Discuss Treatment Options Research Articles

Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study.

Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes. We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately. A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately. Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.

Chemorefractory Gastric Cancer: The Evolving Terrain of Third-Line Therapy and Beyond.

Simple SummaryGastric and gastro-oesophageal junction cancers (GC) are the fourth cause of cancer-related deaths, representing an international problem which needs a proper assessment. Beyond being an aggressive disease, which rapidly progress to different lines of treatment, patients suffering GC normally present a non-depreciable number of symptoms that make them especially fragile. In this context, sequential treatment lines with few toxic adverse events have been associated to an increased survival. A satisfactory GC therapy comprise at least three lines of treatment including chemotherapy and immunotherapy and/or targeted agents when indicated.Gastric and gastro-oesophageal junction cancer (GC) represent a global healthcare problem being the fifth most common tumour type and the fourth cause of cancer mortality. Extremely poor median survival of approximately 10 months is normally reported within advanced GC patients, mainly secondary to two factors, i.e., the fragility of these patients and the aggressiveness of this disease. In this context, the correct treatment of GC patients requires not only a multidisciplinary team with special attention to palliative and nutritional care but also a close follow-up with regular monitoring of disease symptoms and tumour evaluation. Sequential treatment lines with few toxic adverse events have emerged as the best therapeutic approach, and a third line of therapy could further improve survival and quality of life of GC patients. Chemotherapy, immunotherapy, and targeted agents -when indicated- constitute the treatment armamentarium of these patients. In this review, we discuss treatment options in the refractory setting as well as novel approaches to overcome the poor prognosis of GC.

Pre-prostatectomy membranous urethral length as a predictive factor of post prostatectomy incontinence requiring surgical intervention with an artificial urinary sphincter or a male sling.

AimsTo ascertain whether the membranous urethral length (MUL) is predictive of postprostatectomy incontinence (PPI) that requires surgery such as artificial urinary sphincter (AUS) or male sling (MS).MethodsMen who had undergone AUS or MS for PPI were identified from a prospectively maintained database and compared to a control group of men who were continent at 12 months after radical prostatectomy. MUL in sagittal and coronal planes, sphincter height and width were measured on prebiopsy T2‐weighted MRI scans. Sphincter volume was estimated as an ellipsoid cylinder.ResultsA total of 95 patients (64 AUS and 31 MS) were compared to 60 continent controls. There was no statistical difference in presenting PSA, prostate volume, and T‐stage. The mean MUL in sagittal and coronal planes was 11.31 mm (SD: 2.6, range: 6–17 mm) and 11.43 mm (SD: 2.94, range: 5–17 mm) in patients who had AUS and MS, respectively; 15.23 mm (SD: 4.2, range: 8.25–25 mm) and 15.75 mm (SD: 4.1, range: 8–24 mm) in controls (p < 0.01). No men in the PPI surgery group had an MUL >17 mm compared to 35% (20/57 sagittal, 20/58 coronal) of controls. The odds ratio for requiring surgery for PPI was 13.4 for sagittal MUL <9 mm and 3.2 if the MUL <12 mm.ConclusionsPatients who had surgery for PPI had a significantly shorter MUL and sphincter volume than continent controls. Men with an MUL >17 mm are unlikely to require surgery for PPI whereas an MUL <12 mm significantly increases the risk of requiring surgery for PPI. MUL should be considered when discussing treatment options for prostate cancer.

Bidding for a Grateful Patient.

Bidding for a Grateful Patient Joel S. Perlmutter Patients and families frequently want to help support my research efforts, particularly when there is potential for discoveries that may translate to more effective clinical treatments. Support includes potential participation in research studies as well as financial support. Such donor financial support has huge advantages for me as an investigator. These funds can help support preliminary studies to determine whether some new research direction will be productive. These preliminary data form the critical base for a larger application to the National Institutes of Health. Almost all such submissions require such data to be competitive. Thus, these types of donations provide the “seed funds” to pursue new, innovative ideas. Given that background, one can see why the University Development Office wants to encourage interactions between clinician-scientists and potential patient donors. Of course, as a scientist, this aligns with my interests. Yet, as a clinician, I am somewhat reluctant to initiate these discussions with patients or families since I do not want that to intrude on the patient-physician relationship. In particular, I do not want to have any sense that I am coercing someone who depends upon me for care, nor do I want the patient to feel an obligation. Most particularly, I also want to avoid “reciprocity” in which the patient, their family, or my office feels an obligation to ask for or provide different care. Note that I state “different care” since I aim to provide all of my patients and families with “special and personalized care.” Thus, if a patient and family raises the question of support, I refer them to the development office. Well, I have not always followed this rule. Let me tell you a story of a different interaction that I still question. One Wednesday evening when finishing with the last patient of the day—it was about 8:30 pm—I had just completed the evaluation and discussion of treatment options with a man that I had treated for several years. His adult son, who had accompanied him on this visit, asked me about what was going on in my lab. I knew that it was late, but quite frankly, I rather enjoy talking about my work, so I did. I told them about a new drug that had been developed at Washington University by one of my colleagues, Laura Dugan, and we had just completed a study demonstrating that this drug can recover damage in the brain produced by a neurotoxin that causes an animal model of parkinsonism. Quite frankly, this was rather amazing since the treatment of Parkinson disease has only included symptomatic treatment and nothing slowed the relentless progression. The son then asked me about the next steps, and I explained that [End Page 7] I wanted to develop a measure of the action of this drug in the brain so that I could rationally know that if I extended this work to people with Parkinson disease, I could hit the target in the brain and with the appropriate dose. That evening he asked if I had time to meet with him on Friday morning before he left St. Louis to return home. I said fine, not really knowing anything about him or his family. I had assumed that perhaps he would donate $100 or so to help. But I could not pass up a chance to talk more about my work so we planned on a one hour meeting in two days. So, two days later the son walked into my research office, sat on the other side of my desk and he asked me some rather poignant questions. What were my goals of the research? How long would it take to collect enough preliminary data to submit a viable federal grant application? What was the value of the new methods that I wanted to develop if the drug that we had been testing failed to work in humans? Finally, how much money would this cost? I was not really prepared for that last question so I turned to my computer, pulled up a spreadsheet, quickly formulated a budget and said “about a million dollars.” To which he responded, “fine...

Hyperthyroidism in the Domestic Cat (Felis Catus): Informed Treatment Choice Based on Survival Analysis

Abstract Hyperthyroidism is the most frequently diagnosed endocrine disorder in cats. Therapy may include pharmacological, surgical (thyroidectomy), radioactive (iodine), and dietary treatment. The choice of treatment is believed to be strongly influenced by the veterinarian’s experience, level of education, and knowledge of the current scientific literature. The history of survival rates can affect the decision for treatment by both the veterinarian and the owner. This study aimed to explore the longevity in cats diagnosed with hyperthyroidism and to identify significant variables which affect survival rates by using retrospective data from the practice. A multivariate Cox regression was applied with the following results: surgical thyroidectomy and methimazole medication produced similar longevity (median 23.5 months, P&gt;0.05); Domestic Short Hair cats survived longer than pure breeds (median 27.2 vs 9.4 months, P&lt;0.05); as do cats without chronic renal disease (median 28.1 vs 6.2 months, P&lt;0.001); and those with low activities of alanine aminotransferase (median 27.1 vs 17.0 months, P&lt;0.01). Hyperthyroidism is comorbid with renal diseases, but no cumulative effect was found on survivability. There was no difference in survival rates between surgical and pharmaceutical treatment, therefore the discussion of treatment options with owners can focus on other factors (e.g., cost, owners’ compliance, cats’ tolerance to medication, presence of comorbidities). We propose that surgery may be the preferred treatment when the survival rates are expected to be higher than one year. This would avoid high costs and potential side effects of medication.

Management of cardiovascular manifestations in Loeys – Dietz syndrome: a systematic review

Ieva Daniliauskaitė1, Olivija Gustienė2 1 Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania 2 Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania Abstract Loeys – Dietz syndrome (LDS) is an autosomal dominantly inherited genetic disorder associated with significant and often life-threatening cardiovascular damage. The major cause of death in these individuals is aortic dissection. The primary choice for both prophylactic and emergency surgical interventions remains aortic valve-sparing root replacement due to the lower incidence of complications and the need for reoperation. Also, open surgery is more often recommended than endovascular stenting due to the possible accelerated development of aortic aneurysm in the native aortic stent fixation zones. To date, there are no approved guidelines for the treatment of aortic aneurysm and dissection in patients with LDS, but it is well known that multidisciplinary management of this syndrome must involve cardiovascular surgeons, cardiologists and geneticists. Nevertheless, the current literature provides a number of treatment options and recommendations for LDS. Therefore, the purpose of this systematic literature review is to analyze and discuss treatment options for aortic injury in patients with LDS, including both prophylactic and emergency interventions. Keywords: Loeys – Dietz, aortic aneurysm, aortic dissection, management of aortic aneurysm.

Stigma May Exacerbate Disproportionately Low Guideline-Concordant Treatment Rates for Patients With Advanced-Stage Lung Cancer in the United States

Stigma May Exacerbate Disproportionately Low Guideline-Concordant Treatment Rates for Patients With Advanced-Stage Lung Cancer in the United States

2022 AAHA Pain Management Guidelines for Dogs and Cats.

These updated guidelines present a practical and logical approach to the assessment and management of acute and chronic pain in canine and feline patients. Recognizing pain is fundamental to successful treatment, and diagnostic guides and algorithms are included for assessment of both acute and chronic pain. Particularly for chronic pain, capturing owner evaluation is important, and pain-assessment instruments for pet owners are described. Expert consensus emphasizes proactive, preemptive pain management rather than a reactive, "damage control" approach. The guidelines discuss treatment options centered on preemptive, multimodal analgesic therapies. There is an extensive variety of pharmacologic and nonpharmacologic therapeutic options for the management of acute and chronic pain in cats and dogs. The guidelines include a tiered decision tree that prioritizes the use of the most efficacious therapeutic modalities for the treatment of acute and chronic pain.

What Defines Quality of Life for Older Patients Diagnosed with Cancer? A Qualitative Study.

Simple SummaryQuality of life has a different meaning for every individual. In older patients with cancer, quality of life is important because anti-cancer treatment may influence their quality of life. In order to assess the aspects of quality of life that matter most to older patients with cancer, we interviewed 63 patients. We used both open-ended questions and asked them to select the most important items from a predefined list: cognition, contact with family or with community, independence, staying in your own home, helping others, having enough energy, emotional well-being, life satisfaction, religion and leisure activities. Physical functioning, social functioning, physical health and cognition are important components of quality of life. In conclusion, maintaining cognition and independence, staying in one’s own home, and maintaining contact with family and community appear to be the most important aspects of quality of life for older patients with cancer. These aspects should be included when making a shared treatment decision.The treatment of cancer can have a significant impact on quality of life in older patients and this needs to be taken into account in decision making. However, quality of life can consist of many different components with varying importance between individuals. We set out to assess how older patients with cancer define quality of life and the components that are most significant to them. This was a single-centre, qualitative interview study. Patients aged 70 years or older with cancer were asked to answer open-ended questions: What makes life worthwhile? What does quality of life mean to you? What could affect your quality of life? Subsequently, they were asked to choose the five most important determinants of quality of life from a predefined list: cognition, contact with family or with community, independence, staying in your own home, helping others, having enough energy, emotional well-being, life satisfaction, religion and leisure activities. Afterwards, answers to the open-ended questions were independently categorized by two authors. The proportion of patients mentioning each category in the open-ended questions were compared to the predefined questions. Overall, 63 patients (median age 76 years) were included. When asked, “What makes life worthwhile?”, patients identified social functioning (86%) most frequently. Moreover, to define quality of life, patients most frequently mentioned categories in the domains of physical functioning (70%) and physical health (48%). Maintaining cognition was mentioned in 17% of the open-ended questions and it was the most commonly chosen option from the list of determinants (72% of respondents). In conclusion, physical functioning, social functioning, physical health and cognition are important components in quality of life. When discussing treatment options, the impact of treatment on these aspects should be taken into consideration.

Short- and long-term survival after adrenalectomy in 53 dogs with pheochromocytomas with or without alpha-blocker therapy.

To report data related to the short- and long-term survival of dogs undergoing adrenalectomy for pheochromocytoma, and to determine the influence of preoperative alpha-blocker therapy. Retrospective. Fifty-three dogs. Medical records were reviewed for dogs diagnosed with pheochromocytoma and treated with adrenalectomy between 2010 and 2020. Preoperative management, imaging studies, intraoperative cardiovascular instability, complications, and procedural information were recorded. When applicable, duration of survival and cause of death, time to recurrence or metastasis, and postoperative complications were recorded. During anesthesia, a hypertensive episode was documented in 46/53 dogs and arrhythmias were recorded in 16/53 dogs. Of these, 37/46 hypertensive dogs and 11/16 dogs with arrhythmias were treated with an alpha-blocker before surgery. Intraoperative systolic blood pressures reached higher levels by a magnitude of nearly 20% in dogs that were treated preoperatively with an alpha-blocker (P= .01). All dogs survived surgery and 44 survived to discharge. Follow up ranged from 6 to 1653 days (median 450 days). Median survival time for dogs discharged from the hospital was 1169 days (3.2 years). Recurrence and metastasis were suspected in 3 and 8 dogs, respectively. Most dogs survived the immediate postoperative period and achieved long-term survival with a low reported incidence of tumor recurrence or metastasis. Preoperative alpha-blocker therapy was not associated with increased survival. The favorable outcomes reported in this study should be taken into consideration when discussing treatment options for dogs with pheochromocytomas. This study provides no evidence to support preoperative alpha-blocker therapy.

Small fiber neuropathy.

Small fiber neuropathy (SFN) is a peripheral nervous system disease due to affection of A-delta or C-fibers in a proximal, distal, or diffuse distribution. Selective SFN (without large fiber affection) manifests with pain, sensory disturbances, or autonomic dysfunction. Though uniform diagnostic criteria are unavailable, most of them request typical clinical features and reduced intra-epidermal nerve fiber density on proximal or distal skin biopsy. Little consensus has been reached about the treatment of SFN, why this narrative review aims at summarizing and discussing treatment options for SFN. Treatment of SFN can be classified as symptomatic, pathophysiologic, or causal. Prerequisites for treating SFN are an established diagnosis, knowledge about the symptoms and signs, and the etiology. Pain usually responds to oral/intravenous pain killers, antidepressants, anti-seizure drugs, or topical, transdermal specifications. Some of the autonomic disturbances respond favorably to symptomatic treatment. SFN related to Fabry disease or hATTR are accessible to pathogenesis-related therapy. Immune-mediated SFN responds to immunosuppression or immune-modulation. Several of the secondary SFNs respond to causal treatment of the underlying disorder. In conclusion, treatment of SFN relies on a multimodal concept and includes causative, pathophysiologic, and symptomatic measures. It strongly depends on the clinical presentation, diagnosis, and etiology, why it is crucial before initiation of treatment to fix the diagnosis and etiology. Due to the heterogeneous clinical presentation and multi-causality, treatment of SFN should be individualized with the goal of controlling the underlying cause, alleviating pain, and optimizing functionality.

Trust in the Healthcare System and Physicians in Croatia: A Survey of the General Population.

Trust in healthcare systems and physicians is considered important for the delivery of good healthcare. A cross-sectional survey was conducted on a random three-stage sample of the general population of Croatia (N = 1230), stratified by regions. Of respondents, 58.7% displayed a high or very high level of trust in the healthcare system, 65.6% in physicians, and 78.3% in their family physician. Respondents’ views regarding patients’ roles in the discussion of treatment options, confidence in physicians’ expertise, and underlying motives of physicians were mixed. Respondents with a lower level of education, those with low monthly incomes, and those from smaller settlements had lower levels of trust in physicians and the healthcare system. Trust in other institutions, religiosity and religious beliefs, tolerance of personal choice, and experience of caring for the seriously ill and dying were predictors of trust in healthcare and physicians. Our findings suggest that levels of healthcare-related trust in Croatia are increasing in comparison with previous research, but need improvement. Levels of trust are lowest in populations that are most vulnerable and most in need of care and protection.

Qualitative Analysis of the Roles of Physicians and Nurses in Providing Decision Support to Patients With Relapsed or Refractory Leukemia and Lymphoma.

IntroductionThis study examined the roles of hematologists and other professionals in providing decision support to patients with relapsed or refractory leukemia and lymphoma.MethodsThis was a qualitative study using in-depth semi-structured interviews involving 11 hematologists in Japan.ResultWe identified 7 categories related to the roles of hematologists in providing direct decision support to patients: (1) preparing patients before informed consent, (2) selecting the information to convey, (3) choosing a method for conveying this information, (4) respecting the intentions of patients and their families, (5) directing decision-making and considering fairness, (6) considering the emotional aspects of patients and their families, and (7) providing support after discussing treatment options. We also identified the following 5 subcategories related to the roles of hematologists in multidisciplinary collaboration: (1) communicating with other professionals, (2) gathering information from them, (3) providing information to them, (4) managing the entire medical team, and (5) encouraging nurses to actively participate with patients throughout the decision-making process.ConclusionThrough content analysis, the hematologist’s direct role in decision-making was extracted as preparation and consideration in situations where information about decision-making is communicated, and emotional support after the information is communicated. In addition, active participation in discussions, sharing information about the patient’s situation and relevant discussions, and emotional support as the hematologist’s expected roles in other professions were extracted. The results therefore suggest that a multidisciplinary team is needed to share information and provide multidimensional support to patients.

COVID-19-Related Complications

The COVID-19 Pandemic has affected millions of people worldwide. In its aftermath some individuals have been left with a sequela. This article aims to describe the symptoms and clinical findings reported among patients with Long-COVID and discuss treatment options. Authors collected, analyzed, and presented information on pulmonary, cardiovascular, endocrinological and neurological complications of COVID-19. Literature review was done across multiple journals from January 2020 till July 2022 using key words, such as COVID-19, long-COVID, cardiovascular, pulmonary, endocrinological and neurological complications. These words were used as Mesh terms, in order to cover other relevant possible words missing. Similar works found in the references of the studies identified were also reviewed. Long-COVID patients reported a number of findings including dyspnea, pneumonia, myocarditis, thyroiditis, increased complications of diabetes mellitus and neurological complications. Clinical findings indicate the likelihood of compromised health in some individuals with long-COVID. Treatment modalities recommend an interdisciplinary approach to ensure an all-encompassing perspective to rehabilitation and enhanced surveillance in individuals with predisposed risks factors.

Rehabilitation, Restrictions, and Return to Sport After Cartilage Procedures

AbstractThe ability to return to sport (RTS) after articular cartilage injury is of vital importance to athletes. Discussing the likelihood of returning to sport with patients is necessary, yet patients should be informed of the heterogeneous nature of the variables associated with successful RTS and the methodologic limitations behind current RTS rate estimates. Patient-specific factors affecting RTS are numerous and, in most cases, their isolated effect on RTS rates have yet to be examined and will remain difficult to do so. The purpose of this review is to discuss current RTS rates, explore factors leading to successful RTS, and examine the variability in physical therapy protocols after cartilage procedures, including microfracture, osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), and meniscal allograft transplantation (MAT). The senior author’s postoperative protocols will also be presented, as with a discussion on using RTS as a metric of patient and procedural success. Overall, there is significant variation in reported RTS rates among procedures examined, and providers must continue managing patient expectations when discussing treatment options.

An Algorithmic Approach to Managing Parotid Duct Injury Following Buccal Fat Pad Removal.

The principles of achieving an aesthetically pleasing and harmonious facial appearance are influenced by our evolving understanding of the three-dimensional topography of the face coupled with novel approaches to midface volumization and contouring. In parallel with the evolving landscape of facial aesthetic surgery, an increasing number of publications have emerged focusing on the role of intraoral buccal fat pad removal (BFPR) for the purposes of aesthetic midface contouring. The authors sought to emphasize an underreported and potentially preventable and untoward complication involving iatrogenic parotid duct injury following BFPR. The purpose of this publication is 3-fold: (1) to review the relevant anatomy and literature on intraoral BFPR, (2) to present a case example of this complication, and (3) to discuss treatment options as part of a proposed management algorithm. The authors detail the surgical indications for performing BFPR and review the relevant anatomic considerations. Complication prevention strategies are outlined, and details regarding avoidance of parotid duct injury are reviewed. The diagnostic criteria and clinical presentation of parotid duct injuries following BFPR are comprehensively outlined. The authors present a clinically actionable algorithm for managing a suspected or diagnosed parotid duct injury following BFPR. A clinical case example is discussed to highlight this complication, the diagnostic criteria, and the systematic and algorithmic approach to management. Intraoral BFPR is an incredibly valuable and powerful procedure that can improve facial contour in patients with buccal lipodystrophy or buccal fat pad pseudoherniation. The authors propose a proper diagnostic approach and treatment algorithm to manage this untoward complication.Level of Evidence: 5

Rituximab during the COVID-19 pandemic: time to discuss treatment options with patients

Rituximab during the COVID-19 pandemic: time to discuss treatment options with patients

Evaluating the perceived utility of an artificial intelligence-powered clinical decision support system for depression treatment using a simulation center

Aifred is a clinical decision support system (CDSS) that uses artificial intelligence to assist physicians in selecting treatments for major depressive disorder (MDD) by providing probabilities of remission for different treatment options based on patient characteristics. We evaluated the utility of the CDSS as perceived by physicians participating in simulated clinical interactions. Twenty physicians who were either staff or residents in psychiatry or family medicine completed a study in which they had three 10-minute clinical interactions with standardized patients portraying mild, moderate, and severe episodes of MDD. During these scenarios, physicians were given access to the CDSS, which they could use in their treatment decisions. The perceived utility of the CDSS was assessed through self-report questionnaires, scenario observations, and interviews. 60% of physicians perceived the CDSS to be a useful tool in their treatment-selection process, with family physicians perceiving the greatest utility. Moreover, 50% of physicians would use the tool for all patients with depression, with an additional 35% noting that they would reserve the tool for more severe or treatment-resistant patients. Furthermore, clinicians found the tool to be useful in discussing treatment options with patients. The efficacy of this CDSS and its potential to improve treatment outcomes must be further evaluated in clinical trials.

How to choose first salvage therapy in Hodgkin lymphoma: traditional chemotherapy vs novel agents.

Approximately 10% to 30% of patients with classical Hodgkin lymphoma (cHL) develop relapsed or refractory (R/R) disease. Of those patients, 50% to 60% show long-term progression-free survival after standard salvage chemotherapy followed by high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT). In the past decade, novel therapies have been developed, such as the CD30-directed antibody-drug conjugate brentuximab vedotin and immune checkpoint inhibitors, which have greatly extended the treatment possibilities for patients with R/R cHL. Several phase 1/2 clinical trials have shown promising results of these new drugs as monotherapy or in combination with chemotherapy, but unfortunately, very few randomized phase 3 trials have been performed in this setting, making it difficult to give evidence-based recommendations for optimal treatment sequencing. Two important goals for the improvement in the treatment of R/R cHL can be identified: (1) increasing long-term progression-free and overall survival by optimizing risk-adapted treatment and (2) decreasing toxicity in patients with a low risk of relapse of disease by evaluating the need for HDCT/ASCT in these patients. In this review, we discuss treatment options for patients with R/R cHL in different settings: patients with a first relapse, primary refractory disease, and in patients who are ineligible or unfit for ASCT. Results of clinical trials investigating novel therapies or strategies published over the past 5 years are summarized.

The Influence of Emotions on Treatment Decisions About Low-Risk Thyroid Cancer: A Qualitative Study.

Background: Little is known about the role of emotions in treatment decisions for thyroid cancer. We aimed to characterize the emotional content of patient-surgeon communication during decision-making about low-risk thyroid cancer treatment. Methods: We audio-recorded conversations about treatment for clinically low-risk thyroid cancer or biopsy suspicious for thyroid cancer between patients (n = 30) and surgeons (n = 9) in two diverse, academic hospitals in the United States. Inductive and deductive content analyses were used to characterize the emotional content in verbatim transcripts. Results: Patients' expression of emotion focused on primarily on their diagnosis and treatment outcomes. Patients commonly expressed negative emotions like fear and anxiety about "the C-word" and worried about the cancer growing or spreading. In response, most surgeons used education, as opposed to empathy or validation, to reassure patients, often highlighting low probabilities of adverse events. Surgeons emphasized the "slow-growing" nature and excellent prognosis of thyroid cancer compared with other malignancies. When discussing treatment options, surgeons often described alternatives in terms of their emotional outcomes. Some described total thyroidectomy as providing "peace of mind" or a "sense of completeness," warning that cancer or thyroid tissue remaining in the body with active surveillance or lobectomy might "worry" or "bother" patients. Surgeons supported deliberation by reassuring patients that there are "two right answers" and "no rush" to decide. Conclusions: Patients express negative emotions during treatment decision-making. In response, surgeons often miss opportunities to provide empathy in addition to education. Surgeons and patients both acknowledge patient fear and anxiety as a reason to choose thyroidectomy instead of active surveillance. Peace of mind gained by patients and surgeons as a result of thyroidectomy may lead to overtreatment of patients with low-risk thyroid cancer.