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.

Neuroendocrine hepatic metastases exhibit various contrast uptake enhancement patterns in dynamic contrast-enhanced MRI. Using a dual-input two-compartment distributed parameter model, we analyzed the dynamic contrast-enhanced MRI datasets of seven patient study cases with the aim to relate the tumor contrast uptake patterns to parameters of tumor microvasculature. Simulation studies were also performed to provide further insights into the effects of individual microcirculatory parameter on the tumor concentration-time curves. Although the tumor contrast uptake patterns can be influenced by many parameters, initial results indicate that hepatic blood flow and the ratio of fractional vascular volume to fractional interstitial volume may potentially distinguish between the patterns of neuroendocrine hepatic metastases. Key words: neuroendocrine hepatic metastases; DCE MRI; tracer kinetics modeling Neuroendocrine tumors are a rare and heterogeneous group of hormone-secreting neoplasms that arise from neoplastic proliferation of enterochromaffin or Kulchitsky cells of the neuroendocrine system (1,2). Primary tumors can occur in various organs, predominantly in the gastrointestinal tract, pancreas, and lung. Despite their relatively low incidence, neuroendocrine tumors pose a significant clinical challenge due to their varied presentations and the primary tumor is often revealed through detection of metastases (2).Although neuroendocrine hepatic metastases have been described as predominantly hypervascular (1), in practice various contrast uptake enhancement patterns have been observed in dynamic contrast-enhanced (DCE) MRI, possibly due to their heterogeneous histology from diverse locations of origin. Apart from the usual contrast uptake pattern of rapid increase followed by rapid washout commonly associated with hypervascular hepatic lesions, neuroendocrine hepatic metastases can exhibit a spectrum of other contrast uptake behavior ranging from a progressively increasing pattern (within a few minutes following bolus administration of contrast medium) to patterns with an initial moderate increase followed by either a plateau, gradual increase or decrease.Although there are considerable interests in studying the various shapes of tumor contrast uptake patterns, the physiological basis of these patterns has remained unclear. Tracer kinetics analysis of these tumor contrast uptake patterns may provide insights into the differences in tumor microvasculature that result in these patterns. We aim to study the various contrast uptake patterns of neuroendocrine hepatic metastases and relate these patterns to tumor microcirculatory parameters derived from tracer kinetics modeling. MATERIALS AND METHODS Tracer Kinetics ModelingTracer kinetics modeling of the liver is uniquely challenging in two ways: (i) The liver has a dual blood supply derived from the hepatic artery and portal vein. (ii) Normal liver sinusoids are fenestrated, which allow free access of low-molecular weight compounds (including conventional gadolinium-bas...

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.