <i>Cyclin D1</i> mRNA (F) and <i>RHCG</i> mRNA (G) were determined.</p

β-catenin knockdown decreases <i>RHBG</i> expression in HepG2 hepatoma cells.

<p>A-F) HepG2 cells were reverse transfected with β-catenin or control (scramble) siRNAs. 72 hours after transfection, expression levels of <i>β-catenin</i> mRNA (A), β-catenin protein (B), <i>RHBG</i> mRNA (C), <i>Axin2</i> mRNA (D), <i>Cyclin D1</i> mRNA (E) and <i>RHCG</i> mRNA (F) were determined.</p

Activation of β-catenin signaling increases <i>RHBG</i> expression.

<p>A) HEK293T cells were treated with LiCL (20mM) for 24 hours. β-catenin localization was determined by immunofluorescence using β-catenin antibody. Nuclei were stained with DAPI. B) HEK293T cells were treated with LiCL (10 or 20mM) for 24 hours. β-catenin protein level was determined in total cell lysates by immunoblotting using β-catenin antibody. C) Same culture conditions as in B. The <i>RHBG</i> mRNA level was determined by qRT-PCR.</p

<i>RHBG</i> and <i>GLUL</i> are highly expressed in HepG2 hepatoma cells.

<p>A) The level of mRNA expression of <i>RHBG</i> in HEK293T, HepG2 and Hep3B cells was determined by qRT-PCR and normalized to β-actin. B) The mRNA expression of <i>GLUL</i> in HepG2 and Hep3B was determined by qRT-PCR. C) Western Blot analysis of GS protein from total cell lysates of HepG2 and Hep3B cells. D) The level of mRNA expression of <i>RHCG</i> in HEK293T, HepG2 and Hep3B cells was determined by qRT-PCR and normalized to β-actin. E) Western Blot analysis of β-catenin protein from total cell lysates of HEK293T, HepG2 and Hep3B cells.</p

<i>RHBG</i> expression is dependent on TCF4.

<p>A-B) HepG2 cells were treated with PKF118-310 (0,2 or 0,4 μM) for 24 hours. The <i>RHBG</i> (A) and <i>GLUL</i> (B) mRNA levels were determined by qRT-PCR. C-G) HepG2 cells were reverse transfected with TCF4 or control (scramble) siRNAs. 72 hours after transfection, levels of <i>TCF4</i> mRNA (C), TCF4 protein (D), <i>RHBG</i> mRNA (E), <i>Axin2</i> mRNA (F), and <i>Cylcin D1</i> mRNA (G), were determined.</p

Deletion analysis of <i>RHBG</i> promoter sequence.

<p>HepG2 cells were transfected with the empty plasmid (pGL3) or <i>RHBG</i> promoter (pGL3-RHBG) together with Renilla plasmid. 48 hours after transfection, <i>RHBG</i> promoter activity in total cell lysates was determined by luciferase assay. B) HepG2 cells were transfected with <i>RHBG</i> promoter (pGL3-RHBG) or the indicated construct together with Renilla plasmid. 48 hours after transfection, <i>RHBG</i> promoter activity was determined by measuring luciferase activity in total cell lysates. Data are expressed as mean of triplicate determinations ± S.E.M of the pGL3-RHBG construct relative to pGL3-Basic. C) HepG2 cells were transfected with the indicated construct together with Renilla plasmid. 48 hours after transfection, <i>RHBG</i> promoter activity was determined by measuring luciferase activity in total cell lysates.</p

Promoter region of <i>RHBG</i> gene.

<p>The potential human <i>RHBG</i> promoter sequence was obtained from eukaryotic promoter database (<a href="http://epd.vital-it.ch/" target="_blank">http://epd.vital-it.ch/</a>). Black arrow (↓) indicates the predicted transcription start site (TSS) which is designated nucleotide 0. The GC boxes are shadowed. A selection of potential binding sites (with 0 or less than 5% dissimilarity) of transcription factors identified using PROMO [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0128683#pone.0128683.ref054" target="_blank">54</a>,<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0128683#pone.0128683.ref055" target="_blank">55</a>] is underlined. Potential TCF4 binding sites are indicated with empty boxes. Horizontal arrows (→) indicate the starting residue position of each promoter construct analyzed in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0128683#pone.0128683.g008" target="_blank">Fig 8</a>.</p