Healthy doctors understand us better, make good decisions, and offer us the best chance of good health. 1 In October of 2017, the World Medical Association updated and amended its 'physician's pledge' -the Declaration of Geneva 2 -to include a new affirmation: 'I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.' This was a major addition to a time-honoured set of principles, significant enough to prompt worldwide attention in both the medical and lay press. 3 An argument could be made, though, that such a public call for doctors to attend to their own health was long overdue. For many years now the evidence has been clear that factors such as burnout, untreated mental health problems, and other illnesses in doctors impart considerable risk to patients. 4 Burnout, in particular, is an issue for our specialty. Burnout is a well-recognised constellation of emotional responses: a loss of enthusiasm for work, feelings of cynicism and depersonalisation, and a reduced sense of personal accomplishment. 5 The 2018 Medscape Physician burnout and depression survey found that obstetrics and gynaecology specialists reported among the highest rates of burnout with a prevalence of 46% in respondents. 6 Among

A 57-year-old woman was referred following an acute episode of left-sided pyelonephritis associated with Klebsiella spp infection. After antibiotic treatment and resolution of the infection, the left flank pain continued and imaging revealed left hydronephrosis and hydroureter, with apparent obstruction on the left pelvic sidewall associated with the presence of a round lesion approximately 36 mm in diameter (Fig. 1). The left ovary appeared to be in close relation to the obstructing lesion, but separate. The right renal tract was normal. Her serum creatinine level was elevated at 102 μmol/L, but tumour markers were equivocal with normal results for carcinoembryonic antigen and CA-125, but an elevated level of CA19.9 (84 kU/L).The woman had undergone hysterectomy 8 years prior, for menorrhagia associated with a fundal leiomyoma (fibroid), and the uterus had been morcellated to effect delivery. No other abnormality had been observed at the time of hysterectomy, and the ovaries and fallopian tubes had been preserved. The patient had been completely well and asymptomatic in the intervening period. After the diagnosis of ureteric obstruction was made she wished to delay definitive surgery as her daughter was about to get married, so as an interim

These guidelines have been produced by a working party of the Association of Local Authority Medical Advisors to help doctors arrive at equitable decisions when assessing applications for ill health retirement. The general guidelines are intended to apply to all pension schemes and the specific ones to those such as The Local Government Pension Scheme where there is a requirement for the applicant to have permanent ill health.

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Aim:To discuss the management of the uncommon situation of metastatic gastrointestinal tumour coexisting with pregnancy. Method: We describe two cases of women with metastatic gastrointestinal stromal tumor (GIST) who successfully achieved a full-term pregnancy without complications and with the delivery of healthy infants. In both cases, treatment with imatinib mesylate was withheld during pregnancy because of its unknown effects and questionable safety for the developing fetus. The available data in the medical literature regarding the use and safety of imatinib and pregnancy are reviewed. We also examine whether the knowledge of the exon mutational status would have influenced treatment decisions. Results: Both women had wild type GIST, but with different tumor growth characteristics, treatment responses and outcomes. The first patient deferred imatinib therapy to fall pregnant and her disease progressed rapidly off treatment. The second patient had a more indolent GIST where active surgical management allowed her to experience a long durable clinical response. She potentially belongs to a pediatric subgroup which carries a better prognosis despite being off imatinib. Conclusion: While we have successfully managed two pregnant women with metastatic GIST, the issue of initiating imatinib therapy in treatment-naive women, and treatment interruption in women already on therapy, remain difficult areas. Patients and their partners need to make an informed choice regarding the associated risks and the potential long-term sequelae if pregnancies are contemplated. Further research into the natural history of wild type GIST and how to tailor subsequent treatment are needed.