Unique Clinical Considerations Research Articles

Clinical Features and Long-Term Outcomes of a Pan-Canadian Cohort of Adolescents and Young Adults with Myeloproliferative Neoplasms: A Canadian MPN Group Study.

Myeloproliferative neoplasms (MPNs) are a group of chronic hematologic malignancies that lead to morbidity and early mortality due to thrombotic complications and progression to acute leukemia. Clinical and mutational risk factors have been demonstrated to predict outcomes in patients with MPNs and are used commonly to guide therapeutic decisions, including allogenic stem cell transplant, in myelofibrosis. Adolescents and young adults (AYA, age ≤45 years) comprise less than 10% of all MPN patients and have unique clinical and therapeutic considerations. The prevalence and clinical impact of somatic mutations implicated in myeloid disease has not been extensively examined in this population. We conducted a retrospective review of patients evaluated at eight Canadian centers for MPN patients diagnosed at ≤45 years of age. In total, 609 patients were included in the study, with median overall survival of 36.8 years. Diagnosis of prefibrotic or overt PMF is associated with the lowest OS and highest risk of AP/BP transformation. Thrombotic complications (24%), including splanchnic circulation thrombosis (9%), were frequent in the cohort. Mutations in addition to those in JAK2/MPL/CALR are uncommon in the initial disease phase in our AYA population (12%); but our data indicate they may be predictive of transformation to post-ET/PV myelofibrosis.

The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology.

The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning. Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified. There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux. Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

SAT313 Therapeutic Dosing Of Steroids In Patients On Mitotane

Abstract Disclosure: C. Pham: None. S.M. Cannon: None. J.S. Lopresti: None. Introduction: Mitotane is a known inhibitor of steroidogenesis with some patients requiring supraphysiologic dosing for steroid replacement. Clinical Case: A 43-year-old female with a history of adrenal cell carcinoma (ACC) on multiagent chemotherapy and mitotane presents with a pruritic rash. Three weeks prior, she had received her first dose of pembrolizumab. Her other home medications included mitotane 500mg QID and hydrocortisone 180mg (40mg-40mg-30mg -20mg QID). Labs on admission were notable for an ALT of 458 (ref 10-35 U/L), AST of 272 (ref 10-35 U/L), and normal alkaline phosphatase and bilirubin with otherwise normal electrolytes. Due to the temporal relation of her transaminitis and rash to recent pembrolizumab infusion with an otherwise negative work-up, the patient was diagnosed with immune-mediated liver injury from checkpoint inhibitors (ILICI). Per National Comprehensive Cancer Network (NCCN) guidelines, high dose methylprednisolone was initiated (1mg/kg) equivalent to approximately 525 mg hydrocortisone total daily. Over five days, the patient’s transaminases continued to rise and methylprednisolone was increased to 3mg/kg/day to account for the known effects of mitotane on steroid metabolism. The patient’s rash subsequently resolved followed by slow improvement of her transaminitis with steroid taper. Mitotane level obtained one week after discontinuation of mitotane was noted to be 21mcg/mL demonstrating persistent therapeutic levels (14-20mcg/mL). Mitotane has a profound inhibitory effect on steroidogenesis through multiple mechanisms, inhibiting glucocorticoid production by the adrenal and increasing hepatic disposal of glucocorticoids leading to subtherapeutic doses1, Furthermore, mitotane can persist in the body for a prolonged period, with a half-life between 18-154 days. As such, patients who develop adrenal insufficiency on mitotane typically require higher doses for physiologic replacement up to three times standard physiologic dose1. In this case, only when the patient’s methylprednisolone dose was tripled did her ILICI begin to improve. Conclusion: This is one of the first cases to describe ILICI in a patient with ACC highlighting unique clinical considerations in management. Higher doses of corticosteroids may be required to overcome the effects of mitotane on steroid metabolism in patients with adverse effects from immune checkpoint inhibitor therapy. 1.)Puglisi, S., Calabrese, A., Basile, V., Pia, A., Reimondo, G., Perotti, P., & Terzolo, M. (2020). New perspectives for mitotane treatment of adrenocortical carcinoma. Best Practice & Research Clinical Endocrinology & Metabolism, 34(3), 101415. https://doi.org/10.1016/j.beem.2020.101415 Presentation: Saturday, June 17, 2023

Pulmonary hypertension in hereditary hemorrhagic telangiectasia: A clinical review.

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disorder characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectasias, and solid organ arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is an increasingly recognized complication in patients with HHT, most often precipitated by high-output heart failure in the presence of hepatic AVMs as well as pulmonary arterial hypertension in the form of a proliferative vasculopathy. The presence of PH in patients with HHT is associated with significant elevations in rates of morbidity and mortality. Additionally, there is growing recognition of a thromboembolic propensity in this population that increases the risk of chronic thromboembolic PH, posing unique clinical considerations regarding the use of anticoagulation. Patients with HHT are also at risk of PH due to disorders commonly seen in the general population, including left-sided heart and lung disease. The etiology of PH in HHT is multifaceted and complex; the diagnostic approach and treatment strategies must consider the underlying pathophysiology of HHT. This comprehensive review summarizes current knowledge of PH in HHT, detailing the pathogenesis of known etiologies, diagnostic evaluation, and suggested treatment modalities as well as emerging therapies that may be of future interest.

The Use of Electroconvulsive Therapy on Death Row.

Despite high rates of mental illness among incarcerated people in the United States, use of electroconvulsive therapy (ECT) remains limited in jails and prisons. There are some published guidelines regarding the provision of mental health care, including ECT, in U.S. correctional facilities, but little attention has been paid to the use of ECT for individuals sentenced to death. This article examines ECT within the context of the death penalty, including court consideration of ECT in capital cases and historic uses of ECT to facilitate execution of people on death row. Given the unique clinical, legal, and ethics considerations in the use of ECT for people sentenced to death, the authors call for greater attention to these practices and propose general guidelines regarding the use of ECT in this population.

Best Practices and Considerations for Clinical Pharmacology and Pharmacometric Aspects for Optimal Development of CAR-T and TCR-T Cell Therapies: An Industry Perspective.

With the promise of a potentially "single dose curative" paradigm, CAR-T cell therapies have brought a paradigm shift in the treatment and management of hematological malignancies. Both CAR-T and TCR-T cell therapies have also made great progress toward the successful treatment of solid tumor indications. The field is rapidly evolving with recent advancements including the clinical development of "off-the-shelf" allogeneic CAR-T therapies that can overcome the long and difficult "vein-to-vein" wait time seen with autologous CAR-T therapies. There are unique clinical pharmacology, pharmacometric, bioanalytical, and immunogenicity considerations and challenges in the development of these CAR-T and TCR-T cell therapies. Hence, to help accelerate the development of these life-saving therapies for the patients with cancer, experts in this field came together under the umbrella of International Consortium for Innovation and Quality in Pharmaceutical Development (IQ) to form a joint working group between the Clinical Pharmacology Leadership Group (CPLG) and the Translational and ADME Sciences Leadership Group (TALG). In this white paper, we present the IQ consortium perspective on the best practices and considerations for clinical pharmacology and pharmacometric aspects toward the optimal development of CAR-T and TCR-T cell therapies.

Oral Antineoplastics in Acute Myeloid Leukemia: A Comprehensive Review.

AML is a biologically and clinically heterogeneous disease that is associated with poor overall long-term survival. The expanding knowledge of genomic landscape in AML as well as advancements in molecular and chemical biology over the pathway in AML. After 40 years of stagnancy, the recent approval of numerous novel oral anti-leukemic agents for the treatment of AML has changed both the armamentarium of medications and treatment paradigms. These agents have unique clinical considerations in terms of administration, adverse effects, and monitoring parameters which may differ from clinician's historical expectations. Understanding the data, indication and clinical considerations for such novel oral anti-leukemic agents is paramount for clinicians caring patients with AML.

Implementation of a standardized process for outpatient COVID-19 treatments at a Veterans Affairs medical center

BackgroundThe initial availability and distribution of new therapeutic options for outpatients with mild to moderate coronavirus disease 2019 (COVID-19) was limited by insufficient supply, challenges related to administration and dispensing, and unique clinical considerations of each medication. ObjectiveThis study aimed to describe the implementation of a standardized process for prescribing, dispensing, and administering medications for outpatients with mild to moderate COVID-19 infection. MethodsPatients evaluated in outpatient clinics, the emergency department, or urgent care locations who tested positive for COVID-19 with mild to moderate symptoms were candidates for outpatient management. An interdisciplinary team involving physicians from primary care and the emergency department, pharmacists, and nursing developed a standardized note template to gather relevant information before initiating outpatient COVID-19 treatment. Pharmacists reviewed the patients’ eligibility for treatment and discussed the available options with providers to facilitate the timely provision of appropriate treatment. ResultsA total of 134 outpatients were evaluated for COVID-19 treatment from January 10, 2022, to March 10, 2022. Following a retrospective chart review, it was determined that a medication was administered or dispensed to 80 of those patients. ConclusionCollaboration as an interdisciplinary team allowed for the efficient development of a systematic process in which outpatients with COVID-19 could be evaluated, prescribed, and administered appropriate medications to reduce their risk of disease progression.

Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

Background:Distal clavicle fractures account for a significant proportion of clavicle fractures in the pediatric and adolescent age groups, but clinical decision making to date has largely been informed by adult studies. However, surgical treatment in this younger population may have unique technical and clinical considerations, due to distinct fracture patterns, increased healing potential and periosteal thickness.Hypothesis/Purpose:The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes.Methods:A retrospective review was performed of all operatively-treated clavicle fractures extending to the coracoclavicular ligaments or lateral, between 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic characteristics, surgical fixation construct, time to radiographic healing, return to sports, and complications were analyzed.Results:Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), with type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of removal of implants was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Patient age was comparable in suture and plate cohorts (12.9 vs. 13.5, p = 0.19). Total complication rate, including unplanned removal of implants, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014).Conclusion:The vast majority of distal clavicle fractures treated operatively in pediatric and adolescent athletes are posteriorly displaced fractures. When chosen in the appropriate patient, suture-only constructs can lead to similar healing and faster return to sports compared to plate-based constructs, with greatly reduced need for removal of hardware. These data provide a foundation for future comparative research further elucidating precise surgical indications and optimal treatment approaches.Table 1.Fixation Methods for Distal Clavicle Fractures

Clinical Features and Long-Term Outcomes in a Molecularly-Annotated Cohort of Adolescents and Young Adults with Myeloproliferative Neoplasms

▪Background:Myeloproliferative neoplasms (MPNs) are a heterogenous group of chronic hematologic malignancies that lead to morbidity and early mortality primarily due to thrombotic complications and progression to acute leukemia. Clinical and mutational risk factors have been demonstrated to predict outcomes in patients with MPNs, and are used commonly to guide therapeutic decisions (including allogenic stem cell transplant) in myelofibrosis. Adolescents and young adults (AYA, age ≤45 years) comprise less than 10% of all MPN patients, and have unique clinical and therapeutic considerations. The prevalence and clinical impact of somatic mutations implicated in myeloid disease has not been extensively reported in this population.Methods:We conducted a retrospective review of patients evaluated at the Princess Margaret Cancer Centre (PMCC) between 1/1/2000 and 30/6/2021 for an MPN diagnosed at ≤45 years of age. Diagnoses were defined per 2016 WHO criteria using available information on chart review. Targeted mutational profiling of clinically relevant myeloid genes (49- or 54-gene panel) was previously performed on peripheral blood or bone marrow samples. Pathologic variants in ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1 Q157 were categorized as high-molecular risk (HMR). Categorical variables were compared using the χ2 test. Kaplan-Meier method was used for overall survival (OS) and time-to-event analysis; and were compared using the log-rank test.Results:A total of 237 patients with initial MPN diagnosis ≤45 years were included in the study, with median age of diagnosis 35 (range 12-45) years. MPN diagnosis included: essential thrombocythemia (ET, n=100), polycythemia vera (PV, n=75), prefibrotic primary myelofibrosis (Pre-PMF, N=29), overt PMF (n=24), and MPN-unclassifiable (MPN-u, n=9). Driver mutation data, available for 230 (97%) patients, were: JAK2 in 134 (56%), CALR in 70 (30%), MPL in 6 (2.5%), and triple-negative in 20 (8.4%) patients.Median follow-up was 10.2 (range 0.3-45.3) years, and median OS was the shortest for those with overt PMF (21.4 years, P=0.001) compared with PV (33.0 years), ET (31.4 years), and Pre-PMF (median OS not reached). No difference in OS based on driver mutation was observed. Progression to a secondary MF (SMF) was observed in 84 patients (47% of ET, 48% of PV) after median time of 19.7 years; with no difference in time to progression due to diagnosis or driver mutation. Progression to an accelerated/blast phase (AP/BP) was observed in 26 patients and was associated with diagnosis of overt PMF (P=0.04) and triple-negative for driver mutation (P=0.04).Thrombosis was observed in 61 (26%) patients: 34 (14%) patients with thrombosis prior to/concurrent with MPN diagnosis, and 34 (14%) patients with thrombosis after diagnosis. Splanchnic circulation thrombosis was found in 29 (12%) patients and 12 (5%) patients had Budd-Chiari syndrome. Portal hypertension was reported in 37 (16%) patients. CALR type-2 mutations were associated with the lowest frequency of total thrombosis (4%, P=0.02); while JAK2 had the greatest frequency of splanchnic circulation clot (17%, P=0.03).Targeted mutational profile was obtained for 202 (85%) of patients: 135 samples obtained during the initial disease phase, 51 samples during a secondary MF phase, and 16 during an AP/BP. For the patients with mutation analysis in the initial phase, 24 pathogenic mutations were observed in 16 (12%) patients including 3 patients with HMR mutations. The most frequent mutations observed were in TET2 (n=12, 9%), and ASXL1 (n=3, 2%). Presence of additional mutations did not predict OS, AP/BP progression, or thrombosis; though TET2 mutation was associated with shorter time to SMF progression in patients with PV/ET (P=0.002). Additional mutations were found in 34/51 (67%) patients in whom mutational analysis was first performed during a SMF disease phase.Conclusions:A long-term follow-up study of a large molecularly annotated cohort of AYA patients with MPN demonstrated excellent long-term survival for these patients. Overt PMF is associated with the lower OS and higher risk of AP/BP transformation. Thrombotic complications including splanchnic circulation thrombosis are frequent complications. Mutations aside from JAK2/MPL/CALR are uncommon and HMR mutations rare in the initial phase of MPN in the AYA population. [Display omitted] DisclosuresGupta: Roche: Consultancy; Pfizer: Consultancy; AbbVie: Consultancy, Honoraria; BMS-Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sierra Oncology: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Incyte: Honoraria, Research Funding; Constellation Pharma: Consultancy, Honoraria. Maze: Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene-BMS: Honoraria; Takeda: Research Funding; PharmaEssentia: Research Funding; Kronos Bio: Research Funding.

NCMP-18. FIXED PTOSIS AS A SYMPTOM OF MYOSITIS SECONDARY TO CHECKPOINT INHIBITION

Abstract BACKGROUND A growing number of patients with cancer receive checkpoint inhibitor (CPI) based immunotherapy. Peripheral nervous system toxicities including myositis, myasthenia gravis and inflammatory neuropathy are distinct from their non immunotherapy-related equivalents, with unique clinical presentations and therapeutic considerations. METHODS Patients with CPI myositis and non-fatigable ptosis were identified, and clinical data was retrospectively extracted from the electronic medical record in compliance with MD Anderson Cancer Center Institutional Review Board guidelines. RESULTS 14 patients were identified. Average maximum creatine kinase (CK) was 3571 U/L (range 20-19,794). 9 patients had electromyography and nerve conduction studies documented in our system; all had electrodiagnostic evidence of myopathy and two had evidence of concomitant myasthenia gravis by electrodecrement. Two muscle biopsies revealed myositis with inflammatory T-cell infiltrate. 6 had positive anti-striated muscle antibody titers, 9/14 had concomitant myocarditis, 2 had hepatitis, 2 had pneumonitis and 1 had thyroiditis. All received high dose steroids, 11 received plasma exchange, 4 received rituximab, 4 received tacrolimus and 2 received tocilizumab. 7/14 patients died (50%). Mean time from initial neurology consultation for symptoms to death was 6.46 months (range .3-24). 5 patients had documented clinical stabilization or mild improvement on post-discharge follow-up. CONCLUSIONS While ptosis in patients receiving CPI can initially suggest myasthenia gravis, in patients with rapid onset and ultimately fixed deficits there should be a high index of suspicion for immunotherapy related restricted localized myositis. Myositis may coincide with other toxicities, such as myocarditis and pneumonitis, and can be fatal despite aggressive treatment. Deficits persist on post-discharge follow-up, suggesting protracted recovery for patients who survive.

Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU.

The goal of the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was to define indications and appropriate practices for peripherally inserted central catheters (PICC) use; however, MAGIC recommendations virtually reduced the use of PICC in hospital settings, including critical care. The aim of this review is to present an assessment of the MAGIC guidelines, considering contemporary evidence to date. The validity of the MAGIC recommendations and their applicability to current practice are called into question given important concerns with the methodology for their development (e.g. high volume of clinical scenarios for evaluation) and the supporting evidence used. There is a considerable amount of contemporary evidence not considered in MAGIC that reports on evolving practices, techniques, and technologies targeted to reduce complications associated with central venous access devices (CVADs). Recent evidence dictates that CVADs are necessary in the intensive care unit (ICU), and that PICCs are a safe, reliable, and appropriate type of central lines, which cannot be replaced in several ICU situations. In light of evolving evidence and practice, as well as the methodological concerns identified, the MAGIC guidelines should be revisited. It is also recommended to create a clinical assessment tool that identifies potential uses of specific CVADs, based on patient needs. The choice of the CVAD should be based on unique clinical considerations and current scientific evidence, not on fears informed by antiquated data.

359 Tailoring of Cognitive Behavior Therapy for Insomnia for Patients with Kidney Failure Undergoing Hemodialysis: The SLEEP-HD Study

Abstract Introduction Patients with kidney failure treated with hemodialysis (HD) frequently report insomnia symptoms. Cognitive-behavior therapy for insomnia (CBT-I) is a first line treatment for insomnia but there are unique issues surrounding kidney failure and HD that impact patients’ ability to access CBT-I and follow standard treatment recommendations. This presentation describes CBT-I protocol modifications made to address these issues as part of an ongoing multi-center clinical trial testing the efficacy of telehealth CBT-I compared to trazodone or medication placebo control. Methods CBT-I protocol modifications were made prior to starting the SLEEP-HD randomized trial based upon unique clinical considerations for HD patients, e.g., irregular sleep-wake scheduling that HD treatment demands, and napping during HD sessions or afterwards due to post-HD treatment fatigue. Participants in the SLEEP-HD study are undergoing thrice-weekly maintenance hemodialysis for >3 months and have baseline Insomnia Severity Index scores >10 with sleep disturbances >3 nights/week for >3 months. Participants randomized into the modified CBT-I protocol receive six weekly sessions, delivered by trained CBT-I therapists (1 MSW, 1 PhD) face-to-face via a HIPPA-compliant video telehealth platform. Participants keep a daily sleep diary throughout the CBT-I treatment period. Results To date, 91 patients (mean age=56.5 years [SD=14.7], 48.4% female) recruited from community-based dialysis facilities in Seattle and Albuquerque have been randomized into the SLEEP-HD study (n=31 CBT-I). Forty-eight percent of CBT-I clients have chosen to conduct their telehealth sessions during dialysis with the remainder choosing a different location. CBT-I adaptations include therapists developing weekly bed restriction recommendations based on non-dialysis treatment days; allowing shifts in dialysis day “bed window” scheduling for patients with very early or very late dialysis schedules so long as a consistent total time in bed in maintained; and including napping during early/late dialysis sessions as part of the allowable bed window duration. Treatment modifications were also designed to accommodate the diverse socioeconomic circumstances of dialysis patients, including housing instability, which can impact adherence to some standard stimulus control and bed restriction CBT-I recommendations. Conclusion It is feasible to deliver CBT-I via telehealth to HD patients but modifications to standard protocols are required. Support (if any) This work was supported by PHS grant 5R01AG053221.

Cancer and Embolic Stroke of Undetermined Source.

One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.

Management of Portal and Mesenteric Venous Thrombosis

AbstractPortal vein thrombosis is a rare condition seen in the general population, though is more prevalent in certain populations with thrombophilia as well as in patients with cirrhosis. Because morbidity and mortality can be significant with portal vein thrombosis, diagnosis and appropriate management are crucial. In noncirrhotic patients, untreated portal vein thrombosis can result in mesenteric ischemia and complications of portal hypertension. In cirrhosis, portal vein thrombosis is often incidentally found on routine screening imaging, and the treatment outside of transplant candidates is more controversial. In this review, we will outline risk factors for portal vein thrombosis, discuss indications for treatment, and evaluate both pharmacological and endovascular treatment options, highlighting unique clinical considerations dependent on the presence or absence of cirrhosis.

Weathering the Storm: Managing Older Adults With Breast Cancer Amid COVID-19 and Beyond.

Caring for older patients with breast cancer presents unique clinical considerations because of preexisting and competing comorbidity, the potential for treatment-related toxicity, and the consequent impact on functional status. In the context of the COVID-19 pandemic, treatment decision making for older patients is especially challenging and encourages us to refocus our treatment priorities. While we work to avoid treatment delays and maintain therapeutic benefit, we also need to minimize the risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposures, myelosuppression, general chemotherapy toxicity, and functional decline. Herein, we propose multidisciplinary care considerations for the aging patient with breast cancer, with the goal to promote a team-based, multidisciplinary treatment approach during the COVID-19 pandemic and beyond. These considerations remain relevant as we navigate the “new normal” for the approximately 30% of breast cancer patients aged 70 years and older who are diagnosed in the United States annually and for the thousands of older patients living with recurrent and/or metastatic disease.

AGA Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic

In early December 2019, a series of pneumonia cases was reported in Wuhan, China resulting from a novel coronavirus infection designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses as of January 7, 2020, and named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) as of February 11, 2020.1Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (27656) Google Scholar SARS-CoV-2 is a novel enveloped RNA betacoronavirus, that represents the seventh member of the coronavirus family, which includes 4 common human coronaviruses (229E, NL63, OC43, and HKU1) and 2 other strains, including SARS-CoV and Middle East respiratory syndrome–related coronavirus (MERS-CoV).2Lu R. Zhao X. 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Ren H.G. et al.Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional multicenter study.Am J Gastroenterol. 2020; 115: 766-773Crossref PubMed Scopus (1009) Google Scholar Of note, the first reported case of COVID-19 in the United States presented with a 2-day history of dry cough, fatigue, nausea and vomiting, followed by diarrhea on hospital day 2, with subsequent confirmation of SARS-CoV-2 in a stool specimen.12Holshue M.L. DeBolt C. Lindquist S. et al.First case of 2019 novel coronavirus in the United States.N Engl J Med. 2020; 382: 929-936Crossref PubMed Scopus (3727) Google Scholar Subsequent studies have confirmed positive SARS-CoV-2 cases using real-time reverse transcriptase polymerase chain reaction in stool specimens of patients with COVID-19 infection,13Gu J. Han B. Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission.Gastroenterology. 2020; 158: 1518-1519Abstract Full Text Full Text PDF PubMed Scopus (899) Google Scholar,14Xiao F. Tang M. Zheng X. et al.Evidence for gastrointestinal infection of SARS-CoV-2.Gastroenterology. 2020; 158: 1831-1833.e3Abstract Full Text Full Text PDF PubMed Scopus (1697) Google Scholar with immunofluorescence data demonstrating that angiotensin converting enzyme II is abundantly expressed in gastric, duodenal, and rectal epithelia, thereby implicating angiotensin converting enzyme II as a potential viral receptor for entry to uninfected host cells, and raising the possibility for fecal–oral transmission, although it is unclear whether the viral concentration in the stool is sufficient for transmission.14Xiao F. Tang M. Zheng X. et al.Evidence for gastrointestinal infection of SARS-CoV-2.Gastroenterology. 2020; 158: 1831-1833.e3Abstract Full Text Full Text PDF PubMed Scopus (1697) Google Scholar Furthermore, angiotensin converting enzyme II receptors may additionally be expressed in hepatic cholangiocytes, potentially permitting direct infection of hepatic cells, and early cohort studies of COVID-19 have revealed that abnormal liver enzymes are commonly observed.15Zhang C. Shi L. Wang F.S. Liver injury in COVID-19: management and challenges.Lancet Gastroenterol Hepatol. 2020; 5: 428-430Abstract Full Text Full Text PDF PubMed Scopus (1124) Google Scholar Multiple questions have been raised regarding the GI and liver manifestations of COVID-19 infection and the implications of SARS-CoV-2 infection on GI endoscopy. A joint society statement by the American Gastroenterological Association (AGA), the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy on March 15, 2020 highlighted the potential for SARS-CoV-2 transmission through droplets, an established mode of transmission, and possibly fecal shedding, and the associated risk for transmission to endoscopy personnel during GI endoscopy procedures.16American Gastroenterological AssociationJoint GI Society Message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers.https://www.gastro.org/press-release/joint-gi-society-message-covid-19-clinical-insights-for-our-community-of-gastroenterologists-and-gastroenterology-care-providersDate accessed: March 21, 2020Google Scholar In this document, we seek to summarize the data and provide evidence-based recommendation and clinical guidance. This rapid recommendation document was commissioned and approved by the AGA Governing Board to provide timely, methodologically rigorous guidance on a topic of high clinical importance to AGA members in the context of an emerging pandemic. It was published online on April 1st, 2020 and has an expiration date of six months. This rapid guideline was developed by gastroenterologists and guideline methodologists from the AGA Clinical Guidelines Committee and Clinical Practice Updates Committee, who were assembled on March 15, 2020, in collaboration with the AGA Governing Board, to define time-urgent clinical questions, perform systematic reviews, develop summary evidence profiles, and formulate rapid recommendations. Additionally, to ensure representation of the public/consumer, this guideline was reviewed by 2 COVID-19–positive patients. Panel members disclosed all potential conflicts of interest according to the AGA Institute policy. The target audience of these guidelines includes gastroenterologists, hepatologists, advanced practice providers, nurses, and other health care professionals involved in GI endoscopy. Patients, the public, as well as policy-makers may also benefit from these guidelines. These guidelines are not intended to impose a standard of care for individual institutions, health care systems, or countries. They provide the basis for rational informed decisions for patients, parents, clinicians, and other health care professionals in the setting of a pandemic. This rapid review and guideline was developed using a process described elsewhere.17American Gastroenterological AssociationAGA Institute clinical practice guideline development process.http://www.gastro.org/guidelines-policiesGoogle Scholar Briefly, the AGA process for developing clinical practice guidelines uses the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and best practices as outlined by the National Academy of Medicine (formerly the Institute of Medicine) and Guidelines International Network.18Graham R. Mancher M. Miller et al.Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines.in: Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Crossref Google Scholar With the help of an information specialist, we electronically searched OVID Medline to identify all relevant English studies from inception to March 23, 2020 (including randomized controlled trials, observational studies, and cases series) related to COVID-19 using the newly developed Medical Subject Headings term. Additionally, we looked for indirect evidence related to SARS, MERS, Ebola, and influenza using the systematic review filter. The reference lists of relevant articles were scanned for additional studies. See Supplementary Figure 1 for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram and Supplementary Figure 2 for the search strategy. One reviewer (S.S.) screened titles and abstracts and retrieved relevant articles for each question. A second reviewer (O.A., P.D., J.F., or S.M.S.) confirmed the selected studies and, in certain circumstances, conducted additional Google scholar searches to identify relevant articles. The WHO and CDC websites were also reviewed for relevant articles. Pairs of reviewers extracted the data from the primary studies identified from existing systematic review documents, reviewed the judgments for risk of bias, and conducted specific subgroup analyses using Review Manager software, version 5.3 (The Cochrane Collaboration, Copenhagen, 2014). Evidence profiles were used to display the summary estimates as well as the judgments about the overall certainty of the body of evidence for each clinical question across outcomes. Within the GRADE framework, evidence from randomized controlled trials starts as high-certainty evidence and observational studies start as low-certainty evidence, but can be rated down for the following reasons: risk of bias, inconsistency, indirectness, imprecision, and publication bias. Additionally, evidence from well-conducted observational studies starts as low-certainty evidence but can be rated up for large effects or dose-response. Judgments about the certainty were determined via videoconference discussion to achieve consensus. The certainty of evidence was categorized into 4 levels ranging from very low to high (Table 1). For each question, an overall judgment of certainty of evidence was made based on critical outcomes.Table 1Interpretation of the Certainty in Evidence of Effects Using the Grading of Recommendations Assessment, Development and Evaluation FrameworkCertainty levelDescriptionHighWe are very confident that the true effect lies close to that of the estimate of the effect.ModerateWe are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.LowOur confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.Very LowWe have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect Open table in a new tab During online communications and conference calls, the Guideline Panel developed several recommendations based on the following elements of the GRADE evidence to decision framework: certainty of the evidence, balance of benefits and harms, assumptions about values and preferences, and resource implications. For each guideline statement, the strength of the recommendation and the certainty of evidence to support the recommendation are provided. The phrase “the AGA recommends” is used for strong recommendations, and “the AGA suggests” is used for conditional recommendations (Table 2). The Panel deliberated about the impact of resource limitations on the feasibility and implementation of these recommendations. Therefore, the panel’s main recommendations assume an ideal scenario where there are no resource constraints. However, for settings in which resources require rationing, additional guidance is also provided.Table 2Interpretation of Strong and Conditional RecommendationsaStrong recommendations are indicated by statements that lead with “we recommend” and conditional recommendations are indicated by statements that lead with “we suggest.” Using the Grading of Recommendations Assessment, Development and Evaluation FrameworkImplicationsStrong recommendationConditional recommendationFor patientsMost individuals in this situation would want the recommended course of action and only a small proportion would not.The majority of individuals in this situation would want the suggested course of action, but many would not.For cliniciansMost individuals should receive the intervention. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.Different choices will be appropriate for individual patients consistent with his or her values and preferences. Use shared decision-making. Decision aids may be useful in helping patients make decisions consistent with their individual risks, values, and preferences.For policy-makersThe recommendation can be adapted as policy or performance measure in most situationsPolicy-making will require substantial debate and involvement of various stakeholders. Performance measures should assess whether decision-making is appropriate.a Strong recommendations are indicated by statements that lead with “we recommend” and conditional recommendations are indicated by statements that lead with “we suggest.” Open table in a new tab Low confidence in effect estimates can rarely be tied to strong recommendations. Within the GRADE framework, there are 5 paradigmatic situations in which strong recommendations may be warranted despite low or very low certainty of evidence.19Schünemann H, Brożek J, Guyatt G, et al, eds. GRADE handbook for grading quality of evidence and strength of recommendations. The GRADE Working Group. Available at: guidelinedevelopment.org/handbook. Published October 2013. Accessed March 27, 2020.Google Scholar These situations can be conceptualized as those in which there are clear benefits in the setting of a life-threatening situation, clear catastrophic harms, or equivalence between 2 interventions with clear harms for 1 of the alternatives. The Panel invoked these paradigmatic situations in developing these recommendations. Recommendations in this document may not be valid in the near or immediate future. We will conduct periodic reviews of the literature and monitor the evidence to determine whether recommendations require modification. Based on the rapidly evolving nature of this pandemic, this guideline will likely need to be updated within the next few months. Guan et al20Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (17406) Google Scholar published the largest cohort study to date, which included 1099 hospitalized patients from China with confirmed COVID-19 infection. They reported that 5.0% of COVID-19–infected patients had nausea or vomiting and 3.8% had diarrhea. Across the different published cohort studies, 2.0%–13.8% of patients had diarrhea, 1.0%–10.1% had nausea or vomiting, and 1 study reported the presence of abdominal pain in 2.2% of patients. The cohorts ranged in size from 13 to 191 patients, primarily from Hubei Province, China.1Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (27656) Google Scholar,21Chen N. Zhau M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507Abstract Full Text Full Text PDF PubMed Scopus (12323) Google Scholar, 22Chen L. Liu H.G. Liu W. et al.Analysis of clinical features of 29 patients with 2019 novel coronavirus pneumonia.Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43: 203-208PubMed Google Scholar, 23Chang D. Lin M. Wei L. et al.Epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside Wuhan, China.JAMA. 2020; 323: 1092-1093Crossref PubMed Scopus (435) Google Scholar, 24Liu K. Fang Y.-Y. Deng Y. et al.Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province.Chin Med J (Engl). 2020; 133: 1025-1031Crossref PubMed Scopus (875) Google Scholar, 25Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China.JAMA. 2020; 323: 1061-1069Crossref PubMed Scopus (13910) Google Scholar, 26Young B.E. Ong S.W.X. Kalimuddin S. et al.Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore.JAMA. 2020; 323: 1488-1494Crossref PubMed Scopus (1331) Google Scholar, 27Zhou F. Ting Yu Ronghui D. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15960) Google Scholar Most recently, Pan et al11Pan L. Mu M. Ren H.G. et al.Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional multicenter study.Am J Gastroenterol. 2020; 115: 766-773Crossref PubMed Scopus (1009) Google Scholar reported in a cross-sectional study of 204 COVID-19–positive patients from 3 hospitals in Hubei Province, that 29 patients (14.3%) developed diarrhea, 8 patients (3.9%) experienced vomiting, and 4 patients (2.0%) had abdominal pain. A recent meta-analysis of 4243 patients from China suggested that approximately 17.6% of patients had any GI symptom, including 9.2% with pain, 12.5% with diarrhea, and 10.2% with nausea/vomiting.28Cheung K.S. Hung I.F.N. Chan P.P.Y. et al.Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong Cohort: systematic review and meta-analysis.Gastroenterology. 2020; 159: 81-95Abstract Full Text Full Text PDF PubMed Scopus (928) Google Scholar A concern with many of the published studies is the possible duplicate inclusion of the patients across reports, thereby limiting valid performance of pooled estimates in a meta-analysis.29Bauchner H, Golub RM, Zylke J. Editorial concern: possible reporting of the same patients with COVID-19 in different reports [published online ahead of print March 16, 2020]. JAMA https://doi.org/10.1001/jama.2020.3980.Google Scholar There is evidence for the presence of SARS-CoV-2 RNA in stool specimens independent of the presence of diarrhea. Some studies showed that stool continued to be positive for SARS-CoV-2 RNA even after respiratory samples became negative.12Holshue M.L. DeBolt C. Lindquist S. et al.First case of 2019 novel coronavirus in the United States.N Engl J Med. 2020; 382: 929-936Crossref PubMed Scopus (3727) Google Scholar,15Zhang C. Shi L. Wang F.S. Liver injury in COVID-19: management and challenges.Lancet Gastroenterol Hepatol. 2020; 5: 428-430Abstract Full Text Full Text PDF PubMed Scopus (1124) Google Scholar,21Chen N. Zhau M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507Abstract Full Text Full Text PDF PubMed Scopus (12323) Google Scholar,30Wang W. Xu Y. Gao R. et al.Detection of SARS-CoV-2 in different types of clinical specimens.JAMA. 2020; 323: 1843-1844PubMed Google Scholar, 31Yan P. Zhang D. Yang P. et al.Viral load of SARS-CoV-2 in clinical samples.Lancet Infect Dis. 2020; 20: 411-412Abstract Full Text Full Text PDF PubMed Scopus (1019) Google Scholar, 32Chen L. Lou J. Bai Y. COVID-19 disease with positive fecal and negative pharyngeal and sputum viral tests.Am J Gastroenterol. 2020; 115: 790Crossref PubMed Scopus (87) Google Scholar, 33Zhang W. Du R. Li B. et al.Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes.Emerg Microbes Infect. 2020; 9: 386-389Crossref PubMed Scopus (1182) Google Scholar Chen et al32Chen L. Lou J. Bai Y. COVID-19 disease with positive fecal and negative pharyngeal and sputum viral tests.Am J Gastroenterol. 2020; 115: 790Crossref PubMed Scopus (87) Google Scholar reported a case of COVID-19 based on compatible symptoms and lung imaging in a patient with positive stool real-time reverse transcriptase polymerase chain reaction for SARS-CoV-2 RNA, but negative pharyngeal swabs and sputum samples. Furthermore, Wang et al30Wang W. Xu Y. Gao R. et al.Detection of SARS-CoV-2 in different types of clinical specimens.JAMA. 2020; 323: 1843-1844PubMed Google Scholar reported confirmation of SARS-CoV-2–positive fecal samples in 2 patients without diarrhea. Liver injury is estimated to occur in up to 20%–30% of patients at the time of diagnosis with SARS-CoV-2 infection.14Xiao F. Tang M. Zheng X. et al.Evidence for gastrointestinal infection of SARS-CoV-2.Gastroenterology. 2020; 158: 1831-1833.e3Abstract Full Text Full Text PDF PubMed Scopus (1697) Google Scholar Severe hepatitis has been reported but liver failure appears to be rare.21Chen N. Zhau M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507Abstract Full Text Full Text PDF PubMed Scopus (12323) Google Scholar The pattern of liver injury appears to be predominantly hepatocellular, and the etiology remains uncertain but may represent a secondary effect of the systemic inflammatory response observed with COVID-19, although direct viral infection and drug-induced liver injury cannot be excluded. One study of liver biopsy specimens obtained from a patient with COVID-19 revealed microvesicular steatosis and mild lobular and portal activity suggestive of either SARS-CoV-2 infection or drug-induced liver injury.34Xu Z. Shi L. Wang Y. et al.Pathological finding of COVID-19 associated with respiratory distress syndrome.Lancet Respir Med. 2020; 8: 420-422Abstract Full Text Full Text PDF PubMed Scopus (5483) Google Scholar Abnormal liver enzymes may be observed in both adults and children with COVID-19,35Xia W. Shao J. Guo Y. et al.Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults.Pediatr Pulmonol. 2020; 55: 1169-1174Crossref PubMed Scopus (649) Google Scholar and do not appear to be a major predictor of clinical outcomes.15Zhang C. Shi L. Wang F.S. Liver injury in COVID-19: management and challenges.Lancet Gastroenterol Hepatol. 2020; 5: 428-430Abstract Full Text Full Text PDF PubMed Scopus (1124) Google Scholar Early studies have multiple methodologic limitations, with variable laboratory thresholds, limited longitudinal assessment of liver enzymes, heterogeneous evaluation for alternative etiologies, and limited information regarding baseline liver diseases and confounding variables. Additional studies are needed to further characterize the unique clinical considerations for SARS-CoV-2 infection in patients with chronic liver disease and/or cirrhosis,36Xiao Y. Pan H. She Q. et al.Prevention of SARS-Co-V-2 infection in patients with decompensated cirrhosis.Lancet Gastroenterol Hepatol. 2020; 5: 528-529Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar although preliminary guidance was provided by the American Association for the Study of Liver Diseases on March 23, 2020.37AASLD COVID-19 GuidanceAmerican Association for the Study of Liver Disease.https://www.aasld.org/sites/default/files/2020-03/AASLD-COVID19-ClinicalInsights-FINAL-3.23.2020.pdfDate accessed: March 23, 2020Google Scholar SARS-CoV-2 is presumed to spread primarily via respiratory droplets from talking, coughing, sneezing, and close contact with symptomatic individuals. However human-to-human transmission can occur from unknown infected persons (eg, asymptomatic carriers or individuals with mild symptoms), as well as individuals with virus shedding during the pre-incubation period before symptoms develop.38Cai J. Sun W. Huang J. et al.Indirect virus transmission in cluster of COVID-19 cases, Wenzhou, China, 2020.Emerg Infect Dis. 2020; 26: 1343-1345Crossref PubMed Google Scholar Data related to the spread of SARS-CoV-2 in the early phase of the pandemic have confirmed that health care professionals are at higher risk of infection than the general population. The WHO and Chinese Center for Disease Control and Prevention reported infection of 2055 health care workers as of February 20, 2020 during the index outbreak in Hubei Province, with health care workers facing a rate of infection approximately 3 times that of the general population.39Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), February 16–24, 2020.https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdfGoogle Scholar This prompted the Chinese Department of Health Reform to deploy more than 40,000 additional health care workers to the region, preserve personal protective equipment (PPE), and implement surveillance measures and quarantine protocols.39Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), February 16–24, 2020.https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdfGoogle Scholar Such measures appear to have slowed the spread to health care workers, with recent cases primarily attributable to household contacts rather than occupational exposure. Similar trends have been observed in Europe, with an estimated 20% of COVID-19 infections in Italy occurring in health care workers.40Remuzzi A. Remuzzi G. COVID-19 and Italy: what next?.Lancet. 2020; 395: 1225-1228Abstract Full Text Full Text PDF PubMed Scopus (1902) Google Scholar Preliminary reports in the United States also suggest that health care workers are at risk of nosocomial infections, including infection of 20 health care workers among the first 67 COVID-19–positive individuals in Philadelphia, PA, and additional health care workers cases in Washington, New York, and Massachusetts.41COVID-19 testing site opens in South Philadelphia, but with restrictionsABC News Local Philadelphia. March 21, 2020.https://6abc.com/6031085/Google Scholar, 42COVID-19 hits doctors, nurses, EMTs, threatening the health systemWashington Post. March 17, 2020.https://www.washingtonpost.com/health/covid-19-hits-doctors-nurses-emts-threatening-health-system/2020/03/17/f21147e8-67aa-11ea-b313-df458622c2cc_story.htmlGoogle Scholar, 43With 160 employees in quarantine, Berkshire Medical Center taps 54 temporary nursesBerkshire Eagle. March 26, 2020.https://www.berkshireeagle.com/stories/with-160-employees-in-quarantine-bmc-taps-54-temp-nurses,600096?newsletter=600097Google Scholar The spread of disease via health care workers is conce

Клинический тренинг психологов, работающих с нелегальными несовершеннолетними латиноамериканскими иммигрантами: примеры из практики и критический анализ результатов использования концепции Модели супервизии мультикультурного развития (MDSM)

As of 2017, the number of international immigrants worldwide increased from 220 million to 248 million, and will continue to rise [16]. Growing diversity worldwide requires a stronger emphasis on multicultural competency among mental health professionals. Learning multicultural competency skills is a career-long commitment that begins in practicum training and is modeled and reinforced through supervision. The Multicultural Developmental Supervisory Model (MDSM) is an evidence-based model that focuses on supervisory dyads and multicultural competence [12]. Using the MDSM [12] as a guide reflective of our training, four graduate supervisees share their supervision experiences in learning to conduct clinical interviews in Spanish with undocumented Latinx immigrant minors in government custody in the United States, a rising population with unique clinical considerations. Our supervisor includes her experience in training and fortifying beginning mental health professionals’ skills in conducting these evaluations. In this contribution, we illustrate our trajectory from different training developmental stages, including the process of conceptualizing clinical cases, and transitioning languages in conducting clinical interviews, as well as considering our own cultural identities in clinical work. While our experience focuses on bicultural and bilingual training in the U.S., this aspect of clinical training is growing increasingly relevant around the world, especially in Europe where 54% of the population is multilingual [10]. Although we used the MDSM model as a helpful framework in guiding our multicultural development, empirical research is needed to examine the utility of this model.

Indigenous health disparities: a challenge and an opportunity

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.

Indigenous health disparities: a challenge and an opportunity

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.