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1.
Cancer Prevention Research ; : OF1-OF6, 2022.
Article in English | MEDLINE | ID: covidwho-2001974

ABSTRACT

Female carriers of pathogenic/likely pathogenic (P/LP) BRCA1/2 variants are at increased risk of developing breast and ovarian cancer. Currently, the only effective strategy for ovarian cancer risk reduction is risk-reducing bilateral salpingo-oophorectomy (RR-BSO), which carries adverse effects related to early menopause. There is ongoing investigation of inhibition of the RANK ligand (RANKL) with denosumab as a means of chemoprevention for breast cancer in carriers of BRCA1 P/LP variants. Through the NCI Division of Cancer Prevention (DCP) Early Phase Clinical Trials Prevention Consortia, a presurgical pilot study of denosumab was developed in premenopausal carriers of P/LP BRCA1/2 variants scheduled for RR-BSO with the goal of collecting valuable data on the biologic effects of denosumab on gynecologic tissue. The study was terminated early due to the inability to accrue participants. Challenges which impacted the conduct of this study included a study design with highly selective eligibility criteria and requirements and the COVID-19 pandemic. It is critical to reflect on these issues to enhance the successful completion of future prevention studies in individuals with hereditary cancer syndromes.

2.
American Journal of Respiratory and Critical Care Medicine ; 205:2, 2022.
Article in English | English Web of Science | ID: covidwho-1880322
4.
Chest ; 160(4):A2192, 2021.
Article in English | EMBASE | ID: covidwho-1466201

ABSTRACT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

5.
Global Advances in Health and Medicine ; 10:22-23, 2021.
Article in English | EMBASE | ID: covidwho-1234511

ABSTRACT

Objective: Integrative medicine is a key framework for the treatment of chronic medical conditions, particularly chronic pain. In-person visits pose notable barriers for individuals with pain or limited mobility, particularly in rural or underserved areas. However, many barriers are pertinent to the expansion of telehealth use in integrative medicine settings, such as concerns about maintaining patient-clinician rapport in the delivery of holistic, relationship-based care. The COVID-19 pandemic served as impetus for an immediate and complete transition to telehealth services in this interdisciplinary outpatient integrative medicine clinic. This poster will present rich qualitative perspectives from multiple stakeholder levels on the experience of virtual visits to examine whether telehealth represents an acceptable, accessible, and high-quality option for providing integrative healthcare. Methods: Patients (N=180), providers (N=19), and administrative staff (N=7) in our outpatient integrative health clinic were surveyed about their experience of providing or receiving care via telehealth. Specifically, participants were asked to describe what telehealth visits were like in comparison to in-person visits. Free-text responses were analyzed for major and minor emergent themes. Results: Major themes identified from the data included acceptability, ease/convenience, comfort, interpersonal connection, technology difficulties, application of telehealth to group/movement classes, and equity/access. Overwhelmingly, participants described telehealth as an acceptable and adequate, at times equal or superior, alternative to in-person visits. Importantly, telehealth improved comfort for patients who could hold visits at home where they were most comfortable. Challenges were also welldescribed including technological issues and loss of interpersonal connection. Conclusion: Telehealth visits represent an acceptable, at times preferable, way to deliver care in an outpatient integrative medicine setting. Telehealth represents a particularly promising care modality for patients experiencing chronic pain or limited mobility, or those residing in rural and underserved communities. Detailed qualitative results provide rich perspective to inform future implementation and health policy regarding telehealth use.

6.
Global Advances in Health and Medicine ; 10:21-22, 2021.
Article in English | EMBASE | ID: covidwho-1234506

ABSTRACT

Objective: Interdisciplinary integrative medicine is key to treatment of chronic pain conditions. In-person visits can burden this population, particularly in rural and underserved areas with limited transportation options. Telehealth visits, were historically unsupported by payment models, delivery platforms, health and technological literacy, and clinician buy-in. The COVID-19 pandemic initiated a rapid transition to telehealth at our interdisciplinary outpatient integrative medicine center. This poster will describe the quantitative experience of telehealth integrative medicine services among stakeholders. Methods: Patients (n=472), clinicians (n=25), and staff (n=12) ranked telehealth vs in-person visits by survey with custom scale quality judgments and discrete choice after transitioning to telehealth and three months later. Results: Patient quality judgements significantly favored telehealth at baseline, B=.77 [0.29-1.25], SE=.25, t(712)= 3.15, p=.002, and increased in preference for telehealth at three months, B=.27 [-0.03-0.57], SE=.15, t(712)= 1.76, p=.079. Quality of technology, residing outside the county, and experiencing multiple disciplines predicted patient telehealth favorability. Clinicians did not favor one modality over the other, B=-1.00 [-1.56--0.44], SE=.29, t(799)=-3.48, p<.001. Patient discrete choice split at baseline and favored telehealth at three months. Overall, discrete choice favored telehealth at follow-up across clinicians and patients. Administrative staff's overall impression of telehealth was most favorable of all groups. Conclusion: Telehealth is a promising care modality for patients experiencing chronic pain. Far from a temporary preference, after three months, the majority of patients indicated they would choose telehealth visits over inperson visits, if they were equally safe. Policy that does not support telehealth for outpatient integrative medicine cannot do so under the name of patient preference, perceptions of quality, patient choice, or access.

7.
AJIL Unbound ; : 74-79, 2020.
Article in English | Scopus | ID: covidwho-1062717

ABSTRACT

Joseph R. Biden was elected President of the United States during a period of compound crises for global health and security: the worst pandemic in a century, as well as steep reverses in progress toward reducing poverty, hunger, and disease. The United States has been in full retreat from global health leadership, fraying relationships with allies, weakening global institutions, and engaging in nationalist populism that threatens global cooperation to address worldwide challenges. Yet these tragic circumstances are also fertile soil for deep structural reforms. President Biden can both bolster the immediate responses to COVID-19 and its vast ramifications, and spearhead lasting changes to create a healthier and safer world, from which the United States would richly benefit.1 His immediate task will be to bring U.S. economic and scientific strength to the COVID-19 response in partnership with the World Health Organization (WHO). The Biden administration should also assume financial and strategic leadership in bolstering world efforts to achieve the Sustainable Development Goals (SDGs), including its singular pledge to leave no one behind. Finally, President Biden should empower the WHO and lead on reforms to the global health architecture to advance the right to health. At a time when the United States is facing its own COVID-19 crisis, the agenda we propose for President Biden is ambitious. And global health leadership will need to complement other, related actions to address pressing global crises that have immense health consequences, like climate change and mass migration. Yet bold leadership on global health will benefit all people, including Americans. As COVID-19 devastatingly demonstrates, Americans' health security is inextricably tied to global health security. Healthier populations are more economically productive;better global health will mean larger markets for U.S. goods and services. U.S. global health leadership will open doors for cooperation on global challenges that themselves threaten the United States, from climate change and antimicrobial resistant organisms to cybersecurity. Such leadership should also help the United States to gain allies for stopping the global advance of authoritarianism and the erosion of human rights. While requiring new funds, the spending linked to our proposals would be minute compared to the overall federal budget, much less the U.S. economy. © Lawrence O. Gostin, Eric A. Friedman, Sarah Wetter 2021. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

8.
Feminist Studies ; 46(3):629-638, 2021.
Article in English | Scopus | ID: covidwho-1016456
9.
Chest ; 158(4):A2558, 2020.
Article in English | EMBASE | ID: covidwho-871911

ABSTRACT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Refractory septic shock is characterized by persistent hypotension with end-organ damage due to an underlying infection that fails to respond to maximal vasopressor support. Beyond IV fluids and antibiotics, treatment options are limited. Here, we present a case of refractory septic shock that rapidly improved following methylene blue (MB) administration. CASE PRESENTATION: An 82-year-old man with a past medical history of coronary artery disease presented to the hospital with one week of altered mental status and dyspnea. He was tachycardic to 159 bpm, hypotensive to 64/41 mmHg, and tachypneic. Bloodwork revealed mild leukopenia, acute kidney injury, and severe metabolic acidosis with pH 7.15 and lactate 10.7 mmol/L. A nasopharyngeal swab for SARS-CoV-2 was positive. Urinalysis was concerning for infection. CT chest showed bilateral patchy airspace opacities consistent with multifocal pneumonia. The patient was intubated for airway protection and administered IV fluids, piperacillin-tazobactam, and vancomycin. Despite aggressive fluid resuscitation, he remained persistently hypotensive, necessitating maximum dosages of norepinephrine, vasopressin, epinephrine, and phenylephrine infusions. Point-of-care ultrasound revealed preserved cardiac function. The decision was made to administer MB at 1 mg/kg over one hour. Within 3 hours, epinephrine infusion was successfully weaned off. Phenylephrine infusion was discontinued 24 hours later. Vasopressin and norepinephrine infusions were successfully stopped by hospital day 4 and 6, respectively, and patient's shock had resolved. Urine culture grew Escherichia coli. Antibiotic regimen was narrowed to ceftriaxone. The patient was extubated on hospital day 6 and was discharged home on hospital day 13. DISCUSSION: In septic shock, uncontrolled cytokine and nitric oxide (NO) lead to loss of vascular tone, which results in inadequate tissue oxygenation and end-organ damage. MB inhibits guanylate cyclase, which is a second messenger in NO-mediated vasodilatation. Several studies have noted a decrease in vasopressor requirements and preservation of cardiac performance markers (such as left and right ventricular stroke work index) when comparing MB to placebo in refractory septic shock;however, current literature does not suggest a reduction in mortality or length of hospital stay. Pulmonary vasoconstriction resulting in hypoxia was the most serious adverse effect, but was only noted with higher MB dosing (3-4 mg/kg). This case supports the previously described beneficial effects of MB and suggests that further trials should be conducted to assess the effect of MB on clinical outcomes. CONCLUSIONS: This case highlights the potential role of MB in refractory septic shock. Its use is considered safe when administered in low doses. Reference #1: Mayer B, Brunner F, Schmidt K. Inhibition of nitric oxide synthesis by methylene blue. Biochem Pharmacol 1993;45: 367–74 Reference #2: Kirov MY, Evgenov OV, Evgenov NV, et al. Infusion of methylene blue in human septic shock: a pilot, randomized, controlled study. Crit Care Med 2001;29:1860–7. Reference #3: Memis D, Karamanlioglu B, Yuksel M, et al. The influence of methylene blue infusion on cytokine levels during severe sepsis. Anaesth Intensive Care 2002;30:755–62. DISCLOSURES: No relevant relationships by Mouhanned Eliliwi, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by Jennifer Meyfeldt, source=Web Response

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