Medical education challenges and innovations during COVID-19 pandemic.

COVID-19 pandemic has undoubtedly disrupted the well-established, traditional structure of medical education. Τhe new limitations of physical presence have accelerated the development of an online learning environment, comprising both of asynchronous and synchronous distance education, and the introduction of novel ways of student assessment. At the same time, this prolonged crisis had serious implications on the lives of medical students including their psychological well-being and the impact on their academic trajectories. The new reality has, on many occasions, triggered the 'acting up' of medical students as frontline healthcare staff, which has been perceived by many of them as a positive learning and contributing experience, and has led to a variety of responses from the educational institutions. All things considered, the urgency for rapid and novel adaptations to the new circumstances has functioned as a springboard for remarkable innovations in medical education,including the promotion of a more "evidence-based" approach.

Career barriers for women in surgery.

BACKGROUND: Despite the increasing numbers of female medical students, surgery remains male-dominated. PURPOSE: To highlight the principal career obstacles experienced by aspiring female surgeons. METHODS: A narrative review of literature on the position and career barriers of female surgeons has been conducted, using the MEDLINE and EMBASE databases. MAIN FINDINGS: Implicit and even explicit biases against female surgeons remain prevalent, negatively impacting their training performance and overall professional trajectory. Female surgeons are globally underrepresented in leadership positions and senior academic rankings, especially that of a full professor. They feel hampered by lack of effective mentorship, whose value for a successful career has been acknowledged by all medical students, surgeons and surgical leaders. Their work-life imbalance is sometimes expressed as lower likelihood than their male contemporaries of getting married or having children and may be attributed to their conventional association with the role of caretaker, their personal desire to accommodate occupational and family duties and the inadequate implementation of parental leave and childcare policies. Female surgeons' "infertility" may be further explained by direct and indirect pregnancy-related difficulties. Female surgeons are also financially undercompensated compared to their male contemporaries. Finally, specialty-specific challenges should not be overlooked. CONCLUSIONS: While encouraging steps have been made, women in surgery feel still hindered by various obstacles. The qualitative, interview-based nature of current literature requires more meticulous studies on these barriers with a more quantitative and objective approach. Attenuation of gender imbalance in surgical specialties requires further changes in mentality and more targeted modifications in relevant policies.

Combined hepatocellular-cholangiocarcinoma: An update on epidemiology, classification, diagnosis and management.

BACKGROUND: Combined hepatocellular-cholangiocarcinoma (CHC) is a rare subtype of primary hepatic malignancies, with variably reported incidence between 0.4%-14.2% of primary liver cancer cases. This study aimed to systematically review the epidemiological, clinicopathological, diagnostic and therapeutic data for this rare entity. DATA SOURCES: We reviewed the literature of diagnostic approach of CHC with special reference to its clinical, molecular and histopathological characteristics. Additional analysis of the recent literature in order to evaluate the results of surgical and systemic treatment of this entity has been accomplished. RESULTS: The median age at CHC's diagnosis appears to be between 50 and 75 years. Evaluation of tumor markers [alpha fetoprotein (AFP), carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA)] along with imaging patterns provides better opportunities for CHC's preoperative diagnosis. Reported clinicopathologic prognostic parameters possibly correlated with increased tumor recurrence and grimmer survival odds include advanced age, tumor size, nodal and distal metastases, vascular and regional organ invasion, multifocality, decreased capsule formation, stem-cell features verification and increased GGT as well as CA19-9 and CEA levels. In case of inoperable or recurrent disease, combinations of cholangiocarcinoma-directed systemic agents display superior results over sorafenib. Liver-directed methods, such as transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), hepatic arterial infusion chemotherapy (HAIC), radioembolization and ablative therapies, demonstrate inferior efficacy than in cases of hepatocellular carcinoma (HCC) due to CHC's common hypovascularity. CONCLUSIONS: CHC demonstrates an overlapping clinical and biological pattern between its malignant ingredients. Natural history of the disease seems to be determined by the predominant tumor element. Gold standard for diagnosis is histology of surgical specimens. Regarding therapeutic interventions, major hepatectomy is acknowledged as the cornerstone of treatment whereas minor hepatectomy and liver transplantation may be applied in patients with advanced cirrhosis. Despite all therapeutic attempts, prognosis of CHC remains dismal.

Penicillamine-Induced Localised Cutis Laxa in a Patient with Wilson Disease: A Case Report.

Introduction: Wilson disease is a rare genetic disorder, characterised by excessive deposition of copper in the liver, brain, and other tissues. Penicillamine, a copper-chelating agent, is used in high doses in the treatment of Wilson disease leading to a variety of cutaneous reactions, including hyper-sensitivity reactions, pseudoxanthoma elasticum, elastosis perforans serpiginosa, anetoderma, and cutis laxa (CL). We present a rare case of localised CL induced by penicillamine for Wilson disease, in the absence of elastosis perforans serpiginosa. Case Description: A 41-year-old male with Wilson disease treated with long-term high-dose penicillamine was referred to us for a basal cell carcinoma on the scalp. On physical examination, diffusely flaccid and redundant skin on the right side of the neck were observed. Histopathology revealed findings consistent with CL. Conclusion: Long-term treatment with penicillamine for Wilson disease may induce localized CL, possibly by direct inhibition of cross-linkage of collagen fibres.

Use of Dermoscopy among Greek Dermatologists in Everyday Clinical Practice: A National Questionnaire-Based Study.

Background: Dermatoscopy has been established as an important diagnostic tool for a wide range of skin diseases. This study aims to evaluate the use of dermatoscopy in clinical practice among Greek dermatologists. Methods: A nationwide questionnaire-based survey was conducted collecting data on the frequency of dermatoscopic examinations, the types of lesions examined, training and educational resources, as well as factors influencing the choice to incorporate dermatoscopy into daily clinical routines. Results: A total of 366 Greek dermatologists participated in the survey. Most of the respondents reported the daily use of dermatoscopy in their practice. Pigmented and non-pigmented lesions, inflammatory diseases, cutaneous infectious, hair disorders, and nail lesions were the most common indications for dermatoscopy. Factors influencing the utilization of dermatoscopy included increased diagnostic accuracy, enhanced patient care, better patient communication and general compliance, and improved satisfaction among dermatologists. Conclusions: This national questionnaire-based study demonstrates that dermatoscopy has become an integral part of daily dermatological practice in Greece. The findings highlight the significance of structured training and education to promote dermoscopy's effective and routine use. Incorporating dermatoscopy into clinical practice not only improves diagnostic precision but also enhances patient care, contributing to the overall quality of dermatological services in Greece.

Gender disparity trends in genitourinary oncology academic publishing over the past 3 decades: A bibliometric analysis.

OBJECTIVES: To examine gender disparities in genitourinary (GU) oncology academic publishing over the past three decades. MATERIALS AND METHODS: We performed a bibliometric analysis of eight academic journals featuring GU oncology research articles: Journal of Clinical Oncology, Cancer, European Journal of Cancer, European Urology, Journal of Urology, BJU International, Prostate Cancer and Prostatic Diseases, and Urologic Oncology: Seminars and Original Investigations. After selecting four time points (1990, 2000, 2010, 2020), we recorded the gender of the first and senior authors and investigated their association with independent variables including publication year, research field, and geographic continent. Results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A total of 14,786 articles were included in our analyses. Females comprised 25.7% of first and 18.1% of senior authors. Compared to 1990, there was a trend of progressively higher female first author (OR 1.47 [95% CI 1.27-1.69] in 2000; 2.28 [95% CI 2.00-2.59] in 2010; 3.10 [95% CI 2.71-3.55] in 2020) and senior author positions (OR 1.23 [95% CI 1.05-1.45] in 2000; 1.67 [95% CI 1.45-1.93] in 2010; 2.55 [95% CI 2.20-2.96] in 2020). Compared to GU oncology, non-GU oncology articles were more likely to have female first (OR 2.61, 95% CI 2.38-2.86) or senior authors (OR 2.61, 95% CI 2.35-2.91). Articles from Asia (OR 0.45, 95% CI 0.38-0.51), Africa (OR 0.45, 95% CI 0.22-0.91), and international collaborations (OR 0.62, 95% CI 0.50-0.76) had a lower proportion of female first authors compared to North America. First authors were significantly more likely to be female when senior authors were also female (OR 2.45, 95% CI 2.23-2.69). CONCLUSIONS: Despite the bridging trend demonstrated, GU oncology remains a male-predominant discipline. Female leadership and mentorship are pivotal in achieving gender parity in the academic medicine community.

Clinical and Epidemiological Characteristics of Hidradenitis Suppurativa Patients with Paradoxical Psoriasiform Reactions following Treatment with Adalimumab.

Introduction: Immunomodulation using TNF-α inhibitors (anti-TNF-a), especially adalimumab, is highly effective in the treatment of hidradenitis suppurativa (HS) in cases that are poorly controlled by conventional treatments. However, paradoxical psoriasis represents a peculiar type of psoriasis that may occur de novo or as the worsening of pre-existent psoriatic lesions during treatment with adalimumab. Case Presentation: We reported 4 cases of patients suffering from HS, who developed paradoxical psoriasis after treatment with adalimumab for their HS, analyzing their clinical and epidemiological characteristics. All 4 cases were middle aged, smokers, overweight or obese. Half of the patients were males (50%). All of them were classified as Hurley stage III, with a mean duration of HS of 20 years. Two patients had a family history of psoriasis. All 4 patients had been on at least 5 months of successful treatment with adalimumab before the onset of the lesions. Conclusions: Paradoxical psoriasis emerged in 4 patients who received at least 5-month regimen of adalimumab for long-lasting HS. Although different mechanisms have been hypothesized for such events, the exact underlying pathogenetic pathway remains unclear. Consistent reporting of such rare cases, and on a larger scale, is encouraged in order to enrich the available literature.

Maternal and Neonatal Characteristics and Outcomes of COVID-19 in Pregnancy: An Overview of Systematic Reviews.

(1) Background: A considerable number of systematic reviews, with substantial heterogeneity regarding their methods and included populations, on the impact of COVID-19 on infected pregnant women and their neonates, has emerged. The aim was to describe the obstetric-perinatal and neonatal outcome of infected pregnant women and their newborns during the COVID-19 pandemic; (2) Methods: Three bibliographical databases were searched (last search: September 10, 2020). Quality assessment was performed using the AMSTAR-2 tool. Primary outcomes included mode of delivery, preterm delivery/labor, premature rupture of membranes (PROM/pPROM) and abortions/miscarriages. Outcomes were mainly presented as ranges. A separate analysis, including only moderate and high-quality systematic reviews, was also conducted. The protocol was registered with PROSPERO (CRD42020214447); (3) Results: Thirty-nine reviews were analyzed. Reported rates, regarding both preterm and term gestations, varied between 52.3 and 95.8% for cesarean sections; 4.2-44.7% for vaginal deliveries; 14.3-63.8% specifically for preterm deliveries and 22.7-32.2% for preterm labor; 5.3-12.7% for PROM and 6.4-16.1% for pPROM. Maternal anxiety for potential fetal infection contributed to abortion decisions, while SARS-CoV-2-related miscarriages could not be excluded. Maternal ICU admission and mechanical ventilation rates were 3-28.5% and 1.4-12%, respectively. Maternal mortality rate was <2%, while stillbirth, neonatal ICU admission and mortality rates were <2.5%, 3.1-76.9% and <3%, respectively. Neonatal PCR positivity rates ranged between 1.6% and 10%. After accounting for quality of studies, ranges of our primary outcomes remained almost unchanged, while among our secondary outcomes, maternal ICU admission (3-10%) and mechanical ventilation rates (1.4-5.5%) were found to be relatively lower; (4) Conclusions: Increased rates of cesarean sections and preterm birth rates were found, with iatrogenic reasons potentially involved. In cases of symptomatic women with confirmed infection, high maternal and neonatal ICU admission rates should raise some concerns. The probability of vertical transmission cannot be excluded. Further original studies on women from all trimesters are warranted.

Management and Prevention of COVID-19 in Pregnancy and Pandemic Obstetric Care: A Review of Current Practices.

Constant accumulation of data results in continuous updates of guidelines and recommendations on the proper management of pregnant women with COVID-19. This study aims to summarize the up-to-date information about the prevention and management of suspected/confirmed SARS-CoV-2 infection in obstetric patients and obstetric care during prenatal, intrapartum, and postpartum periods. We conducted a comprehensive literature search in PubMed for relevant English-written full-text reviews. We also included relevant guidelines and recommendations. In women with a low risk for infection and uncomplicated pregnancy, elective and non-urgent appointments should be postponed or completed through telehealth. Vaccination should be discussed and distance and personal hygiene preventive measures should be recommended. Routine ultrasound examinations should be adjusted in order to minimize exposure to the virus. Standardized criteria should evaluate the need for admission. Women with moderate/high-risk for infection should be isolated and tested with RT-PCR. The mode and timing of delivery should follow routine obstetric indications. In case of infection, glucocorticoids are recommended in critically ill pregnant women, after individualized evaluation. During labor and concomitant infection, the duration of the first two stages should be reduced as possible to decrease aerosolization, while minimization of hemorrhage is essential during the third stage. Close maternal monitoring and adequate oxygenation when necessary always remain a prerequisite. Discharge should be considered on the first or second day postpartum, also depending on delivery mode. Breastfeeding with protective equipment is recommended, as its benefits outweigh the risks of neonatal infection. Recommendations are currently based on limited available data. More original studies on infected pregnant women are needed to establish totally evidence-based protocols of care for these patients.

Greek translation and cultural adaptation of the scored patient-generated subjective global assessment: A nutritional assessment tool suitable for cancer patients.

BACKGROUND AND AIMS: Patients with cancer frequently present with disease-related malnutrition and functional decline. The scored Patient-Generated Subjective Global Assessment (PG-SGA©) is a malnutrition screening and assessment tool commonly used in patients with cancer. The aim of the current study was to translate and culturally adapt the original English PG-SGA for the Greek setting, including assessment of comprehensibility, difficulty and content validity in patients and healthcare professionals. METHODS: Our study was conducted according to the ten steps of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Principles of Good Practice for Translation and Cultural Adaptation. Comprehensibility and difficulty of the Greek translation were assessed in 100 patients and 100 healthcare professionals (HCPs) from Greece. Content validity of the translation was assessed among HCPs. Item and scale indices were calculated for comprehensibility (I-CI; S-CI), difficulty (I-DI; S-DI), and content validity (I-CVI; S-CVI). RESULTS: Patient perceived comprehensibility and difficulty of the PG-SGA were considered to be excellent (S-CI = 0.97, S-DI = 0.97). HCPs perceived content validity for the patient component was also excellent (S-CVI = 0.95). The perceived content validity, comprehensibility and difficulty for the professional component of the PG-SGA, as perceived by the HCPs, was excellent (S-CVI = 0.94, S-CI = 0.94, S-DI = 0.90), with the physical exam being perceived as most difficult (I-DI = 0.78-0.92). CONCLUSIONS: Our study resulted in the successful translation and cross-cultural adaptation of the original English PG-SGA for the Greek setting. The Greek language version of the PG-SGA is characterized by high comprehensibility, low difficulty, and is considered relevant for use in Greece.

Supravesical hernias: a systematic review of the literature.

BACKGROUND: A supravesical hernia (SH) is a rare abdominal wall hernia that is defined by the protrusion of abdominal viscera through the supravesical fossa. The objective of this study was to review current literature on SHs and elucidate their clinical manifestations and preferred therapeutic approach. METHODS: PubMed, Embase and Cochrane bibliographical databases were searched (last search: 30 March 2020) for articles reporting on SHs. RESULTS: Thirty-four studies met our inclusion criteria and involved collectively 38 patients (94.7% males) with an age of 59.57 ± 14.84 (mean ± standard deviation) years. Abdominal pain (81.6%) and nausea and vomit (71.1%) were the most frequently encountered symptoms. The majority of patients (78.1%) had signs of bowel obstruction. Twenty-nine patients (76.3%) suffered from an internal SH, while nine (23.7%) had an external one. An open hernia repair was conducted at 29 patients (76.3%), while eight (21.1%) had a laparoscopic approach and in one case (2.6%) the laparoscopic operation was converted to an open one. A mesh was applied at 14.3% of included cases. Eight patients (21.1%) underwent a bowel resection and hernia sac was resected at six (15.8%) cases. Four patients (11.8%) experienced postoperative complications and one patient (2.9%) died on first postoperative day. CONCLUSION: SH is an extremely rare type of hernia occurring through the supravesical fossa between the remnants of urachus and foetal umbilical arteries. All clinicians should be aware of this entity and further studies are necessary in order to clarify their aetiology, true incidence and optimal therapeutic approach.