System-level recommendations for improved wellness for gynecologic oncologists: A Society of Gynecologic Oncology Review.

Burnout and its negative sequelae are a persistent problem in gynecologic oncology, threatening the health of our physician workforce. Individual-level interventions such as stress management training, physical activity, and sleep hygiene only partially address this widespread, systemic crisis rooted in the extended work hours and stressful situations associated with gynecologic oncology practice. There is an urgent need for systematic, institution-level changes to allow gynecologic oncologists to continue the crucial work of caring for people with gynecologic cancer. We present recommendations for institution-level changes which are grounded in the framework presented by the National Plan for Health Workforce Well-Being by the National Academy of Medicine. These are aimed at facilitating gynecologic oncologists' well-being and reduction of burnout. Recommendations include efforts to create a more positive and inclusive work environment, decrease administrative barriers, promote mental health, optimize electronic medical record use, and support a diverse workforce. Implementation and regular evaluation of these interventions, with specific attention to at-risk groups, is an important next step.

SGO and the elephant that is still in the room: Wellness, burnout and gynecologic oncology.

OBJECTIVE: To measure wellness and burnout among gynecologic oncology clinicians and identify trends and at-risk populations to inform future interventions. METHODS: Gynecologic oncologist (GO) and advanced practice provider (APP) responses to the 2020 Society of Gynecologic Oncology State of the Society survey were analyzed. The Maslach Burnout Inventory criteria for burnout was used. Work-life balance was scored on a 5-point Likert scale. Chi-square tests were used to compare mental health factors and the prevalence of burnout. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between burnout and gender. RESULTS: 543 survey responses were included for analysis. Most GO (54%) and all APP respondents were female. Female GOs were disproportionately affected by burnout particularly in the Northeast (female(F): 40.9% vs male(M): 19.1%, p = 0.007) and South (F: 42.5% vs M:22.9%, p = 0.01). Burnout in female GOs over 40 was 1.79 (CI: 1.13-2.83; p-value 0.01) times higher than similarly aged males. Females in non-private practice experienced burnout 1.66 times that of males in similar positions (CI: 1.18-2.94; p < 0.0001). Female GOs reported the worst work-life balance across all 5 domains. APPs and female GOs experienced more stress and feeling overwhelmed compared to men. GOs were more reluctant to see a mental health professional (p = 0.0003) or take medication (p = 0.009) than APPs. CONCLUSIONS: Burnout in gynecologic oncology persists in both genders and is felt most acutely by female GOs. APPs are not immune and would benefit from inclusion in future research to mitigate burnout in healthcare clinicians.

Pathologic and clinical tumor size discordance in early-stage cervical cancer: Does it matter?

OBJECTIVE: The objective of this study was to assess the rate of discordance between clinical and pathologic tumor size for women with stage IB1 cervical cancer (FIGO 2009 criteria), assess risk factors for discordance, and determine the impact of discordance on oncologic outcomes. METHODS: This was a secondary analysis of a prior multi-institutional retrospective review of patients diagnosed with stage IB1 (FIGO 2009 staging) cervical cancer undergoing radical hysterectomy between 2010 and 2017. Demographic, clinicopathologic, and oncologic data were collected. Pathologic upstaging was defined as having a preoperative diagnosis of stage IB1 cervical cancer with pathology demonstrating a tumor size >4 cm. Demographic and clinicopathologic data was compared using chi-square, fisher exact or 2-sided t-test. Survival was estimated using the Kaplan-Meier method. RESULTS: Of the 630 patients, 77 (12%) were upstaged. Patients who were upstaged had lower rates of preoperative conization (p < .001) or preoperative tumor sizes ≤2 cm (p < .001). Upstaged patients had increased odds of deep stromal invasion, lymphovascular space invasion, positive margins and positive lymph nodes. Almost 88% of upstaged patients received adjuvant therapy compared to 29% of patients with tumors ≤4 cm (odds 18.49, 95% CI 8.99-37.94). Finally, pathologic upstaging was associated with an increased hazard of recurrence (hazard ratio [HR] 1.95, 95% CI 1.03-3.67) and all-cause death (HR 2.31, 95% CI 1.04-5.11). CONCLUSIONS: Pathologic upstaging in stage IB1 cervical cancer is relatively common. Upstaging is associated with an 18-fold increased risk of receipt of adjuvant therapy. Patients undergoing preoperative conization and those with tumors <2 cm had lower risks of upstaging. Improvement in preoperative assessment of tumor size may better inform primary treatment decisions.

An integrated ultra-high vacuum apparatus for growth and in situ characterization of complex materials.

Here, we present an integrated ultra-high vacuum apparatus-named MBE-Cluster -dedicated to the growth and in situ structural, spectroscopic, and magnetic characterization of complex materials. Molecular Beam Epitaxy (MBE) growth of metal oxides, e.g., manganites, and deposition of the patterned metallic layers can be fabricated and in situ characterized by reflection high-energy electron diffraction, low-energy electron diffraction, Auger electron spectroscopy, x-ray photoemission spectroscopy, and azimuthal longitudinal magneto-optic Kerr effect. The temperature can be controlled in the range from 5 K to 580 K, with the possibility of application of magnetic fields H up to ±7 kOe and electric fields E for voltages up to ±500 V. The MBE-Cluster operates for in-house research as well as user facility in combination with the APE beamlines at Sincrotrone-Trieste and the high harmonic generator facility for time-resolved spectroscopy.

Nature of the metal-insulator transition in few-unit-cell-thick LaNiO3 films.

The nature of the metal-insulator transition in thin films and superlattices of LaNiO3 only a few unit cells in thickness remains elusive despite tremendous effort. Quantum confinement and epitaxial strain have been evoked as the mechanisms, although other factors such as growth-induced disorder, cation non-stoichiometry, oxygen vacancies, and substrate-film interface quality may also affect the observable properties of ultrathin films. Here we report results obtained for near-ideal LaNiO3 films with different thicknesses and terminations grown by atomic layer-by-layer laser molecular beam epitaxy on LaAlO3 substrates. We find that the room-temperature metallic behavior persists until the film thickness is reduced to an unprecedentedly small 1.5 unit cells (NiO2 termination). Electronic structure measurements using X-ray absorption spectroscopy and first-principles calculation suggest that oxygen vacancies existing in the films also contribute to the metal-insulator transition.

Deterministic and robust room-temperature exchange coupling in monodomain multiferroic BiFeO3 heterostructures.

Exploiting multiferroic BiFeO3 thin films in spintronic devices requires deterministic and robust control of both internal magnetoelectric coupling in BiFeO3, as well as exchange coupling of its antiferromagnetic order to a ferromagnetic overlayer. Previous reports utilized approaches based on multi-step ferroelectric switching with multiple ferroelectric domains. Because domain walls can be responsible for fatigue, contain localized charges intrinsically or via defects, and present problems for device reproducibility and scaling, an alternative approach using a monodomain magnetoelectric state with single-step switching is desirable. Here we demonstrate room temperature, deterministic and robust, exchange coupling between monodomain BiFeO3 films and Co overlayer that is intrinsic (i.e., not dependent on domain walls). Direct coupling between BiFeO3 antiferromagnetic order and Co magnetization is observed, with ~ 90° in-plane Co moment rotation upon single-step switching that is reproducible for hundreds of cycles. This has important consequences for practical, low power non-volatile magnetoelectric devices utilizing BiFeO3.

Hyperoxia exacerbates microvascular lung injury following acid aspiration.

OBJECTIVES: To examine the effects of an increase in ambient oxygen (O2) concentrations on the extent of inflammatory pulmonary damage following acid aspiration. DESIGN: Prospective, controlled laboratory study. SETTINGS: University-affiliated animal research facility. SUBJECTS: Male, Long Evans rats weighing 250 to 300 g. INTERVENTION: Rats were injured by instillation of 1.2 mL/kg normal saline solution/HCl, pH= 1.25 (acid), into the lungs via a tracheotomy. Animals were allowed to awaken and were exposed to 21%, 50%, or 98% O2 for 0 to 5 h (n/group > or = 10). In a separate set of experiments, injured rats exposed to 98% O2 were treated with different doses of deferoxamine, just prior to injury. Uninjured rats and rats injured with normal saline solution, pH = 5.3, were used as the control group. MEASUREMENTS: Injury was determined by assessing lung function (lung compliance and arterial blood gases) and alveolar-capillary wall integrity (wet/dry weight, lung albumin permeability index [PI], and intrapulmonary hemorrhage [HI]). RESULTS: Intrapulmonary instillation of acid increased PI, HI, and decreased static lung compliance compared to uninjured control animals. Increased ambient oxygen following acid aspiration decreased lung compliance, 1.06+/-0.03 mL/kg/cm H2O, in oxygen-exposed lungs when compared to the lungs exposed to air, 1.26+/-0.04, following a low pH aspirate (p<0.05). An increase in protein leakage into the lung tissue was noted in oxygen-exposed animals, PI=1.33+/-0.10, vs air-exposed rats, 0.89+/-0.07 (p<0.05). The hyperoxia-induced increase in lung injury was prevented by 30 mg/kg or higher deferoxamine treatment, 0.78+/-0.05 (p<0.05). Exposure of animals to 98% O2 for 2 h was sufficient to produce the same increase in microvascular protein leakage as 5-h exposure to O2 following low pH aspirate. CONCLUSION: Hyperoxia increases acid aspiration-induced inflammatory microvascular lung injury. This appears to be mediated by production of reactive species of O2.

Lip augmentation using the palmaris longus tendon.

A case is presented in which the upper lip of a 20-year-old woman was augmented by a graft of palmaris longus tendon-muscle. This technique offers several advantages over other lip enlargement techniques. The primary drawback, in my opinion, is the possibility that lip excursion (smiling, animation) might be restricted by tendon-muscle adherence to lip tissues, although this did not occur in this patient. Experience with larger numbers of patients is necessary before this technique can be endorsed for general use.

Concentric circle operation for massive gynecomastia to excise the redundant skin.

A technique is described for excising the excess skin in gynecomastia operations, using a concentric "circle" design to remove a calculated amount in the vertical in the horizontal directions. The sole residual scar is a circular one around the periphery of the areola.

Surface octahedral distortions and atomic design of perovskite interfaces.

Atomic engineering of perovskite films and interfaces is significantly improved by in situ optimization of reflection high-energy electron diffraction (RHEED) features resulting from surface BO6 octahedral rotations seen during molecular-beam epitaxy growth. This approach yields Sr-doped manganite films across the phase diagram with magnetotransport properties that are, for the first time, identical to bulk single crystals. Careful structural analysis of manganite/titanate interfaces shows that cation intermixing and unit cell dilations are eliminated, while BO6 rotations and Jahn-Teller-type elongations are nearly completely suppressed at the interface.

Subpectoral breast augmentation emphasizing muscle preservation.

I believe it is desirable to maintain continuity of the pectoralis major muscle to the maximal extent when performing subpectoral breast augmentation. Strong, upward lifting and stretching of the muscle belly facilitates a smooth, natural contour and eliminates the need to cut or avulse the sternal origin of the muscle, thereby preserving strength and reducing bleeding.

Effect of halothane on the replication of animal viruses.

Five RNA- and two DNA-containing viruses were propagated in Vero cells and tested for their ability to replicate in the presence of halothane (2-bromo-2-chloro-1,1,1-trifluoroethane), a commonly used inhalational anesthetic. Halothane did not affect poliovirus replication at any anesthetic concentration tested, but all other viruses were either partially or totally inhibited by clinical doses of the anesthetic. Replication of Sendai virus, simian virus 40, vesicular stomatitis virus, and herpes simplex virus type 1 were moderately inhibited by halothane exposure. At concentrations of 2.2% (vol/vol) halothane, peak virus titers were reduced by ca. 2 orders of magnitude for vesicular stomatitis virus and simian virus 40, 3.5 orders of magnitude for Sendai virus, and 4 orders of magnitude for herpes simplex virus. Newcastle disease virus and measles virus were the most susceptible to exposure to halothane. Total inhibition of the replication of these viruses occurred at 1.6 to 2.0% halothane. All of the viruses whose replication was susceptible to the action of halothane were inhibited in a concentration-dependent manner. Furthermore, with the exception of simian virus 40, the inhibition of the replication of all viruses was reversible after halothane removal, although total recovery of virus synthesis was not observed unless the culture medium was changed or the pH was adjusted after anesthetic removal.

Effect of general anesthetics and pressure on aerobic metabolism of monkey kidney cells.

The authors examined the inhibition of aerobic metabolism in monkey kidney cell cultures exposed to halothane, enflurane, and isoflurane. The ability of hyperbaric pressure to reverse the halothane-induced metabolic inhibition also was examined. Incubation of two monkey kidney cell lines for 24 h with clinically equipotent concentrations (2.6 MAC) of halothane, enflurane, or isoflurane vapors increased the concentration of lactate in the media by 126 to 244% relative to nonexposed control cultures. The increased rate of lactate accumulation was proportional to the concentration of halothane and was accompanied by a decrease in media pH. Removal of halothane restored the normal rate of lactate production. Hyperbaric pressures of 25, 50, and 100 atmospheres did not alter the halothane-stimulated rate of lactate production relative to non-anesthetic-treated controls, although pressure alone did depress the rate of lactate accumulation in all cultures. The stimulation of lactate production likely reflects the known ability of halothane to inhibit mitochondrial respiration. The failure of pressure to reverse the stimulation of lactate production by halothane suggests that inhibition of mitochondrial metabolism cannot be reversed by pressure.

Characterization of a halothane-resistant strain of measles virus.

A strain of measles virus (MVr) whose replication demonstrated increased resistance to halothane (2-bromo-2-chloro-1,1,1-trifluoroethane) exposure compared with the susceptible parental strain (MVs) is described. After exposure to a 1.2% halothane concentration, substantial amounts of the measles virus H protein were detected in MVr-infected Vero cell lysates by immunoprecipitation and polyacrylamide gel electrophoresis or by quantitative immunofluorescence staining. The protein was barely detectable in identically treated MVs-infected lysates, however. The recovery of all other measles virus proteins studied was the same in MVr- and MVs-infected cells at this anesthetic concentration. Thus, the altered expression of a single gene product appears to be responsible for the observed halothane resistance.

Effects of isoflurane and enflurane on intracellular Ca2+ mobilization in isolated cardiac myocytes.

BACKGROUND: Enflurane and isoflurane may reduce cardiac contractility by altering mobilization and clearance of intracellular Ca2+ (Ca2+i). It was hypothesized that the negative inotropic actions of these agents involve limiting both membrane Ca2+ entry and altering intracellular Ca2+ release. METHODS: The Ca2+i transients in rat ventricular myocytes loaded with fura-2 were recorded from a fluorescence microscope. Transients stimulated by membrane depolarization (suction electrode or elevated [K+]o) or 15 mM caffeine to release Ca2+ from the sarcoplasmic reticulum (SR) were analyzed for net amplitude, maximal rate of rise (VR), average rate of decline (VR) in [Ca2+]i, and duration. RESULTS: Enflurane and isoflurane reduced electrically stimulated Ca2+i transients in a dose-dependent manner. Enflurane depressed the Ca2+i transient amplitude more than isoflurane. Enflurane was more effective than isoflurane in reducing VR and VF in a concentration-dependent manner. At similar concentrations, both enflurane and isoflurane reduced the steady state elevation of [Ca2+]i by 50 mM K+o. Similarly, enflurane and isoflurane depressed caffeine-sensitive release of Ca2+ from the SR. The reduction in the Ca2+i transient because of SR Ca2+ release was greater in enflurane than in equal concentrations of isoflurane. Rates of elevation and decline in [Ca2+]i were also reduced in enflurane and isoflurane. CONCLUSIONS: The negative inotropic actions of enflurane and isoflurane involve a depression of Ca2+ influx during membrane excitation, as well as a reduction in SR Ca2+ release. Slowed rates of elevation in [Ca2+]i indicate that the latter mechanism may, in part, be caused by alterations in the kinetics of SR Ca2+ release.

Digital imaging in the radiation oncology environment: a personal computer local area network solution.

Personal computer (PC) driven digital imaging devices are now becoming available in the market place for use in radiation oncology to produce what are known as real time portal images. These limited contrast images are used to verify the patient anatomy under treatment by megavoltage x-rays and are a vital part of the patient treatment. The current generation of devices can produce both single and movie loop images in real time for physician review and approval. To disseminate these images and other digital images used in the planning and delivery of radiation therapy, a PC-based picture archiving and communications system has been developed that is tailored to the special needs of radiation oncology.

Capsular polysaccharide and O-specific antigen divergently modulate pulmonary neutrophil influx in an Escherichia coli model of gram-negative pneumonitis in rats.

Enteric gram-negative bacilli cause a severe, often life-threatening pneumonia. An improved understanding of the pathogenesis of this infection may lead to improved treatment. Nearly all of the responsible gram-negative bacilli possess capsular polysaccharides and/or an O-specific antigen as part of their lipopolysaccharide (LPS). We hypothesized that these surface polysaccharides may modulate the pulmonary host response. To investigate this, a rat pneumonitis model was used, and pulmonary neutrophil influx, a critical aspect of host defense, was measured. To assess for the effect of the capsule and O-specific antigen on this host response, three proven, isogenic derivatives that are deficient in capsular polysaccharide alone (CP9.137), the O-specific antigen moiety of the LPS alone (CP921), and both the capsular polysaccharide and O-specific antigen (CP923), as well as their wild-type parent (CP9), were used as challenge strains at various intratracheal challenge inocula (CI). Total lung myeloperoxidase (MPO), a surrogate marker for neutrophils, was measured for 15 h post-bacterial challenge. To determine the effect of capsule and the O-specific antigen on the measured MPO levels, a mathematical model was developed and used to describe the MPO levels as a function of time for each CI of each of the four strains. The results from this analysis demonstrated that in the absence of the K54 capsule, 80.7 times the CI is necessary to achieve the same maximum MPO level relative to K54 positive strains (P < 0.0001). In contrast, a diametric effect was observed in the absence of the O-specific antigen, where 0.13 times the CI was necessary to achieve the same maximum MPO level relative to O4-positive strains (P = 0.0032). No interactive effect was observed between the capsule and the O-specific antigen. These findings demonstrate that these surface polysaccharides modulate pulmonary neutrophil influx and suggest that the K54 capsular polysaccharide is a proinflammatory mediator and that the O4-specific antigen attenuates the proinflammatory response. If these speculations are substantiated, an understanding of how the capsule and the O-specific antigen modulate host response could have significant therapeutic implications. The potential use of biologic modulators directed against the host response, as well as approaches based on inactivating bacterial components (e.g., surface polysaccharides) in attempts to modify sepsis syndromes, could be developed.

The role of tumor necrosis factor-alpha in the pathogenesis of aspiration pneumonitis in rats.

BACKGROUND: Aspiration pneumonitis is characterized by proteinaceous pulmonary edema and acute infiltration of neutrophils into the alveolar space. This study examined the role of the proinflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha), on the pathogenesis of the injury produced by the different components that may be present in the aspirate, acid, or gastric particles. METHODS: Rats were injured by intratracheal instillation of a vehicle containing acid or gastric particles. TNF-alpha concentration of bronchoalveolar lavage fluid was determined using a bioassay. upregulation of lung TNF-alpha mRNA was also measured. The effect of intratracheal anti-rat TNF-alpha treatment was assessed by lung protein permeability, blood gases, and lung myeloperoxidase activity. RESULTS: Injury vehicle alone and acid injury resulted in a small TNF-alpha peak 1-2 h after injury in the lavage fluid. Both particulate and acidic particulate groups produced a much more robust TNF-alpha signal that reached a plateau at 2-4 h after injury and declined at 8 h. Upregulation of TNF-alpha mRNA was only detected in the particulate-containing groups. Acidic particulate exposure yielded a synergistic increase in protein permeability and decrease in blood oxygenation. Anti-TNF-alpha treatment reduced protein permeability and myeloperoxidase activity and increased blood oxygenation in the groups exposed to only acid. Such treatment had no effect on either of the particulate containing injuries. CONCLUSIONS: TNF-alpha is differentially manifested according to the components that make up the aspirate but the levels of TNF-alpha expression do not correlate with the severity of the resultant injury. However, the reduction in acid-induced lung injury by anti-TNF-alpha treatment indicates that TNF-alpha plays a role in the pathogenesis of aspiration pneumonitis.