A Road Map to Foster Wellness and Engagement in Our Workplace—A Report of the 2018 Summer Intersociety Meeting

The 2018 radiology Intersociety Committee reviewed the current state of stress and burnout in our workplaces and identified approaches for fostering engagement, wellness, and job satisfaction. In addition to emphasizing the importance of personal wellness (the fourth aim of health care), the major focus of the meeting was to identify strategies and themes to mitigate the frequency, manifestations, and impact of stress. Strategies include reducing the stigma of burnout, minimizing isolation through community building and fostering connectivity, utilizing data and benchmarking to guide effectiveness of improvement efforts, resourcing and training “wellness” committees, acknowledging value contributions of team members, and improving efficiency in the workplace. Four themes were identified to prioritize organizational efforts: (1) collecting, analyzing, and benchmarking data; (2) developing effective leadership; (3) building high-functioning teams; and (4) amplifying our voice to increase our influence.     

Understanding the underutilization of cervical brachytherapy for locally advanced cervical cancer

PurposeTo understand the reasons behind current low utilization of brachytherapy for locally advanced cervical cancer in the United States.Methods and MaterialsA 17-item survey was e-mailed to the American Brachytherapy Society (ABS) listserv of active members in 2018. Responses of attending physicians in the United States were included in the analysis.ResultsAmong a total of 135 respondents, 81 completed the survey. Eighty-four percent agree/strongly agree that cervical brachytherapy is underutilized, and 46.9% disagree/strongly disagree that residents are receiving adequate training for brachytherapy; 75.3% agree/strongly agree that inadequate maintenance of brachytherapy skills is a major obstacle to brachytherapy use; and 71.6% agree/strongly agree that increased time requirement constitutes a major obstacle. Over 97% will recommend brachytherapy for most patients with cervical cancer if given access/time; 72.8% always perform their own brachytherapy, whereas 29.6% reported some type of barrier exists in performing brachytherapy themselves, with time required to perform brachytherapy (9.9%) being a leading factor. A quarter (24.7%) routinely refer to other radiation oncologists for brachytherapy. Even among ABS members, 37.0% reported that they would perform an intensity-modulated radiation therapy or stereotactic body radiation therapy boost in specific scenarios in potentially curable patients. The most common scenario is inability to place a uterine tandem (56.7%).ConclusionsThe underutilization of brachytherapy in cervical cancer is widely recognized by ABS members with inadequate training during residency and inadequate maintenance of skills being possible major contributing factors. Even among ABS members, there are identifiable barriers. Continued advocacy and future initiatives in enhancing access to brachytherapy training and efficiency are needed.     

Well-woman Care Barriers and Facilitators of Low-income Women Obtaining Induced Abortion after the Affordable Care Act

Objectives

This study uses the abortion visit as an opportunity to identify women lacking well-woman care (WWC) and explores factors influencing their ability to obtain WWC after implementation of the Affordable Care Act.

Acute dermatomyositis-polymyositis and malignancy

A partial review of selected published case reports of AD-P associated with malignancy has been enhanced by the presentation of pertinent data on 15 unreported examples of the association. It is noteworthy that the first case in current literature of AD-P associated with a malignancy was described in 1916. The brief clinical report of a patient with proximal muscle weakness and skin lesions, with the obvious association with a malignancy (adenocarcinoma of the stomach), describes an example that has been repeated many times with different types of tumors but with essentially no variations in the clinical findings.In 1959 Williams identified 590 cases of AD with an overall tumor rate of 15%,³¹ and recently Barnes identified 258 cases of AD associated with a malignancy.³³The original designation, dermatomyositis or AD, has now been expanded to include proximal muscle polymyositis with systemic involvement, which syndrome at the current state of the art is indistinguishable clinically and pathologically from AD except for the lack of skin lesions. It may be that at some future time one or more immunologic features may differentiate the clinical entity polymyositis from AD and further subdivide each of these entities from similar clinical syndromes associated with a malignancy. However, the problem in management in either AD or polymyositis is similar.¹A number of patients with a malignancy and muscle weakness or neuropathy have been reported. These associations have been mentioned briefly, but insufficient data are available to determine whether these should be considered as a variant of AD-P or only casually related conditions with certain clinical features in common.Most of the patients described in the literature of AD-P with an associated malignancy have had skin lesions; a minority only have lacked this feature. However, unless a patient is followed carefully, it is possible for a transient or evanescent erythema or insignificant skin lesions to be present and not recorded in the case record.In the patients with malignancy and AD-P, there are no clinical features or laboratory findings unique to the malignancy in contrast to a carcinoma unassociated with AD-P, nor are the clinical features or laboratory findings of AD-P with malignancy different from those without a malignancy, except for one feature. The fatal determination, usually attributed to the malignancy, may be associated with a florid type of dermatomyositis, better described as rapidly progressive dermatomyositis, relentless muscle weakness, and failure of the respiratory and pharyngeal musculature.Approximately 15% of the patients with typical AD-P have an associated malignancy. Sometimes it precedes the symptoms of the collagen-vascular disease by one or more years. In other patients, the reverse is true by a similar period of time. In a few patients with AD-P, two related or chronologically unrelated tumors have appeared. Most reports favor a more than casual relationship, e.g., the recent study by Barnes.³³ Another recent survey casts doubt on this relationship.⁹⁷ We still lack epidemiologic information based upon statistically reliable data of cases with the combined condition, nor are there comprehensive data in this country of malignancy in patients without AD-P, in respect to decades of life, sex, and site and type of tumor.³⁴The cause either of AD-P or most malignancies is unknown. It is easy to speculate positively versus negatively as to whether or not two diseases might have had their initiating pathogenesis at the same time, with clinical symptoms or laboratory findings of one or the other predominating for weeks, months, even years. I tend to favor a concomitant pathogenesis associated with disproportionate development of clinical symptoms. At the moment a virus participating in the pathogenesis seems intriguing, but firm proof is lacking.Females tend to predominate because of the larger number of genital and breast tumors, which is not quite counterbalanced by tumors in lung and gastrointestinal tract, which are more common in the male.³³ In the newly reported cases presented in this review, the males exceeded the females by a ratio of 2:1, probably because a majority of the cases came from army or VA hospitals.The clinical appearance of a malignancy associated with AD-P, in adult life, usually comes after age 40 yr. A few examples of noninvasive tumor with AD-P in the prepuberty years have been reported. One girl age 10 yr had a chromophobe adenoma. The tumor probably was present when symptoms of AD appeared. In the second patient, a boy with hyperplasia of the adrenals, symptoms appeared at age 10 yr. Also, three examples of leukemia have been reported in children. Note should also be made of the combined appearance of AD-P and malignancy in a 17-yr-old male with reticuloendotheliosis. This is borderline between childhood and adulthood. One patient in the previously unreported cases had a probable Wilms tumor removed at age 17 yr and developed systemic symptoms of AD 7 yr later. However, not one of these observations negate the statement that AD-P with malignancy is an adult disease.The treatment of dermatomyositis in patients with an associated malignancy is the same as in those without a malignancy; the same holds for the tumor. Furthermore, one might expect that the combined use of corticosteroids and immunosuppressive drugs, useful in either AD-P or a malignancy, might have an enhanced beneficial effect. There are too few cases reported or observed unreported to make any statements in this category. One patient in my series, E.A., received large doses of corticosteroids and a course of methotrexate, but the course was inevitably regressive.Several of the clinical features frequently observed early in the course of AD-P without an associated malignancy were not reported in the cases in the literature nor seen in the series of new cases observed.¹ This concerns the incidence of arthralgias, sometimes called atypical RA, sclerodermatous changes either in the skin or subcutaneous calcinosis, or Raynaud phenomenon. The incidence of each of these three clinical findings may be assumed to be low in either the reported cases or in the cases described and previously unreported.     

Formation of the very low density lipoprotein and metabolism of [1-14C]-oleate by perfused livers from rats treated with triiodothyronine or propylthiouracil

To gain insight into the mechanism(s) responsible for changes in plasma lipid concentrations in thyroid disease, the metabolism of [1-¹⁴C]-oleate by perfused livers from hypothyroid [propylthiouracil (PTU) treated], euthyroid and hyperthyroid (T₃ treated) rats was compared. Livers from hyperthyroid animals secreted decreased amounts of very low density lipoprotein (VLDL) and incorporated less [1-¹⁴C]-oleate into VLDL triglyceride, but produced more ketone bodies and incorporated more radioactivity from [1-¹⁴C]-oleate into ketones than did livers from euthyroid animals. Conversely, incorporation of [1-¹⁴C]-oleate into perfusate and VLDL triglyceride was increased in livers from hypothyroid animals, while rates of production of ¹⁴CO₂ were diminished. Plasma T₃ concentration was inversely correlated with VLDL triglyceride (r = ?0.70, p < 0.003) and VLDL apoprotein (r = ?0.72, p < 0.008), but directly correlated with ketogenesis (r = 0.71, p < 0.002). Thyroid hormone diminished esterification of fatty acids, and inhibited the hepatic production of triglyceride and secretion of VLDL and stimulated ketogenesis, whereas thyroid hormone deficiency increased hepatic esterification of fatty acid to triglyceride, tended to increase output of the VLDL, and diminished oxidation of fatty acid through the tricarboxylic acid cycle. The surface lipid (phospholipid, cholesterol) to apoprotein ratio was directly correlated with the output of VLDL triglyceride (r = 0.85, p < 0.0005). Furthermore, the lipid composition of the secreted VLDL particle was influenced by thyroid status. Plasma T₃ concentration was directly correlated with the molar ratios of phospholipid/triglyceride (r = 0.73, p < 0.001), cholesterol/triglyceride (r = 0.85, p < 0.0001), and cholesteryl ester/triglyceride (r = 0.80, p < 0.0002) in the VLDL particle. A direct correlation was also demonstrable between the ratio apoprotein/triglyceride and plasma T₃ concentration (r = 0.72, p < 0.0084), while the ratio was inversely correlated with output of VLDL triglyceride (r = ?0.76, p < 0.0038). The percentage of certain of the polymorphic forms of arginine-rich peptide was increased, while apo C-III₃ was decreased in VLDL produced by livers from hypothyroid rats. These data are consistent with the hypothesis that as output of VLDL diminished in the progression from hypothyroidism to hyperthyroidism, the VLDL particle secreted became smaller with a larger ratio of surface to core components.     

Thyroid hormones and lipolysis in physically trained rats

In rats a single bout of exercise resulted in increased triiodothyronine (T3), thyroxine (T4), and triiodothyronine/reverse triiodothyronine ($\text{T3}\text{rT3}$) ratio 20 hr after exercise. The effect of norepinephrine on lipolysis in vitro was potentiated.In trained rats no changes were found in T4, T3 or rT3 concentrations. The $\text{T3}\text{rT3}$ ratio as well as basal and stimulated TSH concentrations decreased in comparison with sedentary, freely eating rats. Moderate food restriction to produce a body weight similar to that of trained animals caused no changes in T4, T3 or rT3 concentrations but caused a decrease in $\text{T3}\text{rT3}$ and in TSH levels. Training and moderate food restriction groups were not different. T3 in vitro caused a potentiation of catecholamine induced lipolysis in trained and food-restricted animals. With aging the serum concentration of T3 decreased and that of rT3 increased.Acute and chronic exercise both exert an effect on peripheral hormonal responses of lipolysis, while they have different and opposite effects on thyroid hormone concentrations. Physical training seems to have effects in this regard similar to those of moderate energy intake restriction. The results suggest that changes in peripheral effects of thyroid hormones during training should attract more attention.     

Mechanism of chlorpromazine-induced arrhythmia arrhythmia and mitochondrial dysfunction

In this study, we investigated the mechanism of the arrhythmogenic action of chlorpromazine (CPZ). Thirty-two anesthetized mongrel dogs were used. In each, the chest was opened and a stimulating electrode was attached to the apex of the left ventricle and the ventricular multiple response threshold (VMRT) was measured. The carotid artery was cannulated to measure aortic pressure. The dogs were divided into four groups, and the time course of VMRT, blood pressure, and heart rate were determined. All groups were placed under observation for 30 min after CPZ infusion. In the control group, only saline (2ml/kg) was infused; CPZ group: CPZ (1mg/kg) was infused 10 min after saline (2ml/kg) infusion; CoQ₁₀ group: Coenzyme Q₁₀ (CoQ₁₀) (5mg/kg) was infused 10 min before CPZ (1mg/kg) infusion; FAD group: Flavin-adenine-dinucleotide (FAD) (2mg/kg) was infused 10 min before CPZ (1mg/kg) infusion. In each group, myocardial mitochondria were prepared 30 min after CPZ infusion. The mitochondrial functions, respiratory control index, ADP/0, State III rate of oxygen consumption, and activities of two segments of the electron-transport chain (NADH→CoQ→cyt.c and cyt.c→cyt.a, a₃→O₂) were measured separately. Ca⁺⁺-binding activity of the mitochondria was also determined.CPZ administration decreased VMRT and blood pressure, and caused mitochondrial dysfunction which derived from a disturbance in the first segment of the electrontransport chain. Decreased Ca⁺⁺-binding activity was observed when mitochondrial function was disturbed. CoQ₁₀ prevented significantly the decrease in VMRT and the disturbance of mitochondrial function induced by CPZ, but did not prevent the hypotensive effect of CPZ. FAD prevented not only the decrease in VMRT and the disturbance of mitochondrial function, but also the hypotensive effect of CPZ.These results suggest that the decrease in VMRT is closely related to mitochondrial dysfunction induced by CPZ. Moreover, it is suggested that the arrhythmogenic effect of CPZ is derived from the decreased mitochondrial Ca⁺⁺-binding activity.     

Transcapillary fluid balance in immature rats. Interstitial fluid pressure,serum and interstitial protein concentration,and colloid osmotic pressure

Several of the factors governing transcapillary fluid balance were studied in anesthetized rats from the age of 1 to 60 days. Serum albumin and total protein concentrations rose from 1.7 and 2.4 g/100 ml at birth to 4.1 and 6.2 g/100 ml in adult rats, while colloid osmotic pressure rose from 5.3 to about 20 mm Hg. Interstitial fluid collected from subcutis by the wick technique showed protein concentrations of approximately 60% of serum values in all age groups, and its colloid osmotic pressure rose from about 3 to 10 mm Hg during maturation. Arterial pressure rose from about 50 mm Hg in newborn rats to 120 mm Hg in adult animals. Iliac venous pressure was only 0.5–1 mm Hg in 10-day-old rats compared to 3 mm Hg in adult animals. Interstitial fluid pressures of 0 to ?1 mm Hg were obtained in all age groups with the “wick-in-needle” technique. The data suggest an average capillary pressure of less than 5 mm Hg in newborn animals and a pre- to postcapillary resistance ratio similar to that of adult animals. The safety factors against edema formation seem to be small in immature rats.