US Practice Research Articles

The Court's Discretion in Relation to the Part 26A Cram Down

This article explains that a fundamental purpose of the Court’s discretion whether to exercise its cram down power under the new UK Companies Act Part 26A process would be to ascertain whether the dissenting class was promised a and distribution of the restructuring surplus, i.e. the value expected to be preserved and perhaps created by the proposed plan itself. The concept is familiar from US Chapter 11 practice, where the courts are required to ensure a “fair and equitable” treatment of members of the dissenting class. In the US, however, the much-misunderstood Absolute Priority Rule (‘APR’) supposedly governs this exercise. This article shows that the APR is untenable and is honoured more in breach in US practice than in observance. Similarly, the cram down powers under the new Dutch and the proposed German restructuring regimes also envisage ‘exceptions’ to the APR which are likely in practice to swallow the rule. Understanding why the APR cannot and should not govern the distribution of the restructuring surplus goes a considerable way to establishing a more rational starting point. An important consideration here would be whether the plan allocates the restructuring surplus with due regard to the likely contribution to the creation of that surplus by members of the dissenting class. This contribution is proxied by the ratio of returns in the “relevant alternative” of dissenting class members and any junior classes to whom returns are proposed under the plan. For example, if dissenting class members would receive 40% on their claims in the relevant alternative while members of a junior class would receive 20%, then this 2:1 ratio is presumptively the just and equitable share of the restructuring surplus of members of the two classes. Any departures from this relative priority would likely require justification by reference to one or more significant restructuring goals of the sort recognised in US jurisprudence, such as preserving the debtor’s business as a going concern, making members of the crammed down class better off, and protecting reliance interests. The article also considers the appropriate treatment of “new money” and “sweat equity”, and of classes excluded from the plan.

Recommendations for rheumatology ultrasound training and practice in the UK.

The aim of this paper is to present a UK-based consensus of principles and recommendations to guide rheumatology US training and practice. A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK. A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG) members made seven proposals that were presented to the whole group for further discussion. This resulted in minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consensus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination of the results and future development work. Using a validated process, experts in rheumatology US have worked through an iterative process and have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning, as well as a commitment to support mentors and trainers through the BSRUSSIG. These are the first specific education and practice recommendations for rheumatology US in the UK and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support and validate rheumatology US practice and inform the development of future rheumatology training curricula and education programmes.

Office practices that may improve the experience of the cosmetic dermatology patient.

Patients presenting for cosmetic dermatology procedures are often interested in lifestyle enhancement rather than treatment of an inflammatory or neoplastic disease or condition. In addition to good clinical outcomes, they may also particularly value the quality of the patient experience in the dermatology office. A list of beneficial practices that may improve patient experience was generated by interviewing staff members from several US practices, including clinic administrators, nurses, nurse managers, medical assistants, physician assistants, patient care coordinators, and dermatologists. Each was asked ten open-ended questions. The list of beneficial practices thereby obtained was ordered based on the number of participants who recommended each practice. Practices were further categorized into four categories: clinician improvement, administrative improvement, clinic improvement, and team improvement. For clinics providing cosmetic dermatology services, certain well-accepted beneficial practices may improve patient experience.

Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States.

More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

The Role of Place in Disparities Affecting Black Men Receiving Hemodialysis

IntroductionBlack men are over-represented in the end stage kidney disease population and are at disproportionate risk of unfavorable outcomes. There is a paucity of investigation to elucidate the mediators of this risk. This study attempts to identify residential community attributes as a possible contributor.MethodsA post-hoc analysis of prospectively collected data from a cohort of Black men enrolled in the US Dialysis Outcomes and Practice Patterns Study (DOPPS), 2010-–2015, linked to the American Community Survey, by dialysis facility zip codes was undertaken. The exposure variable was the dialysis facility community composition as defined by percent Black residents. Negative binomial regression was used to estimate incidence rate ratio (IRR) of hospitalization (first outcome) for Black men in crude and adjusted models. Similarly, Cox proportional hazards modeling was used to estimate mortality (second outcome) for Black men by type of community.ResultsA total of 702 Black men receiving chronic hemodialysis were included in the study. Black men receiving hemodialysis in communities with greater proportions of Black residents had lower Charlson scores and fewer comorbidities, but a higher rate of hypertension. They had equivalent adherence to dialysis treatments, but a lower rate of arteriovenous fistula use and fewer dialysis minutes prescribed. Black men receiving dialysis in communities with a greater proportion of Black residents (per 10% increase) had higher adjusted hospitalization rates (IRR 1.09, 95% confidence interval [CI] 1.00–1.19) and mortality (hazard ratio [HR] 1.29, 95% CI 1.05–1.59).ConclusionsThis study supports the unique role of residential community as a risk factor for Black men with end stage kidney disease, showing higher hospitalization and mortality in those treating in Black versus non-Black communities, despite equivalent adherence and fewer comorbidities.

Evaluating the Impact of ESPAC-1 on Shifting the Paradigm of Pancreatic Cancer Treatment

BackgroundIn 2004, the European Study Group for Pancreatic Cancer (ESPAC)-1 long-term data concluded that adjuvant chemotherapy provided a survival benefit for patients with pancreatic ductal adenocarcinoma (PDAC), whereas adjuvant chemoradiation was associated with worse overall survival. In this study, we investigated how long it took for US practice patterns to change following this trial. MethodsThe National Cancer Database was used to identify patients with stage I-III PDAC who underwent R0 or R1 resection followed by adjuvant chemotherapy or chemoradiation between 1998 and 2015. A multivariate analysis was performed to determine predictors of receiving adjuvant chemoradiation in the post-ESPAC-1 era. ResultsBetween 1998 and 2015, adjuvant chemotherapy use increased from 2.9% to 51.6%, whereas adjuvant chemoradiation decreased from 49.5% to 22.9%. In 2010, adjuvant chemotherapy utilization surpassed that of chemoradiation. For patients diagnosed in the post-ESPAC-1 era, adjuvant chemotherapy (n = 7733) and chemoradiation (n = 6969) groups were compared. Patients who underwent adjuvant chemoradiation were younger, had private insurance, underwent surgery at nonacademic centers, and had more pathologically advanced cancers (all P < 0.01). After 2010, R1 resection was the strongest independent predictor of adjuvant chemoradiation use by multivariate analysis (OR 2.05, CI 1.8-2.3, P < 0.01). ConclusionsAdjuvant chemotherapy use exceeded that of adjuvant chemoradiation 6 y after the final publication of ESPAC-1 in 2004, highlighting the challenges of disseminating and adopting clinical data. After 2010, R1 disease was the most significant predictor of receiving adjuvant chemoradiation. Prospective studies are underway to definitively address the role of adjuvant chemoradiation in PDAC.

What Forms of Representation Do American Workers Want? Implications for Theory, Policy, and Practice

Recent evidence documents an increased interest among American workers in joining a union. At the same time, there is revived debate among labor scholars, union leaders, politicians, and activists over what forms of labor representation are best suited to meet the needs of the contemporary workforce. Yet little is known about what contemporary workers have to say about these debates. This article draws on a conjoint survey experiment fielded on a nationally representative sample of more than 4,000 employees to explore the forms of representation workers want and are willing to support by paying dues. The authors compare interest in the forms of labor representation that are currently being debated. Results show that while workers value traditional collective bargaining, they would be even more willing to join and financially support organizations currently unavailable under US law and practice. The authors use these results to draw implications for the labor movement, worker advocacy groups, and the future of labor law.

How we manage smoldering multiple myeloma.

Smoldering myeloma (SMM) is an asymptomatic stage characterized by bone marrow plasma cells infiltration between 10-60% in absence of myeloma-defining events and organ damage. Until the revision of criteria of MM to require treatment, two main prognostic models, not overlapping each other, were proposed and used differently in Europe and in US. Novel manageable drugs, like lenalidomide and monoclonal antibodies, with high efficacy and limited toxicity, improvement in imaging and prognostication, challenge physicians to offer early treatment to highrisk SMM. Taking advantage from the debates offered by SOHO Italy, in this review we will update the evidence and consequent clinical practices in US and Europe to offer readers a uniform view of clinical approach at diagnosis, follow-up and supportive care in the SMM setting.

Tax deed sales and land banking to reuse vacant and abandoned properties

Purpose Tax sales intersect with the market, housing policy and socioeconomic matters, but the topic in this context is understudied. The purpose of this paper is to investigate whether and how land banking is more effective in fostering positive property outcomes than tax lien sales and what market-based measures can be combined with land banking to reuse tax delinquent, vacant and abandoned properties. Design/methodology/approach This paper analyzes the consequences of tax lien sales and land banking in Indianapolis, Indiana, the USA. Various local data sources are used. Findings This paper finds that land banking, when compared to tax lien sales, results in less tax delinquency, less vacancy and abandonment, more increase in assessed value and fewer ownership changes after sales. Also, this paper shows the contributions of non-profit and for-profit developers as business partners to land banks. Practical implications This paper demonstrates the utility of the land banks that have become prevalent in some states in the USA over the past 20 years. The results of this paper recommend the realistic approach of combining government intervention and market forces. Social implications This paper sheds light on the US practice of tax lien sales. It goes largely unnoticed, but malpractice risks harming the vulnerable members of community. Originality/value Housing policy needs to find common ground with the market. It is a dilemma, more or less, for every country. The results of this paper suggest a harmonized public policy approach that includes land banking and the market can be effective in combatting with troubled properties.

CML-085: Discontinuation of Tyrosine Kinase Inhibitor (TKI) Treatment in Patients with Chronic Myeloid Leukemia in Chronic Phase (CML-CP) in US Clinical Practice Following Updates to NCCN CML Practice Guidelines

Context NCCN CML practice guidelines were updated in 11/2016 and 11/2019 to incorporate criteria for TKI discontinuation in patients with CML-CP. Objective To describe TKI discontinuation practices in the US following updates to NCCN CML practice guidelines and compare them to a previously conducted study (Ritchie et al. Leuk Lymphoma. 2019). Patients Using an online case report form by US oncologists/hematologists, patient charts were abstracted (11/2019-12/2019) from adult patients with CML-CP that discontinued TKIs (1/2017-12/2018) after achieving adequate responses. Physicians' assessment of adequate response (TKI duration, molecular response (MR), and MR duration) and relapse were described. Results 153 patient charts were obtained from 61 physicians (academic: 43%; community-based practices: 57%), mostly from large practices (57%), with over 10 years (y) of experience following subspecialty training (59%). They had treated a median of 30 patients with CML-CP in the last 2y. Most (56%) did not have access to precise tests used to detect BCR-ABL1 of ≥4.5 log when attempting TKI discontinuation. Patients that discontinued TKIs had the following characteristics: mean age 56 y, 60% male, 69% white, 96% with TKI discontinuation in first-line. Besides achieving adequate responses, the most common reasons for TKI discontinuation were patient request (54%) and adverse events (18%). Results from physicians' assessment of adequate response for TKI discontinuation were as follows: most patients had ≥3 y of TKI therapy (academic: 57%; community: 43%); most patients had MR4 (academic: 31%; community: 45%) or MR4.5 (academic: 48%; community: 30%); more patients had ≤1 y duration of MR (academic: 36%; community: 61%) than 2 y (academic: 25%; community: 17%), and ≥3 y (academic: 39%; community: 22%). 21% of patients (academic: 12%; community: 30%) relapsed after TKI discontinuation (treatment-free remission [TFR] failure; 66% relapsed within 1 y). Conclusion TKI discontinuation is mainly attempted in patients on first-line therapy (similar to Ritchie et al. 2019) and is being practiced without tools required to accurately monitor response. Despite updates to NCCN CML practice guidelines, there is heterogeneity in US practice regarding TKI discontinuation. In order to improve long-term TFR rates, broader application of practice guidelines is needed for optimal TKI discontinuation, particularly in community-based practices. Study sponsored by Novartis Pharmaceuticals Corporation. © 2020 American Society of Clinical Oncology, Inc. Reused with permission. This abstract was accepted and previously presented at the 2020 ASCO Annual Meeting. All rights reserved.

The Role of Primary Care Practices in Screening for Patient Social Needs in the United States and Other High‐Income Countries

Research ObjectiveUnmet social needs including poverty, housing, or food instability run deeper in the United States compared with ten other high‐income countries, as identified by previous Commonwealth Fund International Patient Surveys. US primary care physicians (PCPs) are increasingly tasked with screening for these needs, given their centrality in providing coordinated and patient‐centered care. This study compares social needs screening rates among US PCPs with those in other high‐income countries, and explores factors associated with screening.Study DesignCross‐sectional analysis of data from the 2019 Commonwealth Fund Survey of Primary Care Physicians, which included a random sample of PCPs contacted between January and June 2019. Screening for social needs was defined as the share of PCPs that reported that they or other personnel in their practice usually screen patients for unmet needs relating to housing, financial insecurity, food insecurity, transportation, utilities, domestic violence, or social isolation/loneliness. We explored the likelihood of screening for any of these needs using logistic regressions adjusted for practice characteristics and demographic variables.Population Studied13 184 PCPs in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States (500‐2569 per country).Principal FindingsUS PCPs were significantly more likely to report screening for social needs (29%) than in most other countries (9‐25%) except France (29%), as well as most individual needs including financial security (19% vs 4‐14% in all other countries), transportation needs (14% vs 2‐12% all other), and social isolation/loneliness (15% vs &lt;1‐7% all other). US physicians remained significantly more likely than those in other countries to screen for social needs, even after adjusting for practice and demographic characteristics (ORs: 0.23‐0.71, Ps &lt; .001 vs other countries except France). PCPs in practices with a social worker were more likely to screen than those without (31% vs. 19%; OR 1.80, P &lt; .001). Among US PCPs, those in practices employing community health workers (45% vs 26%; OR 2.11, P &lt; .001), that saw predominantly (≥50%) Medicaid patients (39% vs 28%; OR 1.53, P = .002), and federally qualified health centers (43% vs 27%; OR 1.97, P &lt; .001) were significantly more likely to screen. Across countries, PCPs who screened were slightly more likely to report job‐related stress (52%) than those who did not (48%; OR 1.12, P = .010, adjusted); however, this was lower for PCPs that had a social worker at their practice (42% vs 55%; OR 0.58, P &lt; .001).ConclusionsUS PCPs more often screen for social needs than those in most other high‐income countries. US practices that employ social workers or community health workers, as well as safety‐net settings, more often screened for social needs. PCP screening for social needs is associated with higher job‐related stress levels, which was attenuated by having a social worker at the practice.Implications for Policy or PracticeUS primary care physicians, particularly those in safety‐net settings, may be more often tasked with screening for patient social needs than their counterparts abroad, in part because of a lack of a robust social safety‐net system. To avoid social screening potentially contributing to physician stress, health systems and payers may want to consider team‐based approaches to screening.Primary Funding SourceThis study was supported by the Commonwealth Fund.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Community Racial Composition and Hospitalization Among Patients Receiving In-Center Hemodialysis

Community racial composition has been shown to be associated with mortality in patients receiving maintenenance dialysis. It is unclear whether living in communities with predominantly Black residents is also associated with risk for hospitalization among patients receiving hemodialysis. Retrospective analysis of prospectively collected data from a cohort of patients receiving hemodialysis. 4,567 patients treated in 154 dialysis facilities located in 127 unique zip codes and enrolled in US Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 5 (2010-2015). Tertile of percentage of Black residents within zip code of patients' dialysis facility, defined through a link to the American Community Survey. Rate of hospitalizations during the study period. Associations of patient-, facility-, and community-level variables with community's percentage of Black residents were assessed using analysis of variance, Kruskal-Wallis, or χ2/Fisher exact tests. Negative binomial regression was used to estimate the incidence rate ratio for hospitalizations between these communities, with and without adjustment for potential confounding variables. Mean age of study patients was 62.7 years. 53% were White, 27% were Black, and 45% were women. Median and threshold percentages of Black residents in zip codes in which dialysis facilities were located were 34.2% and≥14.4% for tertile 3 and 1.0% and≤1.8% for tertile 1, respectively. Compared with those in tertile 1 facilities, patients in tertile 3 facilities were more likely to be younger, be Black, live in urban communities with lower socioeconomic status, have a catheter as vascular access, and have fewer comorbid conditions. Patients dialyzing in communities with the highest tertile of Black residents experienced a higher adjusted rate of hospitalization (adjusted incidence rate ratio, 1.32; 95% CI, 1.12-1.56) compared with those treated in communities within the lowest tertile. Potential residual confounding. The risk for hospitalization for patients receiving maintenance dialysis is higher among those treated in communities with a higher percentage of Black residents after adjustment for dialysis care, patient demographics, and comorbid conditions. Understanding the cause of this association should be a priority of future investigation.

Long-term Outcomes in Children Treated via Transcatheter Approach for Mild Congenital Heart Defects

Abstract Background: Transcatheter interventions in children with mild congenital heart defects (CHD), such as isolated patent ductus arteriosus (PDA) and atrial septal defect (ASD), have become a common practice in the US in contrast to surgical procedures. Such patients may be exposed to unique risks such as late tissue erosion and arrhythmias. However, data regarding the long term outcomes of patients treated by transcatheter approach compared to those treated surgically for similar lesions are …

Addressing Burnout Syndrome From a Critical Care Specialty Organization Perspective.

Health care specialty organizations are an important resource for their membership; however, it is not clear how specialty societies should approach combating stress and burnout on an organizational scale. To understand the prevalence of burnout syndrome in American Thoracic Society members, identify specialty-specific risk factors, and generate strategies for health care societies to combat burnout. Cross-sectional, mixed-methods survey in a sample of 2018 American Thoracic Society International Conference attendees to assess levels of burnout syndrome, work satisfaction, and stress. Of the 130 respondents, 69% reported high stress, 38% met burnout criteria, and 20% confirmed chaotic work environments. Significant associations included sex and stress level; clinical time and at-home electronic health record work; and US practice and at-home electronic health record work. There were no significant associations between burnout syndrome and the selected demographics. Participants indicated patient care as the most meaningful aspect of work, whereas the highest contributors to burnout were workload and electronic health record documentation. Importantly, most respondents were unaware of available resources for burnout. Health care specialty societies have access to each level of the health system, creating an opportunity to monitor trends, disseminate resources, and influence the direction of efforts to reduce workplace stress and enhance clinician well-being.

Oncologists' perceptions of the usefulness of cancer survivorship care plan components.

The Institute of Medicine recommends that cancer patients receive survivorship care plans (SCP) summarizing information important to the individual's long-term care. The various components of SCPs have varying levels of evidence supporting their impact. We surveyed medical oncologists to better understand how they perceived the relative value of different SCP components. Medical oncologists caring for patients in diverse US practice settings were surveyed (357 respondents; participation rate 52.9%) about their perceptions of the usefulness of various components of SCPs to both patients and primary care physicians (PCPs). Oncologists perceived treatment summaries as "very useful" for PCPs but were less likely to perceive them as "very useful" for patients (55% vs. 40%, p < 0.001). Information about the psychological effects of cancer (41% vs. 29%; p < 0.001) and healthy behaviors (67% vs. 41%; p < 0.001) were considered more useful to patients than to PCPs. From 3 to 20% of oncologists believed that any given component of the SCP was not useful to either PCPs or patients. Oncologists who perceived SCPs to be more useful tended to be female or to practice in settings with a fully implemented electronic health record. Oncologists do not perceive all components of SCPs to be equally useful to both patients and PCPs. To be successfully implemented, the SCP should be efficiently tailored to the unique needs and knowledge of patients and their PCPs. A minority of oncologists appear to be late adopters, suggesting that some resistance to the adoption of SCPs remains.

The kidney evaluation of living kidney donor candidates: US practices in 2017.

We surveyed US transplant programs to assess practices used to assess kidney health in living kidney donor candidates in 2017; the response rate was 31%. In this report, we focus on the kidney; a companion piece focuses on the metabolic and cardiovascular aspects of candidate evaluation. Compared to 2005, programs have become more stringent in accepting younger candidates and less stringent in accepting older candidates. The 24-hour creatinine clearance remains the mainstay for kidney function assessment, with 74% continuing to use a value below 80mL/min/1.73m2 for exclusion and 22% using age-based criteria. ApoL1 genotyping is obtained routinely or selectively by 45%, half of which use the high-risk genotype as an absolute exclusion criterion. For history of symptomatic stones, 49% accept if there is no current radiographic evidence of stones and urine profile is low risk, 80%-95% consider candidates with unilateral asymptomatic stones, but only 33%-48% consider if stones are bilateral. In addition, 14% use the risk assessment tool developed by Grams et al routinely for decision-making, and 42% use it sometimes. Also, 57% reported not having yet determined a risk threshold for acceptable postdonation risk above which candidates are excluded. Contemporary practice variation underscores the need for better evidence to guide the donor selection process.

Metabolic, cardiovascular, and substance use evaluation of living kidney donor candidates: US practices in 2017.

We surveyed US transplant centers to assess practices regarding the evaluation and selection of living kidney donors based on metabolic, cardiovascular, and substance use risk factors. Our companion article describes renal aspects of the evaluation. Response rate was 31%. Compared with 2005, programs have become more accepting of hypertensive candidates: 65% in 2017% vs 41% in 2005 consider candidates with hypertension well controlled with 1 medication. One notable exception is black hypertensive candidates, who are frequently excluded regardless of severity. The most common body mass index (BMI) cutoff remains 35kg/m2 , and fewer programs now consider candidates with BMI >40kg/m2 . A 2-hour oral glucose tolerance test of ≥140mg/dL remains the most common criterion for exclusion of prediabetic candidates. One quarter to one third of programs exclude based on isolated cardiac abnormalities, such as mild aortic stenosis; a similar proportion consider these candidates only if older than 50years. Cigarette or marijuana smoking are infrequently criteria for exclusion, although 45% and 37% programs, respectively, require cessation 4weeks prior to surgery. In addition to providing an overview of current practices in living kidney donor evaluation, our study highlights the importance of research evaluating outcomes with various comorbidities to guide practice.

Chinese Investment Treaties in the Belt and Road Initiative Area

Abstract This article examines whether Chinese practice towards the making of investment treaties with developing countries in the Belt and Road Initiative region will be different from the treaties that it makes with developed States. Though there is a shift towards the making of hard treaties with the developed States of Europe, it is suggested that treaties made with developing States will be more nuanced. The article shows that there are political motives behind investment treaties, as the study of US practice shows. Political considerations will induce China to make different types of treaties with different types of treaty partners in the future. A comparison is made with recent Indian practice.

Discontinuation of tyrosine kinase inhibitor (TKI) therapy in chronic myeloid leukemia in chronic phase (CML-CP) in US clinical practice after guideline updates.

7548 Background: NCCN CML practice guidelines were updated in 11/2016 and in 9/2019 to include considerations for discontinuation of TKI therapy in patients (pts) with CML-CP. This study characterized TKI discontinuation practices in the US after these updates and drew parallels with a similar study conducted prior to these guideline updates (Ritchie et al. Leuk Lymphoma. 2019). Methods: Pt charts of adult CML-CP pts with TKI discontinuation (1/2017-12/2018) outside a clinical trial after achieving an adequate response were abstracted (11/2019-12/2019) via an online case report form by US oncologists/hematologists. Physicians’ assessment of adequate response (TKI duration, molecular response [MR], MR duration) and relapse were described. Results: 61 physicians (academic: 43%; community-based practices: 57%) contributed 153 pt charts. Most physicians were from large practices (57%), had &gt; 10 years (y) experience since completing subspecialty training (59%), and treated a median of 30 CML pts in the last 2y; 56% did not have access to precise molecular response monitoring for BCR-ABL of ≥4.5 log when attempting TKI discontinuation. Pts with TKI discontinuation had mean age 56 years, were mostly male (60%), white (69%), and had TKI discontinued in first-line (96%). Most common reasons for TKI discontinuation were pt request (54%) and adverse events (18%), besides achieving an adequate response. Physicians’ assessment of adequate response for TKI discontinuation are reported in the Table. 21% of pts (academic: 12%; community: 30%) relapsed after TKI discontinuation (treatment-free remission [TFR] failure; 66% relapsed within 1y). Conclusions: Although NCCN CML practice guidelines provide guidance for discontinuation of TKI therapy, there remains heterogeneity in US practice and TKI discontinuation is predominantly attempted in first-line (similar to Ritchie et al. 2019). TKI discontinuation is being practiced without adequate sensitive tools mandated by practice guidelines to monitor response. Broader application of practice guidelines for optimal TKI therapy discontinuation in CML-CP pts is needed, particularly in community-based practices, to improve long-term TFR rates. [Table: see text]