The impact of the COVID-19 pandemic on general surgery residency: an analysis of operative volumes by residents at a Canadian general surgery residency program

Background: The COVID-19 pandemic has caused disruptions to surgical training across the world. The majority of the existing research on this topic has been based on qualitative methods. The purpose of this study was to quantify the impact of the pandemic on the operating volume of residents at a single Canadian general surgery program. Methods: The T-Res assessment system (Resilience Software Inc.) is used by many surgical residents to log procedures. Anonymized data for a Canadian program was obtained for the months of July 2019-November 2020. The 8 months before the pandemic (July 2019-February 2020) were compared with the 8 months following the onset of the pandemic (April 2020-November 2020). Residents on research or personal leaves were excluded. To further assess the impact of the first COVID-19 wave, a record of all operative cases was obtained from one of the local major hospitals. Results: We analyzed 7986 cases logged by 18 residents across all postgraduate years (PGY). There was a slight, nonsignificant increase in average number of cases per resident in the pandemic period compared with the prepandemic period (208.2 v. 235.5;p = 0.33). Data from the hospital records showed a 23% reduction in cases during the analyzed timeframe. However, general surgery was affected less than other specialties, with a 10% reduction. Conclusion: The analyzed general surgery program did not see a reduction in resident operative volumes. Possible explanations include the overall large volume of emergency cases at this program, and the lower impact of the pandemic on general surgery compared with other specialties. We acknowledge the limitation that heterogeneity exists within hospital protocols, opportunities obtained on different rotations and resident logging practices. Further quantitative research on the topic, stratified by PGY status is needed.

Sabbaticals in US Medical Schools.

BACKGROUND: Sabbaticals are an important feature of academia for faculty and their institutions. Whereas sabbaticals are common in institutions of higher learning, little is known about their role and utilization in US medical schools. This perspective piece examining sabbaticals in medical school faculty was undertaken at a time that well-being of health professionals was increasingly being recognized as a workforce health priority. METHODS: We surveyed associate deans at US medical schools in 2021 about faculty who had taken sabbaticals within the past 3 years, the parameters of the sabbaticals, and institutional policies and respondents' predictions of future sabbatical use. RESULTS: A total of 53% of respondents reported any faculty had taken sabbaticals in the past 3 years (M = 6.27; Median = 3; range = 1-60). Institutions rated enhancing research as the most important objective, while recognizing other benefits. Sabbaticals were more commonly taken by male, white, senior faculty PhDs. Details about sabbaticals, including eligibility, expectations, length, financial support, and benefits were reviewed. Most (54.8%) respondents expected no change in the number of faculty seeking sabbaticals. Nearly all anticipated the COVID-19 pandemic would not affect sabbatical policies. CONCLUSION: In contrast to other institutions of higher learning, sabbatical-taking by medical school faculty is rare. We explore factors that may contribute to this phenomenon (eg, the tripartite mission, faculty clinical responsibilities, culture of medicine, and student debt). Despite financial and other barriers, a closer look at the benefits of sabbaticals is warranted as a mechanism that may support faculty well-being, retention, and mental health.

Longitudinal immune changes during and after recent flares in lupus

BackgroundPrevious studies suggest substantial immunologic heterogeneity in lupus. However, the majority of these studies were cross-sectional in nature. Here we followed flaring and quiescent patients longitudinally to determine how their immunologic profile changes over time. MethodsForty-seven SLE patients with a recent flare (change in clinical SLEDAI ≥ 2 in the past month that prompted a change in therapy), 25 quiescent SLE patients (clinical SLEDAI = 0 for ≥ 1 year with no increase in immunosuppressive treatment , ≤ 10 mg prednisone, matched for disease duration) and 16 healthy controls (HC) were recruited. The peripheral blood immunologic profile at baseline and follow-up (every 6 months for 1 year, COVID permitting) was examined by multi-parameter flow cytometry. Expression of interferon (IFN)-induced proteins that correlated with gene expression was examined in immune populations of interest using CyTOF.ResultsUsing unsupervised clustering, incorporating all subjects and visits, four distinct immunologic profiles were seen: Cluster 1, with increased levels of activated B cells and age- associated B cells (ABCs);Cluster 2, with Tfh and Tph expansion;Cluster 3, with reduced levels of innate, naïve B, and Tfh cells;and Cluster 4 with expansion of Th1 and innate immune cells relative to other clusters. Although patients with new-onset flares were found in all clusters, Cluster 1 had the highest number of these patients, whereas Cluster 4 has the highest number of patients who were inactive at baseline, as well as HC. Patients moved between clusters over time and/or in response to treatment. A substantial proportion of flaring patients in Cluster 3 transitioned to Cluster 1 on follow-up, suggesting that B cell changes accumulate post-flare. Similar findings were seen for myeloid populations in a smaller subset of patients that transitioned from Cluster 3 to 4. In general, patients in Cluster 1, 2, or 4 at baseline tended to remain in the same cluster subsequently, with a notable exception being patients with early disease (< 6 months duration), where switching between clusters was frequent. Patients in Cluster 1 at follow-up were more likely to remain active or flare than those in Cluster 4. Analysis of IFN-induced protein expression, revealed considerable variability in the levels of these proteins between immune populations in the same patient and between patients, with significantly higher levels in flaring than in quiescent patients in most immune populations. Cluster 1 visits tended to have higher levels of IFN-induced proteins than Cluster 4 visits, particularly within B cell populations and the T helper cell populations that support their activation.ConclusionAccumulation of activated B cells and ABCs can occur during or after flare, is associated with high levels of IFN-induced proteins in these populations, and defines patients who are more likely to have ongoing disease activity or subsequent flares.

Ultrasound Workflow in a Pandemic

The 2019 novel coronavirus (COVID-19) pandemic has posed unique, sudden challenges to health care systems. This is true particularly in the context of ultrasound logistics given the risks of inherent prolonged close contact of patients with sonographers and equipment during sonographic image acquisition. We describe the adaptations and modifications in scheduling, workflow, and imaging protocols implemented in our radiology department ultrasound division (a large urban academic center). The hierarchy of controls to minimize exposures to occupational hazards to protect workers, outlined by The National Institute for Occupational Safety and Health (NIOSH) are listed from most effective to least effective: elimination, substitution, engineering controls, administrative controls, and PPE (personal protective equipment (PPE)). Most of the mitigation techniques used in the ultrasound department to reduce hazards to workers involved administrative controls and PPE. We reduced preventable risks by using sterile precautions, imaging triage, and strategically minimizing image acquisition times. These implementations provide a modifiable framework for rapid adaptation during the evolving COVID-19 pandemic, including resurgences of variant strains. This framework ensures a level of preparedness for possible future pandemics or other widespread emergencies.

Persistence of airway inflammation in smokers who switch to electronic cigarettes.

As opposed to smoking cessation with nicotine-replacement therapy and/or varenicline, nicotine-containing e-cigarette use does not improve some airway inflammatory markers. https://bit.ly/3FyqIt9.

The SARS-CoV-2 Transcriptome and the Dynamics of the S Gene Furin Cleavage Site in Primary Human Airway Epithelia.

The spike (S) polypeptide of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) consists of the S1 and S2 subunits and is processed by cellular proteases at the S1/S2 boundary that contains a furin cleavage site (FCS), 682RRAR↓S686 Various deletions surrounding the FCS have been identified in patients. When SARS-CoV-2 propagated in Vero cells, it acquired deletions surrounding the FCS. We studied the viral transcriptome in Vero cell-derived SARS-CoV-2-infected primary human airway epithelia (HAE) cultured at an air-liquid interface (ALI) with an emphasis on the viral genome stability of the FCS. While we found overall the viral transcriptome is similar to that generated from infected Vero cells, we identified a high percentage of mutated viral genome and transcripts in HAE-ALI. Two highly frequent deletions were found at the FCS region: a 12 amino acid deletion (678TNSPRRAR↓SVAS689) that contains the underlined FCS and a 5 amino acid deletion (675QTQTN679) that is two amino acids upstream of the FCS. Further studies on the dynamics of the FCS deletions in apically released virions from 11 infected HAE-ALI cultures of both healthy and lung disease donors revealed that the selective pressure for the FCS maintains the FCS stably in 9 HAE-ALI cultures but with 2 exceptions, in which the FCS deletions are retained at a high rate of >40% after infection of ≥13 days. Our study presents evidence for the role of unique properties of human airway epithelia in the dynamics of the FCS region during infection of human airways, which is likely donor dependent.IMPORTANCE Polarized human airway epithelia at an air-liquid interface (HAE-ALI) are an in vitro model that supports efficient infection of SARS-CoV-2. The spike (S) protein of SARS-CoV-2 contains a furin cleavage site (FCS) at the boundary of the S1 and S2 domains which distinguishes it from SARS-CoV. However, FCS deletion mutants have been identified in patients and in vitro cell cultures, and how the airway epithelial cells maintain the unique FCS remains unknown. We found that HAE-ALI cultures were capable of suppressing two prevalent FCS deletion mutants (Δ678TNSPRRAR↓SVAS689 and Δ675QTQTN679) that were selected during propagation in Vero cells. While such suppression was observed in 9 out of 11 of the tested HAE-ALI cultures derived from independent donors, 2 exceptions that retained a high rate of FCS deletions were also found. Our results present evidence of the donor-dependent properties of human airway epithelia in the evolution of the FCS during infection.

Impact of Cardiovascular Care of COVID-19: Lessons Learned, Current Challenges, and Future Opportunities.

COVID-19 has disrupted traditional cardiovascular care pathways leading to significant challenges; with these challenges have also come opportunities to iterate our testing strategies to ensure they are patient centered and also that they are most appropriate and best align with infection protection protocols. © RSNA, 2020.

An Open Label Trial to Assess Safety of Losartan for Treating Worsening Respiratory Illness in COVID-19.

Rationale: Coronavirus disease 2019 (COVID-19) can cause disruption of the renin-angiotensin system in the lungs, possibly contributing to pulmonary capillary leakage. Thus, angiotensin receptor blockers (ARBs) may improve respiratory failure. Objective: Assess safety of losartan for use in respiratory failure related to COVID-19 (NCT04335123). Methods: Single arm, open label trial of losartan in those hospitalized with respiratory failure related to COVID-19. Oral losartan (25 mg daily for 3 days, then 50 mg) was administered from enrollment until day 14 or hospital discharge. A post-hoc external control group with patients who met all inclusion criteria was matched 1:1 to the treatment group using propensity scores for comparison. Measures: Primary outcome was cumulative incidence of any adverse events. Secondary, explorative endpoints included measures of respiratory failure, length of stay and vital status. Results: Of the 34 participants enrolled in the trial, 30 completed the study with a mean age SD of 53.8 ± 17.7 years and 17 males (57%). On losartan, 24/30 (80%) experienced an adverse event as opposed to 29/30 (97%) of controls, with a lower average number of adverse events on losartan relative to control (2.2 vs. 3.3). Using Poisson regression and controlling for age, sex, race, date of enrollment, disease severity at enrollment, and history of high-risk comorbidities, the incidence rate ratio of adverse events on losartan relative to control was 0.69 (95% CI: 0.49-0.97) Conclusions: Losartan appeared safe for COVID-19-related acute respiratory compromise. To assess true efficacy, randomized trials are needed.

Rapid Ventilator Splitting During COVID-19 Pandemic Using 3D Printed Devices and Numerical Modeling of 200 Million Patient Specific Air Flow Scenarios.

There has been a pressing need for an expansion of the ventilator capacity in response to the recent COVID19 pandemic. To address this need, we present a system to enable rapid and efficacious splitting between two or more patients with varying lung compliances and tidal volume requirements. Reserved for dire situations, ventilator splitting is complex, and has been limited to patients with similar pulmonary compliances and tidal volume requirements. Here, we report a 3D printed ventilator splitter and resistor system (VSRS) that uses interchangeable airflow resistors to deliver optimal tidal volumes to patients with differing respiratory physiologies, thereby expanding the applicability of ventilator splitting to a larger patient pool. We demonstrate the capability of the VSRS using benchtop test lungs and standard-of-care ventilators, which produced data used to validate a complementary, patient-specific airflow computational model. The computational model allows clinicians to rapidly select optimal resistor sizes and predict delivered pressures and tidal volumes on-demand from different patient characteristics and ventilator settings. Due to the inherent need for rapid deployment, all simulations for the wide range of clinically-relevant patient characteristics and ventilator settings were pre-computed and compiled into an easy to use mobile app. As a result, over 200 million individual computational simulations were performed to maximize the number of scenarios for which the VSRS can provide assistance. The VSRS will help address the pressing need for increased ventilator capacity by allowing ventilator splitting to be used with patients with differing pulmonary physiologies and respiratory requirements, which will be particularly useful for developing countries and rural communities with a limited ventilator supply.

Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter

BACKGROUND: The healthcare burden posed by the coronavirus disease 2019 (COVID-19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. METHODS: We conducted a web-based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. RESULTS: Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID-19 related duties. More than two-thirds of PDs believed that the COVID-19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one-fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one-third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. CONCLUSIONS: The COVID-19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.