Jaundice: a Reflection Through Poetry.

This poem is a personal reflection on how we disclose cancer diagnoses in medicine. "Jaundice" is based on an experience that I witnessed during my core surgical rotation during medical school. It was created to highlight the importance of assessing a patient's thoughts, feelings, and emotions during these cancer conversations. The impact that these moments can have on a person may be tremendous, despite it being a part of our daily careers as physicians.

The accuracy of intraoperative frozen section examination of sentinel lymph nodes in squamous cell cancer of the vulva.

OBJECTIVE: To assess the diagnostic accuracy of intraoperative pathologic examination of sentinel lymph nodes (SLNs) and patient outcomes in vulva cancer. METHODS: This retrospective study included patients with unifocal, <4 cm, invasive vulvar squamous cell carcinoma and clinically negative groin nodes treated with SLN biopsy from January 2008-March 2020. Intraoperative SLN frozen section and final pathology were compared. If the SLN was negative, inguinal femoral lymphadenectomy (IFLD) was omitted. Recurrence location and groin recurrence free survival (RFS) were assessed. RESULTS: The SLN cohort included 173 patients, with 258 groins. On frozen section, there were 36/258 positive and 222 negative groins. On final pathology, there were 39/258 positive: 31 macrometastases, 6 micrometastases, 2 isolated tumor cells (ITCs) and 219 negative groins. The sensitivity, specificity, PPV and NPV for intraoperative detection of metastatic disease, was 89.7% and 99.5%, 97.2% and 98.2%, respectively. There was 1 false positive and 4 false negative frozen section results where final pathology revealed 2 ITCs, 1 micrometastasis and 1 macrometastasis. Based on intraoperative results, thirty patients (17.3%) underwent immediate IFLD. Median follow up was 38.0 (1-137.8) months. The 3-year groin RFS was 91.6% (95% CI 86.2-97.4%) for negative SLNs and 64.6% (95% CI 46.5-89.7%) for positive SLNs on frozen section. Similarly, the 3-year groin RFS was 91.7% (95% CI 86.3-97.4%) for negative, 58.4% (95% CI 38.5-87.7%) for macrometastases and 100% for micrometastases/ITCs on final pathology. CONCLUSIONS: Intraoperative assessment of SLNs is accurate to determine need for IFLD and does not compromise patient outcomes in vulvar cancer.

Placental growth factor as a diagnostic tool for placental mediated fetal growth restriction.

OBJECTIVE: Placental growth factor (PlGF) has shown promise in identification of placental fetal growth restriction (FGR). We aimed to investigate the association between PlGF and sonographic markers of placental dysfunction and assess its ability to diagnose FGR secondary to maternal vascular malperfusion (MVM). STUDY DESIGN: A retrospective study of singleton pregnancies with small for gestational age (SGA) fetuses, who had PlGF testing at 16-36 weeks. Fetuses with major chromosomal and/or structural anomalies and pregnancies with missing outcomes were excluded. Sonographic characteristics, perinatal outcomes and placental histopathology were compared between pregnancies with normal and low PlGF (<10th percentile for gestational age). The diagnostic accuracy of PlGF for prediction of MVM was calculated. RESULTS: 130 fetuses met inclusion criteria. Compared to normal PlGF (n = 65), pregnancies with low PlGF (n = 65) were associated with an estimated fetal weight < 5th centile (73.8% (48) vs 53% (35), respectively, p = 0.01), abnormal uterine, umbilical and MCA Dopplers (p = 0.001 for all), fetal demise (18.8% (12) vs 0% respectively, p = 0.01) and preterm delivery (100% (65) vs 39% (59), respectively, p < 0.001) . Low PlGF had a 70.1% (58.6-80.0) sensitivity and a 79.6% (64.7-90.2) specificity for identifying MVM, with an AUC of 0.73 (0.63-0.84). Positive and negative predictive values were 85.7% (76.8-91.2) and 60.3% (51.2-68.9), respectively. PlGF outperformed other parameters of placental FGR (uterine, umbilical artery, middle cerebral artery and abdominal circumference < 5th centile), in isolation and when combined. CONCLUSION: PlGF is a useful tool to aid in the diagnosis of placental FGR secondary to MVM.

Factors impacting length of stay and survival in patients with advanced gynecologic malignancies and malignant bowel obstruction.

OBJECTIVES: Malignant bowel obstruction in patients with gynecologic malignancies can impose a large symptomatic burden. The objectives of this study were to identify factors associated with shorter length of hospital stay and overall survival in gynecologic oncology patients with malignant bowel obstructions. METHODS: A retrospective chart review was performed from December 2014 to March 2019 on patients admitted to a tertiary care center with a malignant bowel obstruction and advanced gynecologic malignancy. Data collection included patient and tumor characteristics, malignant bowel obstruction management (such as conservative management with bowel rest, nasogastric tube, pharmacotherapy or active intervention with surgery, chemotherapy, radiation, total parenteral nutrition or interventional stents), length of hospital stay, and survival outcomes. Statistical analysis included comparisons with Student's t-test and χ2 test, multivariable analysis, and survival analysis. RESULTS: A total of 107 patients with gynecologic cancer with malignant bowel obstruction were included. The majority of patients (63%, n=67) had ovarian cancer. The median length of hospital stay was 12 days (range 1-23), with a median overall survival after malignant bowel obstruction diagnosis of 7 months (range 0.1-64.1). Patients with active interventions had a longer length of stay compared with those with conservative management (13 vs 6 days, p<0.001). However, patients who received multiple active interventions had increased overall survival (9.1 vs 2.9 months, p=0.049). CONCLUSION: Patients who received multimodal treatment for malignant bowel obstruction had an increased length of stay and improvement in survival of over 6 months. This emphasizes the importance of a multidisciplinary approach to actively manage malignant bowel obstruction in advanced gynecologic cancer.

Does demonstrator relevance affect social preferences and the social transmission of food preferences in female mice (Mus musculus)?

This study examined whether a history of beneficial social learning experiences affects social partner preferences in laboratory mice (Mus musculus) and whether observer mice acquire adaptive model-based social learning strategies through associative learning. We tested whether observers would come to socially prefer demonstrators who provide beneficial information through the social transmission of food preference (STFP), over demonstrators who do not; and whether they would preferentially attend to and learn from such demonstrators. Observers were given repeated exposures to two demonstrators who differed in whether or not they consistently provided beneficial information (which increased observers' ingestion of food via the STFP). After multiple social learning experiences with a "relevant demonstrator" (our CS+) whose demonstrated food was available for consumption (our US) by the observer and a "non-relevant demonstrator" whose demonstrated food was never encountered, neither demonstrator was preferred over the other. Furthermore, observers learned equally well from both relevant and non-relevant demonstrators. The present findings suggest that adaptive model-based social learning strategies are not followed in the STFP, although we recommend further testing of the social preference hypothesis.

An exploration of the aversive properties of 2-deoxy-D-glucose in rats.

Hypoglycemia can alter arousal and negatively impact mood. This study tests the hypothesis that acute drops in glucose metabolism cause an aversive state mediated by monoamine activity. In experiment 1, male Sprague-Dawley rats were either food deprived (FD) or pre-fed (PF) and tested on conditioned place avoidance (CPA; biased place conditioning design; 3 pairings drug/vehicle, each 30 min-long) induced by the glucose antimetabolite 2-deoxy-D-glucose (2-DG; 0, 300 or 500 mg/kg, SC). Locomotion and blood glucose were also assessed. Experiment 2 examined whether clonidine (noradrenergic α2 agonist, 0, 10 or 40 µg/kg, SC) or bupropion (monoamine reuptake blocker, 0, 10 or 30 mg/kg, SC) could alter CPA induced by 500 mg/kg 2-DG. In experiment 3, blood corticosterone (CORT) was measured in response to 500 mg/kg 2-DG, alone or in combination with 40 µg/kg clonidine or 30 mg/kg bupropion. Finally, experiment 4 controlled for possible place conditioning induced by 10 or 40 µg/kg clonidine, or 10 or 30 mg/kg bupropion injected without 2-DG. It was found that 2-DG increased blood glucose and produced a robust CPA. The feeding status of the animals modulated these effects, including CORT levels. Both clonidine and bupropion attenuated the effects of 2-DG on CPA and CORT, but only bupropion reversed suppression of locomotion. Taken together, these results in rats suggest that impaired glucose metabolism can negatively impact arousal and mood via effects on HPA and monoamine systems.