Unique Considerations Research Articles

Unique considerations in the assessment and management of traumatic brain injury in older adults.

The age-specific incidence of traumatic brain injury in older adults is rising in high-income countries, mainly due to an increase in the incidence of falls. The severity of traumatic brain injury in older adults can be underestimated because of a delay in the development of mass effect and symptoms of intracranial haemorrhage. Management and rehabilitation in older adults must consider comorbidities and frailty, the treatment of pre-existing disorders, the reduced potential for recovery, the likelihood of cognitive decline, and the avoidance of future falls. Older age is associated with worse outcomes after traumatic brain injury, but premorbid health is an important predictor and good outcomes are achievable. Although prognostication is uncertain, unsubstantiated nihilism (eg, early withdrawal decisions from the assumption that old age necessarily leads to poor outcomes) should be avoided. The absence of management recommendations for older adults highlights the need for stronger evidence to enhance prognostication. In the meantime, decision making should be multidisciplinary, transparent, personalised, and inclusive of patients and relatives.

"This is how we do it" Maternal and fetal anesthetic management for fetoscopic myelomeningocele repairs: the Texas Children's Fetal Center protocol.

Prenatal repair of myelomeningocele (MMC) is associated with lower rates of hydrocephalus requiring ventriculoperitoneal shunt and improved motor function when compared with postnatal repair. Efforts aiming to develop less invasive surgical techniques to decrease the risk for the pregnant patient while achieving similar benefits for the fetus have led to the implementation of fetoscopic surgical techniques. While no ideal anesthetic technique for fetoscopic MMC repair has been demonstrated, we present our anesthetic approach for these repairs, including considerations for both the pregnant patient and the fetus. We emphasize the importance of the preoperative consultation to optimize any medical conditions and to set expectations for the perioperative course. Our preferred anesthetic technique for the pregnant patient includes general anesthesia with an epidural for postoperative analgesia. Intraoperative anesthetic considerations for patients undergoing fetoscopic surgery include tocolysis, meticulous control of hemodynamics, judicious fluid administration, and maternal temperature regulation. We also avoid long-acting neuromuscular blocking agents due to significant weakness observed when given in combination with magnesium sulfate. While the maternal anesthetic crosses the placenta, direct administration of anesthesia to the fetus is required to reliably blunt the stress response. Additional considerations for the fetus include monitoring, fetal resuscitation strategies, and the theoretical risk of anesthetic neurotoxicity. Postoperatively, we use a multi-modal, opioid sparing regimen for analgesia. As advances in fetal surgery aiming to minimize risk to the pregnant patient alter the surgical approach, maternal-fetal anesthesiologists must adapt and incorporate the unique considerations of fetoscopy into their anesthetic management.

Psychotherapy research in the deaf community: pilot clinical trial lessons learned.

At the time of publication, there are no evidence-based psychotherapies to treat any behavioral health condition with Deaf clients. This article describes unique study design considerations for psychotherapy clinical trials conducted in the U.S. Deaf community. We synthesized emergent themes from participant exit interviews with feasibility data and real-life challenges that our team encountered when implementing the Signs of Safety pilot clinical trial, conducted from 2019 to 2022. Particularly illustrative participant accounts were selected to demonstrate five major lessons learned-expanding reach for recruitment; formally assessing participants' ASL fluency; selecting ethically-sound control groups; streamlining video fidelity monitoring; and making crystallized outcome assessments ASL-accessible. These lessons learned informed the design of the first-ever full-scale psychotherapy trial in the U.S. Deaf community, to be conducted from late autumn 2024 through 2028. This trial will potentially validate the first evidence-based therapy for Deaf people and provide a vital roadmap for conducting Deaf community-engaged clinical trials.

Sotalol poisoning and its unique treatment considerations compared with traditional therapies for beta-adrenoceptor blocking drug poisoning

Introduction Sotalol is a beta-adrenoceptor blocking drug with unique physical and pharmacologic properties. Unlike most beta-adrenoceptor blocking drugs, sotalol is amenable to extracorporeal removal and causes QT interval prolongation and ventricular dysrhythmias. These properties have implications for treating sotalol poisoning. Patients Patient 1 : A man in his seventh decade of life overdosed on sotalol 9 g and presented with bradycardia, hypotension, QT interval >600 ms and transient ventricular tachycardia. Dopamine, isoprenaline (isoproterenol), and a transvenous pacemaker were used instead of high-dose insulin due to the risk of iatrogenic hypokalemia. Hemodynamics improved, and the pacemaker was removed six days later. Patient 2: A woman in her seventh decade of life on sotalol presented with hypotension in the setting of anuric acute kidney failure. Hypotension worsened after administration of additional sotalol. Hemodialysis was performed for refractory hypotension, followed by improvement in hemodynamics and kidney function. Discussion High-dose insulin, a standard therapy in beta-adrenoceptor blocking drug poisoning, causes hypokalemia, which may exacerbate QT interval prolongation and ventricular dysrhythmias in patients with sotalol poisoning. Sotalol is cleared renally and is amenable to extracorporeal removal; hemodialysis may be a useful therapy in patients with cardiotoxicity and concomitant kidney injury. Conclusions Chronotropes and overdrive pacing may be preferred therapies for patients with severe sotalol poisoning. If concomitant kidney injury occurs, hemodialysis may be a useful adjunctive therapy.

P-578. Just “Short of a Cure”: Unique Considerations in Uptake and Use of Long-Acting Injectable Cabotegravir/Rilpivirine Among Long-Term Survivors with HIV

Abstract Background Understanding perspectives of subgroups of people with HIV (PWH) who have accessed long-acting cabotegravir/rilpivirine (CAB/RPV-LA) is crucial for optimizing implementation; especially among long-term survivors (LTS) who have lived through the trauma of the early epidemic to the innovation of today. Methods We analyzed semi-structured interviews collected from 08/2022-05/2023 via a parent study at four Ryan White clinics in Atlanta, Chicago, and San Francisco among early adopters of CAB/RPV-LA (received ≥3 injections or discontinued). Our analysis explored factors impacting CAB/RPV-LA uptake and use in LTS (living with HIV since 2000 or earlier) using a socioecological model of HIV care engagement. Results Among 20 LTS, median age was 56 (Q1-Q3 54-60) years and median time living with HIV was 27 (Q1-Q3 25-34) years. Thirteen (65%) identified as racial/ethnic minorities and seven (35%) as cis or trans women. We identified three primary themes: 1) The majority of LTS eagerly awaited CAB/RPV-LA and seemed unconflicted in their choice to switch from oral antiretroviral therapy (ART). Their confidence stemmed from experience using new iterations of oral ART over decades, with some citing CAB/RPV-LA as being a step closer to a cure. 2) Choosing to start CAB/RPV-LA was sometimes facilitated by input from longstanding, trusted relationships with healthcare providers or other PWH. 3) Reflections on the emotional gravity of witnessing loved ones die from AIDS-related illnesses early in the epidemic, and the mental imprisonment of around-the-clock pill taking required for their own survival, influenced use of CAB/RPV-LA. In fact, many reported transforming HIV-related psychological trauma and tragedy into education, support, and advocacy efforts: using CAB/RPV-LA was a unique mechanism to further benefit their community—indeed, it was an obligation to both PWH who have passed as well as PWH to come, who could learn from their experience. Conclusion The perspectives of LTS who initiated CAB/RPV-LA during early implementation revealed uptake and use was shaped by the emotional, psychosocial, and physical impact of living with HIV for decades. These data serve as a framework to tailor service delivery of current and future long-acting ART options in this population. Disclosures Moira McNulty, MD, Gilead Sciences, Inc.: Advisor/Consultant Katerina Christopoulos, MD, MPH, Janssen: Honoraria

The impact of cultural competence in family law: An overview of Buddhism, Islam, Hinduism, and Judaism

AbstractIn contemporary multicultural societies, the family law profession requires a nuanced understanding of diverse cultural backgrounds to facilitate equitable and effective resolutions. Cultural competence in the family law profession entails recognizing and respecting the beliefs, values, and practices of individuals from different cultural backgrounds. Understanding the impact of religion on family dynamics, decision‐making processes, and conflict resolution is essential for family law professionals to navigate sensitive issues such as divorce, custody arrangements, and parental rights. By delving into the teachings, traditions, and rituals of Buddhism, Islam, Hinduism, and Judaism, this paper elucidates the unique cultural considerations that influence family law disputes within these religious communities. It examines key aspects such as dietary preferences, religious observances, and extended family dynamics, shedding light on how these factors shape co‐parenting arrangements and legal proceedings. Furthermore, this paper underscores the importance of incorporating cultural sensitivity into the family law process to promote mutual understanding, respect, and cooperation among parties. By fostering an environment where diverse religious perspectives are acknowledged and valued, mediators can facilitate more equitable and satisfactory outcomes for families from different cultural backgrounds. Ultimately, this paper advocates for the integration of cultural competence training into family law practices, emphasizing the need for mediators to continuously educate themselves on the religious and cultural nuances of the diverse populations they serve. By embracing cultural competence, family law practitioners can better serve the needs of all families, regardless of their religious affiliations, and contribute to a more inclusive and just legal system.

An Empirical Study on Challenges for LLM Application Developers

In recent years, large language models (LLMs) have seen rapid advancements, significantly impacting various fields such as computer vision, natural language processing, and software engineering. These LLMs, exemplified by OpenAI’s ChatGPT, have revolutionized the way we approach language understanding and generation tasks. However, in contrast to traditional software development practices, LLM development introduces new challenges for AI developers in design, implementation, and deployment. These challenges span different areas (such as prompts, APIs, and plugins), requiring developers to navigate unique methodologies and considerations specific to LLM application development. Despite the profound influence of LLMs, to the best of our knowledge, these challenges have not been thoroughly investigated in previous empirical studies. To fill this gap, we present the first comprehensive study on understanding the challenges faced by LLM developers. Specifically, we crawl and analyze 29,057 relevant questions from a popular OpenAI developer forum. We first examine their popularity and difficulty. After manually analyzing 2,364 sampled questions, we construct a taxonomy of challenges faced by LLM developers. Based on this taxonomy, we summarize a set of findings and actionable implications for LLM-related stakeholders, including developers and providers (especially the OpenAI organization).

Pediatric Transplant and Cellular Therapy Consortium RESILIENT Conference on Pediatric Chronic Graft-versus-Host Disease Survivorship after Hematopoietic Cell Transplantation: Part II. Organ Dysfunction and Immune Reconstitution Considerations for children with chronic GVHD after Hematopoietic Cell Transplantation.

While highly morbid forms of chronic graft versus host disease (cGVHD) and severe late effects of allogeneic hematopoietic cell transplant (HCT) can impact children and adults alike, unique considerations arise in pediatric cases regarding diagnosis, monitoring, treatment, and likelihood of resolution. As children can present with atypical features of cGVHD, and with more significant disease due to inability to communicate symptoms, they may be at increased risk for highly morbid forms of cGVHD and incur greater subsequent late effects, which may be more pronounced in those with underlying chromosomal breakage syndromes, with higher prevalence in pediatric HCT recipients. The long-term effects of cGVHD and its therapies include impaired immune reconstitution, leading to increased risks of infection and secondary malignant neoplasms. However, children also have the greatest potential for full immune reconstitution, due to thymus recovery that could impact the timing of vaccination with respect to tolerance and restoration of optimal immunity. Developing strategies to mitigate the late effects incurred with, and as a result of cGVHD, is of critical importance. The working group recommends surveillance strategies for late effects in patients with cGVHD, increased utilization of emerging diagnostic tools, integration of monitoring for cGVHD treatment response, development of new treatments, and provides aims for future research endeavors.

Clinicians' Experiences of Eating Disorder Focused Family Therapy With Autistic Young People.

Eating disorder focused family therapy (FT-ED) is the leading outpatient intervention for adolescents with Anorexia Nervosa. Autistic people report poorer eating disorder treatment experiences and may be at increased risk of inpatient admissions. There is a need to consider adaptions to eating disorder treatment for this population. The aim of this study is to explore the experiences of clinicians in the delivery of FT-ED for Autistic young people with Anorexia Nervosa and any adaptations currently being implemented. FT-ED trained clinicians who had experience of delivering this modality with young Autistic people and their families, were invited to take part in interviews. Transcripts were analysed using Reflexive Thematic Analysis. Eleven clinicians completed interviews and analysis generated four themes and eight subthemes: (1) Systemic context, (2) Raising potential autism, (3) Autism eating disorders crossover, (4) Manual versus adaptations. This paper is the first exploration of clinician's experience delivering FT-ED to Autistic young people and their families and highlighted unique considerations with this population. It is an initial step to consider adaptations to the FT-ED model, with the aim of making eating disorder treatments more effective, accessible and acceptable for Autistic young people and their families.

Diagnostic and Therapeutic Utility of Extracellular Vesicles in Ocular Disease.

Extracellular vesicles (EVs) are lipid bilayer particles released by virtually all cells, with prominent roles in both physiological and pathological processes. The size, number, and molecular composition of released EVs correlate to the cells of origin, modulated by the cell's environment and pathologic state. The proteins, DNA, RNA, and protein cargo carried by EVs are protected by degradation, with a prominent role in targeted intercellular signaling. These properties make EVs salient targets as both carriers of biomarkers and potential therapeutic delivery vehicles. The majority of EV research has focused on blood, urine, saliva, and cerebrospinal fluid due to easy accessibility. EVs have also been identified and studied in all ocular biofluids, including the vitreous humor, the aqueous humor, and the tear film, and the study of EVs in ocular disease is a new, promising, and underexplored direction with unique challenges and considerations. This review covers recent advances in the diagnostic and therapeutic use of ocular EVs, with a focus on human applications and key preceding in vitro and in vivo animal studies. We also discuss future directions based on the study of EVs in other organ systems and disease sates.

Pain Management in Pediatrics: What the IR has to Offer.

Pediatric pain management presents unique challenges due to the intrinsic characteristics of children such as their developmental stages, communication barriers, and varying pain perceptions. Life-limiting conditions affecting children are a growing medical concern, requiring a comprehensive, multidisciplinary approach to improve quality of life or ensure a dignified end of life. Interventional radiology (IR) plays a critical role in this strategy, similar to its role in adult care. Not only life-limiting conditions pose a challenge in pediatric chronic pain management, but also other benign chronic diseases (e.g., cystic fibrosis, muscular dystrophy, neurodegenerative disorders, metabolic disorders). This review focuses on specific IR strategies for pediatric pain management, including ablation, embolization/chemoembolization, and nerve blocks. It emphasizes the importance of tailored approaches for pediatric patients, considering genetic disorders and oncological diseases, which may require a diverse range of IR treatments. The aim is to provide a summary of these interventional techniques and highlight the unique considerations necessary for effective pediatric pain management.

Updating and Advancing Member-Checking Methods: Use of Video and Asynchronous Technology to Optimize Participant Engagement

Member checking enhances the trustworthiness and transformative potential of qualitative research. There are a variety of aims and approaches to reengaging with participants in sharing data or preliminary analysis and soliciting feedback through member checking. Published studies often lack descriptions of member-checking methods or outcomes, and there is a lack of research on the use of technologies for this purpose. Asynchronous video and internet-based technologies can be valuable tools to improve the accessibility, equity, effectiveness, and acceptability of member checking and foster increased engagement. This publication presents a detailed description of member checking in an exemplar study that used readily available technologies to create a video synopsis of preliminary findings and embed that video in a multimedia, mixed methods web-based survey which was emailed to participants. This member-checking method was purposefully selected to advance the specific research aims of the study, reflect the epistemological stance of the researchers and unique considerations of the study population, and address relevant situational factors to optimize participant engagement. This strategy facilitated wide, cost-effective, and timely distribution and resulted in a good response rate with rich feedback. Asynchronous technologies were a useful alternative to in-person or synchronous meetings to facilitate voluntary participation, foster reflection that deepened analysis, and capture multiple voices and perspectives. Findings from this research support the use of video and electronic survey technologies to enhance study credibility, address ethical and methodological challenges related to member checking, and increase equity and engagement. Future studies are needed to expand and refine integration of technologies into member checking to address diverse research aims, contexts, and study populations.

How to Use Imaging: Complex Cases of Atherosclerosis, Myocardial Inflammation, and Cardiomyopathy in Cardio-Oncology.

It is well understood that cancer therapies including chemotherapy, tyrosine kinase inhibitors, immune checkpoint inhibitors, and radiation can increase the risk of cardiovascular disease in patients with cancer. This can manifest as a multitude of pathologies including left ventricular dysfunction, myocarditis, cardiomyopathy, accelerated atherosclerosis, and coronary vasospasm. Multimodal cardiac imaging plays a critical role in diagnosing such pathologies by relying on noninvasive tools including echocardiograms, cardiac magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, and coronary computed tomography angiography. These methods have unique considerations and in recent years have made significant progress in their diagnostic capabilities in this patient population. As the field of cardio-oncology continues to expand rapidly, guidance on the management of such toxicities and the development of imaging technologies is crucial. In this review, we present 2 complex cases of atherosclerosis and myocarditis in patients with cancer, highlighting our rationale for management and discussing the nuances of various cardiac imaging modalities.

Investigating an artificial object detected in X-ray images in a child: unique considerations related to proton therapy

Investigating an artificial object detected in X-ray images in a child: unique considerations related to proton therapy

Practical advice in the development of a lyophilized protein drug product.

The development of lyophilized protein drug products is a critical and complex task in the pharmaceutical industry, requiring a comprehensive understanding of the myriad of factors affecting product quality, stability, and the efficiency and robustness of the lyophilization process. This review offers practical advice on the critical aspects of lyophilized protein drug product development. Practical considerations across both the early and late stages of development are discussed, underscoring the necessity of a strategic approach from initial development through to commercialization. The review then delves into formulation optimization strategies that are essential for enhancing protein stability and the efficiency of the lyophilization process. This section outlines stable formulation design and highlights the unique considerations required for high protein concentration lyophilized drug products. It further explores the formulation strategies to enhance the lyophilization process' efficiency. Moreover, the paper examines the critical elements in selecting primary containers and closures for lyophilized drug products, focusing on vials and dual chamber systems. The analysis encompasses the effects of the container/closure's material, size, geometry, and fill volume on product quality and process efficiency. Lastly, the review provides practical considerations in lyophilization cycle development, including the design and optimization of the freezing, primary drying, and secondary drying stages to achieve a robust, scalable, and efficient lyophilization process. By offering comprehensive insights into these key areas to enhance their understanding and implementation of best practices in the field, this paper serves as a useful resource for researchers, formulators, and process engineers involved in the development of lyophilized protein drug products.

Integrative Oncology: Incorporating Evidence-Based Approaches for Patients With GI Cancers.

Data have matured to support incorporation of integrative oncology modalities into comprehensive cancer care. Clinical practice guidelines have recently been published by ASCO for diet and exercise (2022) and use of cannabinoids and cannabis (2024) and jointly by ASCO and the Society for Integrative Oncology (SIO) for application of integrative approaches in the management of pain (2022), anxiety and depression (2023), and fatigue (2024) among adults with cancer. Following the ASCO-SIO guidelines, clinicians should recommend mindfulness-based interventions (MBIs) to patients with symptoms of anxiety or depression and MBIs and exercise for management of fatigue during or after completion of cancer treatment. We will review the basis of these recommendations and evidence to support use of other mind-body approaches, exercise, nutrition, acupuncture/acupressure, and natural products in the specific contexts of GI cancers. For example, optimizing physical activity and diet is associated with improved survival after a colorectal cancer (CRC) diagnosis, in addition to conferring symptom management benefits. We will also highlight gaps in research, including that most studies enrolling patients with GI malignancies have focused on CRC. A limitation of nonpharmacologic evidence-based guidelines is that they list broad categories (eg, yoga or acupuncture) and lack implementation details. How to safely and equitably incorporate integrative approaches into conventional cancer care will be addressed. This ASCO Educational Book article aims to be both evidence-informed and practical, with attention to unique considerations for people with GI cancers.

The Intersection of a Life Partner and Professional Wellness for the Plastic Surgeon.

Our literature review describes the complicated intersection of the physician/surgeon's professional practice and their spouse/domestic partner, acknowledging that the existing literature specific to plastic surgeons is limited. Nevertheless, the broader research of physicians and other surgical fields identifies many risk factors for work-home conflicts, which can negatively impact the surgeon and the spouse. Furthermore, certain studied groups have other unique challenges and considerations, such as women surgeons, residents, and dual-physician couples. Fortunately, the presence of a domestic partner has been shown to benefit the surgeon in multiple ways. Finally, we summarize some strategies to support and maintain this important relationship.

Data Migration Strategy for Financial Product Acquisition

The acquisition of financial products by external partners necessitates a meticulous data migration strategy to ensure security, continuity, and compliance. This paper explores the challenges of migrating sensitive financial data when integrating applications through middleware platforms, focusing on IBM DataPower as a robust solution. We propose a structured methodology emphasizing security, operational efficiency, and scalability while highlighting unique considerations for financial institutions. Keywords Data migration, financial product acquisition, middleware integration, IBM DataPower, application integration, data security.

Radiosurgery for Intracranial Meningiomas: A Review of Anatomical Challenges and an Update on the Evidence.

Radiation has been used to treat meningiomas since the mid-1970s. Traditionally, radiation was reserved for patients unfit for major surgery or those with surgically inaccessible tumors. With an increased quantity and quality of imaging, and an aging population, there has been a rise in incidentally diagnosed meningiomas with smaller tumors at diagnosis time. Deciding if, how, and when to intervene must be determined on a case-by-case basis. Anatomical location and adjacent vital structures are crucial for decision-making. Prior review articles have detailed outcomes of radiosurgery in broad anatomical regions such as the skull base, but a recent deluge of research on increasingly specific anatomical subregions deserves attention. This narrative review synthesizes information regarding specific anatomical subregions, including anatomical challenges, radiosurgical outcomes, and unique considerations. Via MEDLINE and ascendancy search, we utilized evidence available for each anatomical region and herein discuss details of published research and explore future directions. Meningioma management remains individualized based on patient comorbidities, tumor location/characteristics, symptomatic burden, and patient age. In addition to stereotactic radiosurgery's established role for surgically inaccessible, recurrent, and high-grade meningiomas, its use as upfront management for small asymptomatic meningiomas is increasingly investigated. For all subregions reported, radiosurgical intervention resulted in high tumor control rates and acceptably low adverse radiation events.

Exploration of the Fertility Decision-Making Experiences of Women of Reproductive Age With Cancer: A Qualitative Systematic Review.

Women of reproductive age with cancer face unique considerations in terms of fertility. The related decision-making process is complicated, and insufficient support can lead to decisional conflict. The aim of this qualitative systematic review was to identify and integrate qualitative evidence regarding the fertility decision-making process of women of reproductive age undergoing treatment for cancer. A qualitative systematic review was conducted following the Joanna Briggs Institute's methodology. Eight electronic databases were searched from inception to June 2023 for articles describing qualitative studies of the fertility decision-making process of women of reproductive age with cancer. Only original, full-text literature was examined, no limitation was placed on the publication language. Finally, 18 studies were included in a thematic analysis. We identified three analytical themes, namely "Perceived changes in fertility," "Influential participants in the decision-making process" and "Hard fertility decision-making processes of women," and nine descriptive themes that described the three analytical themes in detail. The results of qualitative synthesis emphasized that for women of reproductive age with cancer, fertility decision-making is a complex and dynamic process. These patients had experienced decisional conflict. Decision support from health care professionals was considered to be essential, and the use of patient decision aids in clinical settings was recommended. The synthesis results clarify women's fertility decision-making process, decision needs and the influencing factors, which offer evidence to guide the development of applicable patient decision aid tools to provide high-quality fertility services to women. TRIAL REGISTRATION: PROSPERO Registration Number: CRD42023434490.