Thursday, April 18, 2019

Wednesday, April 17, 2019

Tuesday, April 16, 2019

Thursday, April 11, 2019

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On National Siblings Day



Eight days after Tatay passed away, my brothers and I tried to make sense of our grief by visiting the fruit stands along the highway, where Tatay loved to buy pineapples, papayas, mangoes, and watermelons for Nanay. I see so much of my father in my brothers, Manong Ralph (@arveecee) and Sean (@seancatedral)—his pot-bellied tummy, self-deprecating humor, extreme adherence to punctuality. I am grateful to have grown up with them.

Tuesday, April 9, 2019

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Genes turned on

The field of developmental biology answers the fundamental question of how cells make decisions about what kind of cells they will become.

Scientists from the Sloan Kettering Institute studied the mouse endoderm, the germ layer that forms majority of our internal organs. This paper is published in Nature. Using single-cell RNA sequencing (scRNA-seq), where single cells are isolated and the messenger RNAs in them are fully sequenced, scientists could see a snapshot of the actual genes that are turned on during development.

Their findings were as follows:

Trajectories of endoderm cells were mapped as they acquired embryonic versus extra-embryonic fates, and as they spatially converged within the nascent gut endoderm; revealing them to be globally similar but retaining aspects of their lineage history.

From the MSK website:

They found that cells that come from extra-embryonic tissues and those that come from the embryo are 99% identical regardless of origin, yet there is a set of genes whose activity is different between them. What’s more, the investigators were able to decipher some of the signals that help cells make their earliest fate decision: whether to become part of the embryo or part of the extra-embryonic structures. The team also pinpointed the earliest time when cells with organ-specific endoderm can be identified. It is far earlier than previously believed.

What does this mean?

The study adds to our current understanding of how cells develop. It shows that certain genes are crucial in determining the fate of a cell. This research inevitably leads to more investigations: how are those genes activated, for instance? How do those genes affect the cells, the organ, and the body, in all stages of development? The answers may be useful to our understanding of developmental biology and, hopefully, of cancer.

Reference:

Nowotschin S, et al. The emergent landscape of the mouse gut endoderm at single-cell resolution. Nature (2019). Link here.

Monday, April 8, 2019

Sunday, April 7, 2019

Spirituality and cancer

Puchalski et al (2019) reviewed the scientific literature on spiritual care in oncology.

The authors recommend that "all clinicians who develop assessment and treatment plans should assess patients for spiritual or existential distress and for spiritual resources of strength and integrate that assessment into the assessment and treatment or care plan." Another take-home message from the paper is that "clinicians are responsible for attending to the suffering of their patients." This is a tall, albeit reasonable, order.

The authors also put forth recommendations for integrating spiritual care in medical training:

  • All oncologists and clinicians practicing in oncology settings should be trained in spiritual care. This training should be required as part of continuing education.
  • Clinicians should be trained in spiritual care, commensurate with their scope of practice in regard to the spiritual care model.
  • Healthcare professionals should be trained in doing a spiritual history or screening.
  • Healthcare professionals who are involved in the diagnosis and treatment of clinical problems should be trained in the basics of spiritual distress diagnosis and treatment.
  • As part of cultural competency, all clinicians should have training in spiritual and religious values and beliefs that may influence clinical decision-making.
  • Training should also include opportunities for all members of the clinical teams to reflect on the role of their own spirituality and how it impacts their professional call and their own self-care.

Spirituality is "an important component of health and general well-being of patients with cancer, and that spiritual distress has a negative impact on quality of life of patients with cancer. This makes the implementation of spirituality-based interventions essential in order to support the spiritual well-being of patients with cancer. Spirituality and spiritual well-being have been proven to have a positive effect on patients with cancer."

I am interested in doing a study on whether Filipino oncologists are able to integrate spirituality into their practice. I wonder if similar studies have been done locally. Given the massive patient load and the myriad physical problems that cancer patients have, it is a challenge for physicians to look beyond the physical aspects of malignancies and view the patient as a person with a body and soul.

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Puchalski CM, Sbrana A, Ferrell B, et al. Interprofessional spiritual care in oncology: a literature review.  ESMO Open 2019;4:e000465. doi: 10.1136/esmoopen-2018-000465

The waters of baptism

When I attended water baptism on Saturday morning, I was refreshed. Men and women from various ages and backgrounds spoke of lives changed, hearts softened, priorities altered. No wonder why, in his exhortation that morning, Pastor Bob called water baptism one of his favorite duties in the ministry. It is not that baptism saves any one; it is a declaration of one's faith in Jesus Christ.

Stephen Charnock, in his comprehensive and voluminous treatise, The Doctrine of Regeneration, wrote, "What am I now? Here is a new light in my understanding, new inclinations in my will; I can now look upon God with pleasure and run his ways with delight. Christ is my only joy, and Christ is my only gain. My old nature is wearing away, my new nature is rising higher and clearer; now I am freed by the blood of Christ from my filth."

That a Puritan preacher from the 1600s and modern-day Filipinos speak of the same personal spiritual experiences and truths is nothing short of a miracle. It is the supernatural work of God alone: this change in the very nature of men and women who were once lost but now found (Ephesians 2).

Saturday, April 6, 2019

Breast surgery in patients with stage IV disease may increase survival

The ASCO Post, explaining the results of a study by Ross Mudgway (a medical student!) and colleagues:

To assess the impact of primary tumor resection on survival in patients with HER2-positive stage IV breast cancer, they conducted a retrospective cohort study of 3,231 women with the disease, using records from the National Cancer Database from 2010 to 2012.

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The researchers found that surgery was associated with a 44% increased chance of survival, assuming the majority of patients also had systemic treatment.

Read the abstract here, first presented at the AACR Annual Meeting in the USA.

Few things I find interesting:

1. The primary author is a medical student. How cool is that!

2. There's a working database that's a minefield of research possibilities, even for those who are in their early stages of their medical careers. In the Philippines, there's an urgent need for a   comprehensive cancer registry.

3. Patients who have metastatic breast cancer I'm meeting for the first time would invariably ask me if they, too, can have surgery. Unless the patient's breast mass has secondary infection, I would refer to surgery for toilet mastectomy or debridement. This study shows that there is surgical benefit for those whose breast cancer profile is Her2 positive. I hope this makes its way to our guidelines eventually.

(HT: Dr. Dennis Lee Sacadlan for sharing the link, via Facebook)
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