Society Statement Research Articles

Response to the Letter to the Editor on the Canadian Paediatric Society statement on gender-affirming care.

Response to the Letter to the Editor on the Canadian Paediatric Society statement on gender-affirming care.

European Respiratory Society statement on preschool wheezing disorders: updated definitions, knowledge gaps and proposed future research directions.

Since the publication of the European Respiratory Society (ERS) task force reports on the management of preschool wheezing in 2008 and 2014, a large body of evidence has accumulated suggesting that the clinical phenotypes that were proposed (episodic (viral) wheezing and multiple-trigger wheezing) do not relate to underlying airway pathology and may not help determine response to treatment. Specifically, using clinical phenotypes alone may no longer be appropriate, and new approaches that can be used to inform clinical care are needed for future research. This ERS task force reviewed the literature published after 2008 related to preschool wheezing and has suggested that the criteria used to define wheezing disorders in preschool children should include age of diagnosis (0 to <6 years), confirmation of wheezing on at least one occasion, and more than one episode of wheezing ever. Furthermore, diagnosis and management may be improved by identifying treatable traits, including inflammatory biomarkers (blood eosinophils, aeroallergen sensitisation) associated with type-2 immunity and differential response to inhaled corticosteroids, lung function parameters and airway infection. However, more comprehensive use of biomarkers/treatable traits in predicting the response to treatment requires prospective validation. There is evidence that specific genetic traits may help guide management, but these must be adequately tested. In addition, the task force identified an absence of caregiver-reported outcomes, caregiver/self-management options and features that should prompt specialist referral for this age group. Priorities for future research include a focus on identifying 1) mechanisms driving preschool wheezing; 2) biomarkers of treatable traits and efficacy of interventions in those without allergic sensitisation/eosinophilia; 3) the need to include both objective outcomes and caregiver-reported outcomes in clinical trials; 4) the need for a suitable action plan for children with preschool wheezing; and 5) a definition of severe/difficult-to-treat preschool wheezing.

PULMONARY REHABILITATION IN ROMANIA: FROM THE BEGINNINGS TO THE PRESENT

Pulmonary rehabilitation is the standard of care for patients with chronic lung disease. Material and method: Starting from the systematic review of specialized literature and practical expertise obtained both internationally and nationally, the exposition emphasizes the aspects related to pulmonary rehabilitation in patients with chronic lung diseases. Results: The cornerstone of pulmonary rehabilitation is the American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation published in 2006 and developed based on the documents of the American College of Chest Physicians (ACCP) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) published in 1997 and 2004. The document was subsequently updated in 2007, 2013, 2015, 2021 and 2023, with the concept of pulmonary rehabilitation constantly evolving over the years. In Romania, pulmonary rehabilitation is carried out according to these guidelines and international standards, Iasi being a reference center in this field. Conclusions: Pulmonary rehabilitation is one of the most powerful evidence-based therapies for patients with chronic lung disease. Keywords: COPD, exercise capacity, training, quality of life.

European Respiratory Society statement on novel nicotine and tobacco products, their role in tobacco control and "harm reduction"

European Respiratory Society statement on novel nicotine and tobacco products, their role in tobacco control and "harm reduction"

EMAS position statement: Thyroid disease and menopause

IntroductionThyroid diseases are common in women in their late reproductive years; therefore, thyroid disease and menopause may co-exist. Both conditions may present with a wide range of symptoms, leading to diagnostic challenges and delayed diagnosis.AimTo construct the first European Menopause and Andropause Society (EMAS) statement on thyroid diseases and menopause. Materials and methodsLiterature review and consensus of expert opinion (EMAS executive board members/experts on menopause and thyroid disease). Summary recommendationsThis position paper highlights the diagnostic and therapeutic dilemmas in managing women with thyroid disease during the menopausal transition, aiming to increase healthcare professionals' awareness of thyroid disorders and menopause-related symptoms. Clinical decisions regarding the treatment of both conditions should be made with caution and attention to the specific characteristics of this age group while adopting a personalized patient approach. The latter must include the family history, involvement of the woman in the decision-making, and respect for her preferences, to achieve overall well-being.

A Test to Comprehensively Capture the Known Genetic Component of Familial Pulmonary Fibrosis.

The recent European Respiratory Society statement on familial pulmonary fibrosis supports the need for genetic testing in the care of patients and their relatives. However, no solution (i.e., a concrete test) was provided to implement genetic testing in daily practice. Herein, we tabulated and standardized the nomenclature of 128 genetic variants in 20 genes implicated in adult-onset pulmonary fibrosis. The objective was to develop a laboratory-developed test (LDT) on the basis of standard Sanger sequencing to capture all known familial pulmonary fibrosis-associated variants. Targeted DNA fragments were amplified using harmonized PCR conditions to perform the LDT in a single 96-well plate. The new genetic test was evaluated in 62 sporadic cases of idiopathic pulmonary fibrosis. As expected in this population, we observed a low yield of disease-causing mutations. More important, 100% of targeted variants by the LDT were successfully evaluated. Furthermore, four variants of uncertain significance with in silico-predicted deleterious scores were identified in three patients, suggesting novel pathogenic variants in genes known to cause idiopathic pulmonary fibrosis. Finally, the MUC5B promoter variant rs35705950 was strongly enriched in these patients with a minor allele frequency of 41.1% compared with 10.6% in a matched population-based cohort (n = 29,060), leading to an estimation that this variant may explain up to 35% of the population-attributable risk. This LDT provides a solution for rapid clinical translation. Technical laboratory details are provided so that specialized pulmonary centers can implement the LDT in house to expedite the clinical recommendations of expert panels.

Updates on British Thoracic Society Statement on Pleural Disease and Procedures 2023.

Updates on British Thoracic Society Statement on Pleural Disease and Procedures 2023.

Fecal Microbiota Transplantation: Information for the Pediatrician.

Fecal microbiota transplantation (FMT) involves the delivery of an entire microbial community from a healthy donor to a recipient with the intention of ameliorating or curing a specific disease. Current evidence strongly supports a role for FMT in the treatment of Clostridiodes difficile infection, with cure rates of approximately 80% to 90%. This success has led to increasing attention for FMT as a potential therapeutic intervention for other conditions associated with disturbances of the intestinal microbiome, including inflammatory bowel diseases, autism spectrum disorder, and obesity. This clinical report endorses the joint society statement by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition and is meant to provide the general pediatrician with a broad overview to enable appropriate guidance to families seeking FMT as treatment of a child's condition.

47 Clinical Approach to Febrile Urinary Tract Infections in Young Children Presenting to the Paediatric Emergency Department: A Retrospective Study of National Guideline Compliance

Abstract Background Antimicrobial resistance is one of the greatest threats to global health. Antibiotic overuse drives antimicrobial resistance. Suspected urinary tract infection (UTI) is a key area of over-prescribing in many clinical settings but has not been investigated in the paediatric emergency department (ED). Objectives Here, we explore compliance with national UTI management guidelines in a paediatric emergency department setting and characterize patient and provider factors associated with guideline non-compliance. Design/Methods We performed retrospective chart review of patients ages 60 days to 36 months, discharged with a diagnosis of UTI from a single, urban, tertiary care paediatric emergency department (PED) with a diagnosis of UTI. Random visits were chosen using a computer algorithm. Primary outcomes were: 1) proportion of patients receiving guideline-compliant investigation and treatment, and 2) the proportion of children whose antibiotic prescriptions were appropriately adjusted upon return of urine culture and antibiotic susceptibilities (C&amp;S). The guideline was the Canadian Paediatric Society statement on management of UTI, as well as the BC Children’s Hospital institutional UTI management guideline. Descriptive statistics and odds ratios between associations were calculated. Results We reviewed 402 charts. The proportion of infants receiving guideline-compliant testing and treatment was 25.9% (95% CI: 21.8-30.4%). Of those who were prescribed antibiotics, 79.6% (95% CI: 74.7-83.8%) received a first-line recommended agent and 58.9% (95% CI: 53.8-63.8%) received fully compliant therapy with respect to agent, dose, duration, and frequency. 19.4% (15.4-24.2%) of patients who were prescribed empiric cephalexin received an inappropriately high total daily dose. The proportion of patients receiving age-appropriate testing method was 52.2% (95% CI: 47.4-57.1). Febrile children were more likely to receive age-appropriate urine sample collection by catheterized sample (OR: 2.77 95% CI: 1.81-4.25) compared with afebrile children. Ultimately, 50.7% (95% CI: 40.4-49.6%) of patients discharged with a diagnosis of UTI and prescription for antibiotic met diagnostic criteria for UTI based on urinalysis and culture results. Of patients whose C&amp;S mandated a change in therapy, 60.8% (95% CI: 55.8-65.7%) had their agent changed or discontinued. Conclusion Paediatric emergency medicine physicians frequently order inappropriate investigation and empiric treatment of UTI in young children. Discontinuation of empiric antibiotics in culture-negative children may be an impactful stewardship intervention in the PED.

Deep Learning-Based Kernel Adaptation Enhances Quantification of Emphysema on Low-Dose Chest CT for Predicting Long-Term Mortality.

The aim of this study was to ascertain the predictive value of quantifying emphysema using low-dose computed tomography (LDCT) post deep learning-based kernel adaptation on long-term mortality. This retrospective study investigated LDCTs obtained from asymptomatic individuals aged 60 years or older during health checkups between February 2009 and December 2016. These LDCTs were reconstructed using a 1- or 1.25-mm slice thickness alongside high-frequency kernels. A deep learning algorithm, capable of generating CT images that resemble standard-dose and low-frequency kernel images, was applied to these LDCTs. To quantify emphysema, the lung volume percentage with an attenuation value less than or equal to -950 Hounsfield units (LAA-950) was gauged before and after kernel adaptation. Low-dose chest CTs with LAA-950 exceeding 6% were deemed emphysema-positive according to the Fleischner Society statement. Survival data were sourced from the National Registry Database at the close of 2021. The risk of nonaccidental death, excluding causes such as injury or poisoning, was explored according to the emphysema quantification results using multivariate Cox proportional hazards models. The study comprised 5178 participants (mean age ± SD, 66 ± 3 years; 3110 males). The median LAA-950 (18.2% vs 2.6%) and the proportion of LDCTs with LAA-950 exceeding 6% (96.3% vs 39.3%) saw a significant decline after kernel adaptation. There was no association between emphysema quantification before kernel adaptation and the risk of nonaccidental death. Nevertheless, after kernel adaptation, higher LAA-950 (hazards ratio for 1% increase, 1.01; P = 0.045) and LAA-950 exceeding 6% (hazards ratio, 1.36; P = 0.008) emerged as independent predictors of nonaccidental death, upon adjusting for age, sex, and smoking status. The application of deep learning for kernel adaptation proves instrumental in quantifying pulmonary emphysema on LDCTs, establishing itself as a potential predictive tool for long-term nonaccidental mortality in asymptomatic individuals.

European Respiratory Society statement on frailty in adults with chronic lung disease.

Frailty is a complex, multidimensional syndrome characterised by a loss of physiological reserves that increases a person's susceptibility to adverse health outcomes. Most knowledge regarding frailty originates from geriatric medicine; however, awareness of its importance as a treatable trait for people with chronic respiratory disease (including asthma, COPD and interstitial lung disease) is emerging. A clearer understanding of frailty and its impact in chronic respiratory disease is a prerequisite to optimise clinical management in the future. This unmet need underpins the rationale for undertaking the present work. This European Respiratory Society statement synthesises current evidence and clinical insights from international experts and people affected by chronic respiratory conditions regarding frailty in adults with chronic respiratory disease. The scope includes coverage of frailty within international respiratory guidelines, prevalence and risk factors, review of clinical management options (including comprehensive geriatric care, rehabilitation, nutrition, pharmacological and psychological therapies) and identification of evidence gaps to inform future priority areas of research. Frailty is underrepresented in international respiratory guidelines, despite being common and related to increased hospitalisation and mortality. Validated screening instruments can detect frailty to prompt comprehensive assessment and personalised clinical management. Clinical trials targeting people with chronic respiratory disease and frailty are needed.

An Update on Outcomes for COPD Pharmacological Trials: A COPD Investigators Report - Reassessment of the 2008 American Thoracic Society/European Respiratory Society Statement on Outcomes for COPD Pharmacological Trials.

Background: In 2008, a dedicated American Thoracic Society/European Respiratory Society task force published a paper on the possible use and limitations of clinical outcomes and biomarkers to evaluate the impact of pharmacological therapy in patients with chronic obstructive pulmonary disease. Since then, our scientific understanding of chronic obstructive pulmonary disease has increased considerably; there has been a progressive shift from a one-size-fits-all diagnostic and therapeutic approach to a personalized approach; and many new treatments currently in development will require new endpoints to evaluate their efficacy adequately. Objectives: The emergence of several new relevant outcome measures motivated the authors to review advances in the field and highlight the need to update the content of the original report. Methods: The authors separately created search strategies for the literature, primarily based on their opinions and assessments supported by carefully chosen references. No centralized examination of the literature or uniform criteria for including or excluding evidence were used. Measurements and Main Results: Endpoints, outcomes, and biomarkers have been revisited. The limitations of some of those reported in the American Thoracic Society/European Respiratory Society task force document have been highlighted. In addition, new tools that may be useful, especially in evaluating personalized therapy, have been described. Conclusions: Because the "label-free" treatable traits approach is becoming an important step toward precision medicine, future clinical trials should focus on highly prevalent treatable traits, and this will influence the choice of outcomes and markers to be considered. The use of the new tools, particularly combination endpoints, could help better identify the right patients to be treated with the new drugs.

Experiences of UK-based adult transition services for interstitial lung disease in childhood: "There's a lot less cushioning".

Interstitial lung disease in childhood (chILD) is rare and no longer purely a childhood issue as many survive into adulthood, and so have to transition from pediatric to adult healthcare services. Transition is a significant life event that has the potential to impact on physical and mental health outcomes. The European Respiratory Society (ERS) statement on chILD transition highlighted the lack of standardised transition services for chILD transition resulting in a haphazard process. This qualitative study explores how young people and parents in the United Kingdom experienced transition from paediatric to adult healthcare services for chILD. Participants (n = 7) were recruited from chILD patient organisations and online communities. We focused on the experience of transition exploring if there were any information packs or support provided for the transition. Such support may be generic, such as "Ready Steady Go" which provides a systematic approach to transition and disease-specific literature. These latter have not been developed for ILD. Data were analysed by constructivist grounded theory. We present a lived experience of transition with themes of lack of transition preparation and planning, challenges of adapting to adult services, and a changing healthcare scene. Due to the complexity of chILD, parents discussed their need to remain, in part, as an advocate for the young person. Respondents provided recommendations for how transition could be improved along with tips for young people who are new to the transition process, which include educating oneself about the condition, learning medical terminology, and reaching out for support.

Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Stronger Associations of Centrilobular Than Paraseptal Emphysema With Longitudinal Changes in Diffusing Capacity and Mortality in COPD

The factors associated with longitudinal changes in diffusing capacity remain unclear among patients with COPD. Centrilobular emphysema (CLE) and paraseptal emphysema (PSE) are major emphysema subtypes that may have distinct clinical-physiological impacts in these patients. Are CLE and PSE differently associated with longitudinal changes in diffusing capacity and mortality in patients with COPD? This pooled analysis included 399 patients with COPD from two prospective observational COPD cohorts. CLE and PSE were visually assessed on CT scan according to the Fleischner Society statement. The diffusing capacity and transfer coefficient of the lung for carbon monoxide (Dlco and KCO) and FEV1 were evaluated at least annually over a 5-year period. Mortality was recorded over 10 years. Longitudinal changes in FEV1, Dlco, and KCO and mortality were compared between mild or less severe and moderate or more severe CLE and between present and absent PSE in each Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. The Dlco and KCO decline was weakly associated with FEV1 and greater in GOLD stage 3 or higher than in GOLD stages 1 and 2. Furthermore, moderate or more severe CLE, but not present PSE, was associated with steeper declines in Dlco for GOLD stages 1 and 3 or higher and KCO for all GOLD stages independent of age, sex, height, and smoking history. The moderate or more severe CLE, but not present PSE, was associated with additional FEV1 decline and higher 10-year mortality among patients with GOLD stage 3 or higher. A CT scan finding of moderate or more severe CLE, but not PSE, was associated with a subsequent accelerated impairment in diffusing capacity and higher long-term mortality in severe GOLD stage among patients with COPD.

Turkish Thoracic Society's Statement Report on Electronic Cigarettes and Heated Tobacco Products.

Tobacco addiction, which causes the death of more than 8.5 million people in the world every year, is a preventable global public health problem. There are 1.1 billion adult smokers worldwide and 60% of them desire or intend to quit but unfortunately, the tobacco industry continues to profit at the expense of people’s lives by marketing electronic cigarettes and heated tobacco products as a smoking cessation method and they continue to poison young people with new threat tobacco products, promising a “smoke-free future” Turkish Thoracic Society is actively involved in the implementation of the National Tobacco Control Program to protect public health and has warned and raised awareness of new threats to the youth, such as electronic cigarettes and heated tobacco products. The purpose of this report is to provide information about electronic cigarettes and heated tobacco products and to present TTJ’s position on the subject.

In Vivo Temperature Rise Measurements of Rabbit Liver and Femur Bone Surface Exposed to an Acoustic Radiation Force Impulse.

Acoustic radiation force impulse (ARFI) imaging and shear wave elastography use a "push pulse." The push pulse, which is referenced as an ARFI in this study, has a longer duration than that of conventional diagnostic pulses (several microseconds). Therefore, there are concerns regarding thermal safety in vivo. However, few in vivo studies have been conducted using living animals. In this study, to suggest a concept for deciding an ARFI output and cooling time while considering thermal safety, the liver (with and without an ultrasound contrast agent) and femur bone surface of living rabbits were exposed to an ARFI, and the maximum temperature rise, temperature rise for 5-min duration, and cooling time were measured via a thermocouple. While testing within the regulation limits of diagnostic ultrasound outputs, a maximum temperature rise on the femur bone surface exceeded the allowable temperature rise (1.5°C) in the British Medical Ultrasound Society (BMUS) statement. However, using the linear relationships between the pulse intensity integral (PII) of a single pulse and the above three temperature parameters, PII may be determined so that the maximum temperature rise is within the allowable temperature rise in the BMUS statement. The cooling time can be estimated from the PII.

Research Trends on Pulmonary Rehabilitation: A Bibliometric Analysis From 2011 to 2020.

Background and ObjectiveA mounting body of evidence suggests that lung function may deteriorate over time with the development of chronic lung diseases (CRDs). Pulmonary rehabilitation has been proved to improve exercise capacity and quality of life in individuals with CRDs. However, PR remains grossly underutilized all around the world. This study aimed to analyze the research trends on PR over the past 10 years.MethodsThe publications related to pulmonary rehabilitation in the Web of Science Core Collection (WoSCC) from 2011 to 2020 were searched. VOSviewer (1.6.15) and CiteSpace Software (5.5.R2) were used to analyze authors and co-cited authors, countries and institutions, journals and co-cited journals, co-cited references, and keywords.ResultsA total of 4,521 publications were retrieved between 2011 and 2020, and the number of annual publications on pulmonary rehabilitation has shown an overall upward trend in the past decade. The USA was the most productive country, the University of Toronto from Canada was both the first in publications and citations. Spruit MA was both the most productive author and the one with the highest number of co-citations. The first productive journal was the International Journal of Chronic Obstructive Pulmonary Disease, while the first co-cited journal was the American Journal of Respiratory and Critical Care Medicine. The hot keywords were grouped into three clusters, while “Asthma” and “Respiratory society statement” were determined as the frontier topics.ConclusionsThe present study successfully revealed the research status and development trends of pulmonary rehabilitation from 2011 to 2020 by using bibliometric analysis, which may help researchers explore and discover new research directions in the future.

Optimal Assessment of Nutritional Status in Older Subjects with the Chronic Obstructive Pulmonary Disease-A Comparison of Three Screening Tools Used in the GLIM Diagnostic Algorithm.

Chronic obstructive pulmonary disease (COPD) is a recognized risk factor for malnutrition. The European Respiratory Society (ERS) statement included nutritional status assessment and dietary intervention as essential components of comprehensive management in subjects with COPD. According to the GLIM algorithm, the first step in diagnosing malnutrition is risk screening with a validated tool. Our study aimed to assess the diagnostic performance of three screening tools (MNA-SF, MUST, and NRS-2002) used in the GLIM algorithm in older patients with COPD. Additionally, we evaluated the agreement between these tools in the diagnostics of malnutrition. We performed a cross-sectional study of 124 patients aged at least 60 years with COPD diagnosed, based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). We assessed the participants’ nutritional status with the three examined screening questionnaires (MNA-SF, MUST, and NRS-2002). Regardless of their results, we performed full malnutrition diagnostics following the GLIM algorithm in all subjects. The proportion of malnourished participants varied from 18.5% for the MUST questionnaire to 27.4% for the MNA-SF and 57.3% for the NRS-2002 score. Based on the GLIM criteria, malnutrition was diagnosed in 48 subjects (38.7%). All assessed questionnaires had an unsatisfactory sensitivity against the GLIM criteria for malnutrition: it was fair (58.3%) for the MNA-SF tool and poor for the MUST and NRS-2002 questionnaires (47.9% for both questionnaires). Considering the negative health consequences of malnutrition, a full diagnostic including GLIM etiologic and phenotypic criteria should be recommended in all elderly patients with COPD, regardless of the screening results.

WOCN Society, AUA, and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Ostomy Surgery.

ORIGINATED BY: Wound, Ostomy, and Continence Nurses Society™ (WOCN®) Stoma Site Marking Task Force in collaboration with the American Society of Colon and Rectal Surgeons (ASCRS) in 2007. UPDATED/REVISED BY: WOCN Society's Stoma Site Marking Task Force in collaboration with the ASCRS and the American Urological Association (AUA) in 2015 and 2021. TASK FORCE CHAIR Ginger Salvadalena, PhD, RN, CWOCN, Hollister Incorporated, Libertyville, Illinois. [email protected] TASK FORCE MEMBERS Christine Baker, MSN, APRN, CWOCN University of Chicago Comer Children's Hospital, Chicago, Illinois Carole Bauer, MSN, RN, ANP-BC, OCN, CWOCN Beaumont Health System, Troy, Michigan Janice Colwell, APRN, CWOCN, FAAN, University of Chicago Medicine, Chicago, Illinois Daniel L. Feingold, MD, FACS, FASCRS, Rutgers University, New Brunswick, New Jersey Vashti Livingston, MS, RN, CWOCN, DAPWCA, Memorial Sloan Kettering Cancer Center, New York City, New York Michael F. McGee, MD, FACS, FASCRS, Feinberg School of Medicine, Northwestern University, Chicago, Illinois Leanne Richbourg, MSN, APRN-BC, CWON-AP, CCCN, GCNS-BC Duke University Hospital, Durham, North Carolina Elizabeth Savage, MSN, RN, ACNS-BC, CWON, IIWCC-NYU NYU Langone Health, New York City, New York Gary D. Steinberg, MD Perlmutter Cancer Center, NYU Langone Health, New York City, New York WOCN SOCIETY SUPPORT Anna Shnayder Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (JWOCNOnline.com).