The effect of immediate postpartum levonorgestrel contraceptive implant use on breastfeeding and infant growth: a randomized controlled trial

Objective

This study assessed whether immediate postpartum insertion of levonorgestrel contraceptive implants is associated with a difference in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 and 6 months postpartum compared to delayed insertion at 6 to 8 weeks postpartum.

Entitlement: The big problem in medical education we will not talk about

Abstract

Entitlement is a problem in medical education that has received relatively little attention. First, it is felt by educators, who often feel pressured to conform curricula and evaluations to satisfy learner demands and administrative pressures lest their careers are penalized. Second, entitlement affects the medical system, as entitled physicians are less empathetic and focus more on personal goods rather than patient needs. This shifts the humanistic basis for medicine. Thirdly, entitlement is problematic for learners, as constant accommodations ironically undermine self-reliance and adaptability. Constantly meeting these demands can diminish gratitude and overall happiness. To address this issue, learners must acknowledge the problem and seek remedies to it themselves, as top-down interventions will likely be rebuffed. Rather than focusing solely on the learning environment, solutions should also empower learners to engage their environment in effective and productive ways. This should include correcting cognitive distortions that lead learners to expect administrative interventions in all circumstances perceived as harmful. Other solutions include practicing gratitude and developing work friendships. While certainly not all learners are entitled and some environmental amendments should be made, learners and educators must realize that entitlement is shaping medical culture and collectively take steps to mitigate its negative effects.     

JAK2‐positive cutaneous myelofibrosis presenting as sclerosing extramedullary hematopoietic tumors on the scalp: case presentation and review of the literature

We report the second case of cutaneous myelofibrosis with a documented JAK2 activating mutation involving the scalp of a 67‐year‐old woman with primary myelofibrosis in her marrow. In contrast to the previous case, the biopsy revealed extensive lesional collagen deposition and closely mimicked a fibrohistiocytic proliferation. Similar rare lesions occurring in the setting of myeloproliferative neoplasms have been called sclerosing extramedullary hematopoietic tumors. These entities appear histomorphologically and etiologically distinct from extramedullary hematopoiesis, and their diagnosis should prompt the workup for a myeloproliferative neoplasm in the absence of an antecedent diagnosis. The presence of the JAK2 mutation in our case confirmed that the lesions represented skin involvement by a neoplastic myeloid proliferation and not compensatory extramedullary hematopoiesis. Our patient died of disease several months following the appearance of her lesions, which is in keeping with other reports that suggest that cutaneous myelofibrosis may serve as an independent poor prognostic sign in otherwise advanced primary myelofibrosis. A review of the literature further emphasizes the importance of distinguishing this entity from mesenchymal neoplasms and acute myeloid leukemia involving the skin.     

Connecting brain and body: Transdiagnostic relevance of connective tissue variants to neuropsychiatric symptom expression

The mind is embodied; thoughts and feelings interact with states of physiological arousal and physical integrity of the body. In this context, there is mounting evidence for an association between psychiatric presentations and the expression variant connective tissue, commonly recognised as joint hypermobility. Joint hypermobility is common, frequently under-recognised, significantly impacts quality of life, and can exist in isolation or as the hallmark of hypermobility spectrum disorders (encompassing joint hypermobility syndrome and hypermobile Ehlers-Danlos syndrome). In this narrative review, we appraise the current evidence linking psychiatric disorders across the lifespan, beginning with the relatively well-established connection with anxiety, to hypermobility. We next consider emerging associations with affective illnesses, eating disorders, alongside less well researched links with personality disorders, substance misuse and psychosis. We then review related findings relevant to neurodevelopmental disorders and stress-sensitive medical conditions. With growing understanding of mind-body interactions, we discuss potential aetiopathogenetic contributions of dysautonomia, aberrant interoceptive processing, immune dysregulation and proprioceptive impairments in the context of psychosocial stressors and genetic predisposition. We examine clinical implications of these evolving findings, calling for increased awareness amongst healthcare professionals of the transdiagnostic nature of hypermobility and related disorders. A role for early screening and detection of hypermobility in those presenting with mental health and somatic symptoms is further highlighted, with a view to facilitate preventative approaches alongside longer-term holistic management strategies. Finally, suggestions are offered for directions of future scientific exploration which may be key to further delineating fundamental mind-body-brain interactions.     

The Empathy Tank as a revised model for fostering empathy in medical education

Empathy has been difficult to sustain and foster in medical training. Based on empirical evidence and intuitive human experience, this paper proposes that empathy can be re-conceptualized as a dynamic reservoir, referred to as an “empathy tank.” Physicians and learners who have personally experienced or received much empathy will naturally have a stronger tendency and greater capacity for empathy than others who have experienced little. These instances of empathy that fill the “empathy tank” can take the form of personal experiences, re-experiencing memories, and vicarious experiences. As this reservoir is filled, the empathy therein can more readily be poured out to others. Thus, all trainees should be educated to recognize first and foremost their personal need for empathy that they share with patients and subsequently seek encounters that highlight these empathic experiences. Three practical implications for educational interventions are discussed: (1) Learners and preceptors should recognize instances in training of perceived inadequacy as opportunities to provide empathy, (2) Interventions should target foundational rather than secondary issues in empathy, and (3) Interventions should enable empathy in learners to be self-sustaining.     

Astrocytes,the rising stars of the glioblastoma microenvironment

Glioblastoma (GBM) is an aggressive primary tumor, causing thousands of deaths worldwide every year. The mean survival of patients with GBM remains below 20 months despite current available therapies. GBM cells' interactions with their stromal counterparts are crucial for tumor development. Astrocytes are glial cells that comprise ~50% of all brain cells and are therefore likely to establish direct contact with GBM cells. As other tumor cell types can hijack fibroblasts or immune cells to facilitate tumor growth, GBM cells can actually activate astrocytes, namely, the tumor associated astrocytes (TAAs), to promote GBM invasion in the healthy tissue. TAAs have thus been shown to be involved in GBM cells growth and limited response to radiation or chemotherapy (i.e., Temozolomide). Nevertheless, even though the interest in the cancer research community is increasing, the role of TAAs during GBM development is still overlooked. Yet, obtaining an in-depth understanding of the mechanisms by which TAAs influence GBM progression might lead to the development of new therapeutic strategies. This article therefore reports the different levels of GBM progression at which TAAs have been recently described to be involved in, including tumor cells' proliferation/invasion and resistance to therapies, especially through the activity of extracellular vesicles.