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BackgroundThe COVID-19 pandemic has changed the healthcare landscape drastically. Stricken by sharp surges in morbidity and mortality with resource and manpower shortages confounding their efforts, the medical community has witnessed high rates of burnout and post-traumatic stress amongst themselves. Whilst the prevailing literature has offered glimpses into their professional war, no review thus far has collated the deeply personal reflections of physicians and ascertained how their self-concept, self-esteem and perceived self-worth has altered during this crisis. Without adequate intervention, this may have profound effects on their mental and physical health, personal relationships and professional efficacy.MethodsWith mentions of the coronavirus pervading social media by the millions, this paper set out to collate and thematically analyse social media posts containing first-person physician reflections on how COVID-19 affected their lives and their coping mechanisms. A consistent search strategy was employed and a PRISMA flowchart was used to map out the inclusion/exclusion criteria.ResultsA total of 590 social media posts were screened, 511 evaluated, and 108 included for analysis. Salient themes identified include Disruptions to Personal Psycho-Emotional State, Disruptions to Professional Care Delivery, Concern for Family, Response from Institution, Response from Society and Coping Mechanisms.ConclusionIt is evident that the distress experienced by physicians during this time has been manifold, multi-faceted and dominantly negative. Self-concepts were distorted with weakened self-esteem and perceived self-worth observed. The Ring Theory of Personhood (RToP) was adopted to explain COVID-19’s impact on physician personhood as it considers existential, individual, relational and social concepts of the self. These entwined self-concepts serve as ‘compensatory’ to one another, with coping mechanisms buffering and fortifying the physician’s overall personhood. With healthcare institutions playing a vital role in providing timely and targeted support, it was further proposed that a comprehensive assessment tool based on the RToP could be developed to detect at-risk physicians and evaluate the presence and effectiveness of established support structures.

PURPOSE The coronavirus disease 2019 (COVID-19) pandemic has had a global impact, and Singapore has seen 33,000 confirmed cases. Patients with cancer, their caregivers, and health care workers (HCWs) need to balance the challenges associated with COVID-19 while ensuring that cancer care is not compromised. This study aimed to evaluate the psychological effect of COVID-19 on these groups and the prevalence of burnout among HCWs. METHODS A cross-sectional survey of patients, caregivers, and HCWs at the National Cancer Centre Singapore was performed over 17 days during the lockdown. The Generalized Anxiety Disorder-7 and Maslach Burnout Inventory were used to assess for anxiety and burnout, respectively. Self-reported fears related to COVID-19 were collected. RESULTS A total of 624 patients, 408 caregivers, and 421 HCWs participated in the study, with a response rate of 84%, 88%, and 92% respectively. Sixty-six percent of patients, 72.8% of caregivers, and 41.6% of HCWs reported a high level of fear from COVID-19. The top concern of patients was the wide community spread of COVID-19. Caregivers were primarily worried about patients dying alone. HCWs were most worried about the relatively mild symptoms of COVID-19. The prevalence of anxiety was 19.1%, 22.5%, and 14.0% for patients, caregivers, and HCWs, respectively. Patients who were nongraduates and married, and caregivers who were married were more anxious. The prevalence of burnout in HCWs was 43.5%, with more anxious and fearful HCWs reporting higher burnout rates. CONCLUSION Fears and anxiety related to COVID-19 are high. Burnout among HCWs is similar to rates reported prepandemic. An individualized approach to target the specific fears of each group will be crucial to maintain the well-being of these vulnerable groups and prevent burnout of HCWs.

Background Empathy is pivotal to effective clinical care. Yet, the art of nurturing and assessing empathy in medical schools is rarely consistent and poorly studied. To inform future design of programs aimed at nurturing empathy in medical students and doctors, a review is proposed. Methods This systematic scoping review (SSR) employs a novel approach called the Systematic Evidence Based Approach (SEBA) to enhance the reproducibility and transparency of the process. This 6-stage SSR in SEBA involved three teams of independent researchers who reviewed eight bibliographic and grey literature databases and performed concurrent thematic and content analysis to evaluate the data. Results In total, 24429 abstracts were identified, 1188 reviewed, and 136 included for analysis. Thematic and content analysis revealed five similar themes/categories. These comprised the 1) definition of empathy, 2) approaches to nurturing empathy, 3) methods to assessing empathy, 4) outcome measures, and 5) enablers/barriers to a successful curriculum. Conclusions Nurturing empathy in medicine occurs in stages, thus underlining the need for it to be integrated into a formal program built around a spiralled curriculum. We forward a framework built upon these stages and focus attention on effective assessments at each stage of the program. Tellingly, there is also a clear need to consider the link between nurturing empathy and one’s professional identity formation. This foregrounds the need for more effective tools to assess empathy and to better understand their role in longitudinal and portfolio based learning programs.

PURPOSE:We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic.METHODS:Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019.RESULTS:We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations.CONCLUSION:Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

Incidental pancreatic lesions are increasingly being detected due to the increasing use of cross-sectional imaging such as computed tomography (CT) and magnetic resonance (MR) imaging. These pancreatic lesions can be broadly categorised into hypervascular and hypovascular lesions by comparing the degree of lesion enhancement to the background pancreatic parenchymal enhancement. For practicality, we define pancreatic lesions as hypervascular when they show enhancement greater or equal to that of the pancreatic parenchyma on either CT or MR imaging vis-a-vis hypovascular lesions, which characteristically enhance less than the background pancreatic parenchyma. Hypovascular lesions have been widely described, including ductal adenocarcinoma and chronic focal pancreatitis.(1) A few prior published reviews related to hypervascular pancreatic masses have focused on the differential entities or their malignant potential.(2,3) To the best of our knowledge, there is a lack of an algorithm-based approach that enables general radiologists to prospectively differentiate the various hypervascular pancreatic lesions, as presented in this pictorial essay. We further discuss the pertinent radiologic pathologic features of each differential diagnosis and illustrate them using individual case examples. Published version

Purpose To report the safety profile and 2-year functional outcomes of in-bore magnetic resonance (MR)-guided focused ultrasound on single cancer foci in men with prostate cancer. Materials and Methods Ethics approval was obtained from the centralized institutional review board for this prospective single-arm study, and patients provided informed consent. Patients with untreated low-volume low-grade prostate cancer (clinical stage T2a or lower; Gleason score, 3+3; index tumor ≤10 mm

Background The selection of patients for cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy infusion (HIPEC) is important, and relies heavily on imaging. However, it has been reported that Computer Tomographic (CT) scans may only achieve a low sensitivity of 33% for peritoneal disease. We propose a set of radiological criteria for pre-operative determination of resectability of peritoneal disease in peritoneal-based malignancies and validate this in our cohort of patients. Methods A retrospective review of all patients who underwent laparotomy with a view for CRS and HIPEC, at the National Cancer Centre Singapore from January 2000 to April 2010, was performed. Intra-operative Peritoneal Cancer Index (PCI) scores were recorded. The pre-operative imaging was reviewed with a senior radiologist who was blinded, and recorded the radiological PCI scores (CT-PCI) and eight additional CT prognostic factors (CT-PF). The CT-PCI and CT-PF scores were then compared with the intra-operative findings to determine the radiological accuracy. The scores and the individual prognostic factors were then evaluated for their predictive ability for unresectability. Results Comparison of the CT-PCI and PCI scores showed a concordance correlation coefficient at 0.52 (95% CI 0.34–0.7). Accuracy was increased with the addition CT-PF. The presence of omental caking and ascites were predictors of unresectability. We propose a scoring system which is able to predict for unresectable disease with a specificity of 80% and a sensitivity of 62%. Conclusion With our proposed criteria, and scoring system, the selection of patients for CRS and HIPEC can be improved, and unnecessary exploratory operations avoided.

OBJECTIVE. The objective of this article is to describe the imaging appearances of radiation injury to normal tissues in the abdomen that may be seen during imaging surveillance of oncology patients.CONCLUSION. Therapeutic radiation is used to treat various malignant conditions in the abdomen. Radiation damages normal surrounding tissues as well as the intended tumor. Radiation changes vary based on the target organ and the time from completion of therapy. Familiarity with the spectrum of changes that may be seen on follow-up imaging studies should help in the differentiation of radiation injury from other causes such as recurrent malignancy.

OBJECTIVE. The purpose of this article is to show the appearance of atypical sites of metastasis in patients with recurrent ovarian cancer.CONCLUSION. Metastatic disease from ovarian cancer outside of the peritoneal cavity is generally rare at presentation but is increasingly seen in patients who have recurrent disease, despite multiple therapies. It is important for radiologists to recognize atypical sites of metastasis in patients with recurrent ovarian cancer to facilitate earlier diagnosis and treatment.

Purpose To evaluate local experience of phased-array magnetic resonance imaging (MRI) in the staging of locally advanced prostate carcinoma with comparison to clinical staging. Methods The study population was 21 patients who underwent preoperative MRI with pelvic phased-array coils followed by radical prostatectomy. The MRI findings were correlated with completely embedded serially sliced and whole-mounted sections of the prostate gland and clinical staging. Results Overall accuracy of 57.1% was obtained, with specificity of 90.0% and sensitivity of 27.3%. All but one case of locally advanced disease missed by MRI was microscopic. Clinical staging in these cases also achieved accuracy of 57.1%, specificity of 90.0% and sensitivity of 27.3%. Conclusions MRI with a phased-array coil has high specificity but low sensitivity for detection of extraprostatic disease. Phased-array MRI does not image microscopic tumour extension. It did not perform better than clinical staging and is not recommended for routine staging.

To compare four different tracer kinetic models for the analysis of dynamic contrast material-enhanced computed tomographic (CT) data with respect to the prediction of 5-year overall survival in primary colorectal cancer.This study was approved by the ethical review board. Archival dynamic contrast-enhanced CT data from 46 patients with colorectal cancer, obtained as part of a research study, were analyzed retrospectively by using the distributed parameter, conventional compartmental, adiabatic tissue homogeneity, and generalized kinetic models. Blood flow, blood volume, mean transit time (MTT), permeability-surface area product, extraction fraction, extravascular extracellular volume (v(e)), and volume transfer constant (K(trans)) were compared by using the Friedman test, with statistical significance at 5%. Following receiver operating characteristic analysis, parameters of the different kinetic models and tumor stage were compared with respect to overall survival discrimination, with use of Kaplan Meier analysis and a univariate Cox proportional hazard model, with additional cross-validation and permutation testing.Blood flow was lower with the distributed parameter model than with the conventional compartmental and adiabatic tissue homogeneity models (P.0001), and blood flow values determined with the conventional compartmental and adiabatic tissue homogeneity models were similar. Conversely, MTT was longer with the distributed parameter model than with the conventional compartmental and adiabatic tissue homogeneity models (P.0001). Blood volume, permeability-surface area product, and v(e) were higher with the conventional compartmental model than with the adiabatic tissue homogeneity, distributed parameter, or generalized kinetic models (P.0001). The extraction fraction was higher with the distributed parameter model than with the adiabatic tissue homogeneity model. With respect to 5-year overall survival, only the distributed parameter model-derived v(e) was predictive of 5-year overall survival with a threshold value of 15.48 mL/100 mL after cross-validation and permutation testing.Parameter values differ significantly between models. Of the models investigated, the distributed parameter model was the best predictor of 5-year overall survival.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120186/-/DC1.

To compare the reliability of T(1)-weighted, T(2)-weighted, and different phases of dynamic contrast-enhanced MRI in the detection and reproducible size assessment of known carcinoid hepatic metastases.22 patients with known carcinoid hepatic metastases qualified for the study. Three readers reviewed MRI images twice independently at sessions that were2 weeks apart. The best sequences for metastases conspicuity, number and size, and reproducibility of size were compared subjectively. Linear mixed models were used to compare the number and size of metastases between readers and sequences, with the significance level set at p0.05.The best overall sequence rated was T(2) FSE (fast spin-echo). The average numbers of metastases was equivalent using T(1)-weighted arterial and T(2) FSE but less for T(2) FRFSE (fast-recovery, fast spin-echo) or delayed imaging. 1,067 lesions were detected and 66 were measured twice by three readers. There was no significant difference between the sequences or between the readings in size measurement when the same sequence was used. However, there was a difference among sequences for size of metastases (p0.001).T(2) FSE can be used as a basic sequence in detecting and monitoring the size of carcinoid hepatic metastases and may serve as the primary sequence in patients with contrast allergy or at risk for nephrogenic systemic fibrosis.

We present a case of leiomyomatosis peritonealis disseminata (LPD) after laparoscopic myomectomy with imaging features corroborating laparoscopic tract dissemination of the tumor. This would suggest a subset cases of LPD may be secondary to transcoelomic dissemination of a primary uterine leiomyoma rather than de novo peritoneal metaplasia. To our knowledge, this is the first case report of LPD and subcutaneous leiomyoma complicating laparoscopic surgery. The imaging features of LPD are reviewed. Radiologists as well as clinicians should consider LPD as a potential complication of laparoscopic myomectomy.