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BACKGROUND: Limitations in surgical simulation training include lack of access to validated training programs with continuous year-round training and lack of experts' ongoing availability for feedback. A model of simulation training was developed to address these limitations. It incorporated basic and advanced laparoscopic skills curricula from a previously validated program and provided instruction through a digital platform. The platform allowed for remote and asynchronous feedback from a few trained instructors. The instructors were continuously available and provided personalized feedback using a variety of different media. We describe the upscaling of this model to teach trainees at fourteen centers in eight countries. METHODS: Institutions with surgical programs lacking robust simulation curricula and needing instructors for ongoing education were identified. The simulation centers ("skills labs") at these sites were equipped with necessary simulation training hardware. A remote training-the-administrators (TTA) program was developed where personnel were trained in how to manage the skills lab, schedule trainees, set up training stations, and use the platform. A train-the-trainers (TTT) program was created to establish a network of trained instructors, who provided objective feedback through the platform remotely and asynchronously. RESULTS: Between 2019 and 2022, seven institutions in Chile and one in each of the USA, Bolivia, Brazil, Ecuador, El Salvador, México, and Perú implemented a digital platform-based remote simulation curriculum. Most administrators were not physicians (19/33). Eight Instructors were trained with the TTT program and became active proctors. The platform has been used by 369 learners, of whom 57% were general surgeons and general surgery residents. A total of 6729 videos, 28,711 feedback inputs, and 233.7 and 510.2 training hours in the basic and advanced programs, respectively, were registered. CONCLUSION: A remote and asynchronous method of giving instruction and feedback through a digital platform has been effectively employed in the creation of a robust network of continuous year-round simulation-based training in laparoscopy. Training centers were successfully run only with trained administrators to assist in logistics and setup, and no on-site instructors were necessary.

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INTRODUCTION: A limitation to expanding laparoscopic simulation training programs is the scarcity of expert evaluators. In 2019, a new digital platform for remote and asynchronous laparoscopic simulation training was validated. Through this platform, 369 trainees have been trained in 14 institutions across Latin America, collecting 6729 videos of laparoscopic training exercises. The use of artificial intelligence (AI) has recently emerged in surgical simulation, showing usefulness in training assessment, virtual reality scenarios, and laparoscopic virtual reality simulation. An AI algorithm to assess basic laparoscopic simulation training exercises was developed. This study aimed to analyze the agreement between this AI algorithm and expert evaluators in assessing basic laparoscopic-simulated training exercises. METHODS: The AI algorithm was trained using 400-bean drop (BD) and 480-peg transfer (PT) videos and tested using 64-BD and 43-PT randomly selected videos, not previously used to train the algorithm. The agreement between AI and expert evaluators from the digital platform (EE) was then analyzed. The exercises being assessed involve using laparoscopic graspers to move objects across an acrylic board without dropping any objects in a determined time (BD < 24 s, PT < 55 s). The AI algorithm can detect object movement, identify if objects have fallen, track grasper clamps location, and measure exercise time. Cohen's Kappa test was used to evaluate the agreement between AI assessments and those performed by EE, using a pass/fail nomenclature based on the time to complete the exercise. RESULTS: After the algorithm was trained, 79.69% and 93.02% agreement were observed in BD and PT, respectively. The Kappa coefficients test observed for BD and PT were 0.59 (moderate agreement) and 0.86 (almost perfect agreement), respectively. CONCLUSION: This first approach of AI use in basic laparoscopic skills simulated training assessment shows promising results, providing a preliminary framework to expand the use of AI to other basic laparoscopic skills exercises.

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BACKGROUND: The COVID-19 pandemic has had a negative effect on surgical education in Latin America, decreasing residents' surgical training and supervised clinical practice. AIMS: This study aimed to identify strategies that have been proposed or implemented to adapt surgical training and supervised clinical practice to COVID-19-related limitations in Latin America. METHOD: A literature review was performed between April and May 2021, divided into two searches. The first one sought to identify adaptation strategies in Latin America for surgical training and supervised clinical practice. The second one was carried out as a complement to identify methodologies proposed in the rest of the world. RESULTS: In the first search, 16 of 715 articles were selected. In the second one, 41 of 1,637 articles were selected. Adaptive strategies proposed in Latin America focused on videoconferencing and simulation. In the rest of the world, remote critical analysis of recorded/live surgeries, intrasurgical tele-mentoring, and surgery recording with postoperative feedback were suggested. CONCLUSIONS: Multiple adaptation strategies for surgical education during the COVID-19 pandemic have been proposed in Latin America and the rest of the world. There is an opportunity to implement new strategies in the long term for surgical training and supervised clinical practice, although more prospective studies are required to generate evidence-based recommendations.

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ABSTRACT BACKGROUND: The COVID-19 pandemic has had a negative effect on surgical education in Latin America, decreasing residents' surgical training and supervised clinical practice. AIMS: This study aimed to identify strategies that have been proposed or implemented to adapt surgical training and supervised clinical practice to COVID-19-related limitations in Latin America. METHOD: A literature review was performed between April and May 2021, divided into two searches. The first one sought to identify adaptation strategies in Latin America for surgical training and supervised clinical practice. The second one was carried out as a complement to identify methodologies proposed in the rest of the world. RESULTS: In the first search, 16 of 715 articles were selected. In the second one, 41 of 1,637 articles were selected. Adaptive strategies proposed in Latin America focused on videoconferencing and simulation. In the rest of the world, remote critical analysis of recorded/live surgeries, intrasurgical tele-mentoring, and surgery recording with postoperative feedback were suggested. CONCLUSIONS: Multiple adaptation strategies for surgical education during the COVID-19 pandemic have been proposed in Latin America and the rest of the world. There is an opportunity to implement new strategies in the long term for surgical training and supervised clinical practice, although more prospective studies are required to generate evidence-based recommendations.

RESUMO RACIONAL: A pandemia de COVID-19 teve um efeito negativo na educação cirúrgica na América Latina, diminuindo o treinamento cirúrgico dos residentes e a prática clínica supervisionada. OBJETIVOS: Identificar estratégias que foram propostas ou implementadas para adaptar o treinamento cirúrgico e a prática clínica supervisionada às limitações relacionadas ao COVID-19 na América Latina. MÉTODOS: Foi realizada revisão de literatura entre abril-maio de 2021, dividida em duas buscas. O primeiro procurou identificar estratégias de adaptação em América Latina para treinamento cirúrgico e prática clínica supervisionada. A segunda foi realizada como complemento para identificar metodologias propostas no resto do mundo. RESULTADOS: Na primeira busca, foram selecionados 16 dos 715 artigos. Na segunda, foram selecionados 41 dos 1.637 artigos. Estratégias adaptativas propostas na América Latina com foco em videoconferência e simulação. No resto do mundo, foram sugeridas análises críticas remotas de cirurgias gravadas/ao vivo, tele-mentoria intra-cirúrgica e gravação de cirurgia com feedback pós-operatório. CONCLUSÕES: Múltiplas estratégias de adaptação para educação cirúrgica durante a pandemia de COVID-19 foram propostas na América Latina e no resto do mundo. Há uma oportunidade de implementar novas estratégias a longo prazo para treinamento cirúrgico e prática clínica supervisionada, embora mais estudos prospectivos sejam necessários para gerar recomendações baseadas em evidências.

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Drug disposition in the human body is strongly influenced by transporters and metabolizing enzymes expressed in key organs including intestine, liver and kidney. Since drugs and chemicals present in foods such as fruit juices and herb-based products are substrates of the above-mentioned proteins, there is a high probability of pharmacokinetic interactions. Findings from preclinical and clinical studies helped to characterize the mechanisms by which the components of fruit juices and herbs act as perpetrators of pharmacokinetic interactions. The aim of this review is to provide an overview of pharmacokinetic fruit juice- and herb-drug interactions that could be relevant in the clinical setting.

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Drug disposition in the human body is strongly influenced by transporters and metabolizing enzymes expressed in key organs including intestine, liver and kidney. Since drugs and chemicals present in foods such as fruit juices and herb-based products are substrates of the above-mentioned proteins, there is a high probability of pharmacokinetic interactions. Findings from preclinical and clinical studies helped to characterize the mechanisms by which the components of fruit juices and herbs act as perpetrators of pharmacokinetic interactions. The aim of this review is to provide an overview of pharmacokinetic fruit juice- and herb-drug interactions that could be relevant in the clinical setting.

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INTRODUCCIÓN: El cáncer de mama es la primera causa de muerte de la mujer en la Argentina, con una incidencia estimada de más de 19.000 casos nuevos por año. Dentro de estos, el tipo de cáncer hereditario más común es el de mama/ovario hereditario, provocado por mutaciones en los genes BRCA 1(Breast cáncer) y BRCA 2. A su vez el cáncer colorrectal es la segunda causa de muerte en Argentina, con una incidencia estimada de más de 11.000 casos nuevos por año. OBJETIVO: de la presente investigación es evaluar la utilidad de la realización de los estudios genéticos en personas con cáncer hereditario en el contexto del consejo genético, con un asesoramiento antes y después de realizarse la prueba genética POBLACIÓN Y MÉTODOS: Se estudiaron 34 mujeres con diagnóstico de cáncer de mama/ovario y 31 pacientes de ambos sexos con diagnóstico de cáncer colorrectal (CCR). En las mujeres se analizaron los genes BRCA 1 y 2 por secuenciación de próxima generación (NSG) y grandes rearreglos de los genes BRCA 1 y 2 por amplificación de sonda dependiente de la ligadura multiplex (MLPA). En las personas de ambos sexos se determinó la Inestabilidad de Microsatelites(IMS), el análisis de mismatch repair (MMR) por MLPA y la mutación del gen BRAF (Protooncogen B-Raf) RESULTADOS: Los resultados mostraron que las pacientes con cáncer de mama / ovario con antecedentes familiares tienen un alto porcentaje de BRCA negativo. En cuanto a los cambios fenotípicos, el más predominante en este estudio, fue el subtipo triple negativo y la paciente con BRCA 2 positivo presentó este fenotipo. Con respecto al estudio del cáncer de colon detectamos cuatro pacientes con IMS-alta y mutación del V600E del gen BRAF. Cuando se les realizó el análisis de MLPA en los genes MSH6, MLH1, MSH2 y PMS2 a los efectos de establecer la diferencia entre CCR y síndrome de Lynch, los resultados fueron negativos, por lo tanto, estos pacientes fueron diagnosticados como CCR esporádico. CONCLUSIONES: Como lo demuestra este trabajo, para el consejo genético, el estudio de vías moleculares en pacientes con cáncer hereditario es un instrumento de ayuda para la valoración del riesgo génico. (AU)

INTRODUCTION: Breast cancer is the leading cause of death of women in Argentina, with a estimated incidence of more than 19,000 new cases per year. Among these, the most common type of inherited cancer is the breast /ovarian caused by mutations in the BRCA1 and BRCA 2 genes. At the same time, the cancer colorrectal is the second cause of death in Argentina, with an estimated incidence of more than 11,000 new cases per year. OBJECTIVE: of the present investigation is to evaluate the usefulness of the realization of the genetic studies in people with hereditary cancer in the context of genetic counseling, with a advice before and after the genetic test. POPULATIONS AND METHODS: We studied 34 women diagnosed with breast / ovarian cancer and 31 patients of both sexes with diagnosis of colorectal cancer (CRC). In women, the BRCA 1 and 2 genes by next generation sequencing (NSG) and large rearrangements of BRCA 1 and 2 genes by probe amplification dependent on multiplex ligation(MLPA). The instability of microsatellites (IMS) was determined in people of both sexes, the analysis of mismatchrepair (MMR) by MLPA and the mutation of the BRAF gene. RESULTS: There results showed that patients with breast / ovarian cancer with a history family members have a high percentage of negative BRCA. As for the changes phenotypic, the most predominant in this study, was the triple negative subtype and the patient with positive BRCA 2 presented this phenotype. With respect to the study of colon cancer detected four patients with IMS-high and mutation of the V600E of the BRAF gene. When the MLPA analysis was performed on the MSH6, MLH1, MSH2 genes and PMS2, in order to established difference between CRC and Lynch syndrome, the results were negative and therefore these patients were diagnosed as sporadic CRC. CONCLUSIONS: As this work demonstrates, for him genetic counseling, the study of pathways molecules in patients with hereditary cancer is a helpful instrument for risk assessment. (AU)

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INTRODUCCION: Alrededor del 10 al 20 % de las mujeres con cáncer de mama tienen uno o más familiares de primer grado que también están afectados por cáncer de mama. Aunque sólo del 5 al 10 % de las mujeres no seleccionadas con cáncer de mama tienen una forma hereditaria, asociado a un gen mutado, deficitario en su función, hasta el 20 % de las mujeres con antecedentes familiares de cáncer de mama tienen una mutación en un gen de predisposición a cáncer de moderada o alta penetrancia. OBJETIVO PRIMARIO: Describir los antecedentes oncológicos personales y familiares de pacientes a los que se les solicitó el estudio de mutaciones BRCA 1 y BRCA 2 y compararlos con los criterios usados en guías nacionales (INC) e internacionales (NCCN) compararlos con los criterios usados en guías nacionales (INC) e internacionales (NCCN). MATERIALES Y MÉTODOS: Diseño: Estudio retrospectivo, descriptivo y observacional.Población: Se analizarán todas las historias clínicas de los pacientes a los cuales se les haya realizado el proceso de asesoramiento genético y solicitado el estudio para mutaciones BRCA 1 y 2 desde: julio 15 hasta julio 2018, en la Clínica Universitaria Reina Fabiola e instituto Oulton. RESULTADOS: Se solicitó el estudio para mutaciones deletéreas de genes BRCA 1 y 2 a 94 individuos. La edad promedio fue de 45 años. De los 94 individuos 61 tenían cáncer de mama (64,89%), 10 cáncer de ovario (10,63%), y 23 (24%) no tenían cancer. Del total de individuos, 30 no se lo realizaron por diferentes motivos: 13 (43%) por motivos personales, 3 (10%) por falta de cobertura de la obra social, 14 (46%) no retornaron a consulta.Todos, excepto dos pacientes a quienes se le solicitó el estudio de mutaciones BRCA 1 y 2 cumplían los criterios de las guías americanas y nacionales para el testeo de la mutación. De los 64 individuos que realizaron el test, 14 (21,87%) tenían mutaciones deletéreas, 1 de significado incierto, y 49 dieron negativos (76,5%). De las 61 pacientes con cáncer de mama estudiadas, 48 (78%) eran menores de 50 años, 24 (39,3%) tenían tumores triple negativos, 19 (31%) ganglios axilares positivos, 13 (21%) tumores luminales, 31 (50%) antecedentes familiares de cáncer relacionado con las mutaciones BRCA 1 y 2, 2 de ellas (3%) eran de origen judío askenazi. Dentro los 14 pacientes con mutaciones BRCA, 10 (71%) presentaban mutación BRCA 1 y 4 (28%) en el gen BRCA 2. De los mismos, 8 (57%) tenían cáncer de mama, 2 (14%) cáncer de ovario, 4 (28%) no tenían cáncer. De las 8 pacientes con BRCA mutado con cáncer de mama: todas eran menor de 50 años.3 tenían tumores triple negativos, ninguna tenía familiares con enfermedad oncológica relacionada, 3 tenían ganglios axilares positivos, 2 eran pacientes con tumores luminales. 1 era her2 positivo. De los pacientes con mutaciones positivas con cáncer de ovario, ambas pacientes tenían más de 65 años, tumores serosos y ninguna tenía antecedentes familiares de cáncer. CONCLUSIONES: Podemos concluir que la población estudiada en nuestra serie, coincide con los factores de riesgo para screening de mutaciones BRCA según NCCN en cuanto a: edad menor de 50 años, factores de riesgo heredofamiliares, la variedad de los tumores de mama, el tipo histológico de los tumores de ovario. (AU)

INTRODUCTION: About 10 to 20% of women with breast cancer have one or more first degree relatives who are also affected by breast cancer. Although only 5 to 10% of women not selected with breast cancer have a hereditary form, associated with a mutated gene, deficient in their function, up to 20% of women with a family history of breast cancer have a mutation in a predisposition gene for cancer of moderate or high penetrance . PRIMARY OBJECTIVE: To describe the personal and family oncological history of patients who were asked to study BRCA 1 and BRCA 2 mutations and compare them with the criteria used in national (INC) and international (NCCN) guidelines Design: Retrospective, descriptive and observational study. Population: All the clinical histories of the patients who have undergone the genetic counseling process and the study for BRCA 1 and 2 mutations from July 2015 to July 2018, at the Reina Fabiola University Clinic and Oulton, will be analyzed. RESULTS: The study was requested for deleterious mutations of BRCA 1 and 2 genes in 94 individuals. The average age was 45 years. Of the 94 individuals, 61 had breast cancer (64.89%), 10 ovarian cancer (10.63%), and 23 (24%) had no cancer Of the total number of individuals, 30 were not carried out for different reasons: 13 (43%) for personal reasons, 3 (10%) for lack of social work coverage, 14 (46%) did not return to consultation All but two patients who were asked to study BRCA 1 and 2 mutations met the criteria of the American and national guidelines for mutation testing. Of the 64 individuals who performed the test, 14 (21.87%) had deleterious mutations, 1 of uncertain significance, and 49 were negative (76.5%). Of the 61 patients with breast cancer studied, 48 (78%) were younger than 50 years old, 24 (39.3%) had triple negative tumors, 19 (31%) positive axillary lymph nodes, 13 (21%) luminal tumors, 31 (50%) family history of cancer related to BRCA 1 and 2 mutations, 2 of them (3%) were of Ashkenazi Jewish origin. Within the 14 patients with BRCA mutations, 10 (71%) had a BRCA 1 and 4 (28%) mutation in the BRCA 2 gene. Of these, 8 (57%) had breast cancer, 2 (14%) cancer ovary, 4 (28%) did not have cancer. Of the 8 patients with BRCA mutated with breast cancer: all were younger than 50 years 3 had triple negative tumors, none had relatives with related oncological disease, 3 had positive axillary nodes, 2 were patients with luminal tumors 1 was her2 positive.Of the patients with positive mutations with ovarian cancer, both patients were over 65 years old, had serous tumors and none had a family history of cancer. CONCLUSIONS: We can conclude that the population studied in our series coincides with the risk factors for screening BRCA mutations according to NCCN in terms of: age under 50 years, heredity-familial risk factors, the variety of breast tumors, the histological type of Ovarian tumors. (AU)

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