Treatment of Acute Kidney Injury: A Review of Current Approaches and Emerging Innovations.

Acute kidney injury (AKI) is a complex and life-threatening condition with multifactorial etiologies, ranging from ischemic injury to nephrotoxic exposures. Management is founded on treating the underlying cause of AKI, but supportive care-via fluid management, vasopressor therapy, kidney replacement therapy (KRT), and more-is also crucial. Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors, some of which may be more kidney-protective than others. Initiation of KRT is controversial, and studies have not consistently demonstrated any benefit to early start dialysis. There are no targeted pharmacotherapies for AKI itself, but some do exist for complications of AKI; additionally, medications become a key aspect of AKI management because changes in renal function and dialysis support can lead to issues with both toxicities and underdosing. This review will cover existing literature on these and other aspects of AKI treatment. Additionally, this review aims to identify gaps and challenges and to offer recommendations for future research and clinical practice.

Measures to Increase Immunogenicity of SARS-CoV-2 Vaccines in Solid Organ Transplant Recipients: A Narrative Review.

Purpose of review: To review the data on the immunogenicity of COVID-19 vaccines, administered by different strategies, in solid organ transplant recipients (SOTRs). Recent findings: COVID-19 booster vaccines were given to SOTRs as a widespread practice in many transplant centers, mostly as the third and/or fourth dose in an extended vaccine series, with a significantly improved humoral response compared with the initial two-dose scheme. However, one-third of SOTRs remained unresponsive, despite these boosters. Next steps: Vaccination with standard dosing remains the most feasible strategy for attaining protection against COVID-19. Additional booster doses and temporarily holding or reducing mycophenolate mofetil/mycophenolic acid may provide immunogenicity to vaccines, according to recent studies demonstrating some efficacy with these measures. Preexposure prophylaxis with monoclonal antibodies showed benefit in immunocompromised patients but is no longer recommended by the National Institutes of Health (NIH) due to diminished efficacy against Omicron and recent variants. Screening for the presence and titers of SARS-CoV-2-specific antibodies in SOTRs is not recommended in most clinical settings. T cell-based techniques are needed to evaluate vaccine efficacy and risk of infection. As SARS-CoV-2 continues to evolve, new vaccines based on conservative protein component/complexes of the COVID virus, in addition to its spike protein, are warranted to offer prolonged protection.

Assessing Medical Students' Attitudes and Knowledge Regarding LGBTQ Health Needs Across the United States.

BACKGROUND: The lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community experiences health disparities. It is thus imperative that medical trainees receive training in the care of LGBTQ community. The objective of this study was to identify gaps in knowledge and comfort among medical school students in providing care for the LGBTQ community. METHODS: An online survey was administered to medical students at 3 institutions in the United States from December 2020 to March 2021. Using a Likert scale, the survey assessed attitudes, comfort, and knowledge in providing care for the LGBTQ community. The survey included questions for each specific LGBTQ population. Results were quantified using descriptive and stratified analyses, and an exploratory factor analysis was used to calculate attitude summary measure (ASM) scores. A total knowledge score was calculated, with higher values indicating greater knowledge. RESULTS: Among the 300 medical students who completed the survey, the majority were female (55.7%), White (54.7%), and heterosexual (64.3%). The majority of medical students felt comfortable (strongly agree/agree) participating in the care of lesbian (94.3%), gay (96.0%), and bisexual (96.3%) patients; this percentage dropped to 82.3% for non-binary and 71.3% for transgender patients. Only 27.0% of medical students reported confidence in their knowledge of health needs of transgender patients. LGBTQ self-identification, percent of core rotations completed in school, region of country, and friends and/or family who are part of the LGBTQ community were significantly associated with various ASM scores. Knowledge questions yielded high percentages of "neutral" responses, and medical students who identified as LGBTQ had significantly higher total knowledge scores. CONCLUSIONS: Overall, the surveyed medical students feel comfortable and willing to provide care for LGBTQ persons. But, there is limited knowledge about specific LGBTQ health needs. More education and training in the needs of transgender and non-binary patients, in particular, is indicated.

Pathophysiology of Rejection in Kidney Transplantation.

Kidney transplantation has been the optimal treatment for end-stage kidney disease for almost 70 years, with increasing frequency over this period. Despite the prevalence of the procedure, allograft rejection continues to impact transplant recipients, with consequences ranging from hospitalization to allograft failure. Rates of rejection have declined over time, which has been largely attributed to developments in immunosuppressive therapy, understanding of the immune system, and monitoring. Developments in these therapies, as well as an improved understanding of rejection risk and the epidemiology of rejection, are dependent on a foundational understanding of the pathophysiology of rejection. This review explains the interconnected mechanisms behind antibody-mediated and T-cell-mediated rejection and highlights how these processes contribute to outcomes and can inform future progress.

"I need more knowledge": Qualitative analysis of oncology providers' experiences with sexual and gender minority patients.

Background: While societal acceptance for sexual and gender minority (SGM) individuals is increasing, this group continues to face barriers to quality healthcare. Little is known about clinicians' experiences with SGM patients in the oncology setting. To address this, a mixed method survey was administered to members of the ECOG-ACRIN Cancer Research Group. Materials and methods: We report results from the open-ended portion of the survey. Four questions asked clinicians to describe experiences with SGM patients, reservations in caring for them, suggestions for improvement in SGM cancer care, and additional comments. Data were analyzed using content analysis and the constant comparison method. Results: The majority of respondents noted they had no or little familiarity with SGM patients. A minority of respondents noted experience with gay and lesbian patients, but not transgender patients; many who reported experience with transgender patients also noted difficulty navigating the correct use of pronouns. Many respondents also highlighted positive experiences with SGM patients. Suggestions for improvement in SGM cancer care included providing widespread training, attending to unique end-of-life care issues among SGM patients, and engaging in efforts to build trust. Conclusion: Clinicians have minimal experiences with SGM patients with cancer but desire training. Training the entire workforce may improve trust with, outreach efforts to, and cancer care delivery to the SGM community.

Perspectives of Young Women With Gynecologic Cancers on Fertility and Fertility Preservation: A Systematic Review.

BACKGROUND: Gynecologic cancers standard treatment often requires the removal of some reproductive organs, making fertility preservation a complex challenge. Despite heightened oncofertility awareness, knowledge about fertility attitudes and decisions of young patients with gynecologic cancer is scarce. The aim of this systematic review was to highlight what is currently known about knowledge, attitudes, and decisions about fertility, fertility preservation, and parenthood among these patients. METHODS: Peer-reviewed journals published in English were searched in PubMed, Web of Science and EMBASE from January 1, 2000 to July 1, 2020. Childbearing, fertility, fertility preservation, pregnancy, and parenthood attitudes/decisions after gynecologic cancer from women's perspective were evaluated. RESULTS: A total of 13 studies comprised the review. Most of the women valued fertility preservation procedures that could be regarded as a means to restore fertility. A unique feature identified was that fertility preservation was seen also as a way to restore gender identity perceived to be lost or threatened during diagnosis and treatment. Fertility counseling was suboptimal, with wide variability among studies reviewed. Comparisons between gynecologic cancers and other cancer types about fertility counseling rates were inconclusive. The potential negative impact of impaired fertility on patients' mental health and quality of life was also documented. CONCLUSIONS: Fertility and parenthood were important matters in patients' lives, with the majority of patients expressing positive attitudes toward future childbearing. Results confirm that the inclusion of patients with gynecologic cancer in research studies focusing on this topic still remains low. Additionally, the provision of fertility counseling and referral by health professionals is still suboptimal.

Organic vs Stimulant-Induced Psychosis in the Peripartum Period.

This is the case of a 30-year-old pregnant female who presented to the medical emergency department with signs and symptoms consistent with a psychotic episode. At the time of presentation, the patient was noted to have paranoia and delusions focused on her current pregnancy. On further evaluation in the emergency department, the patient's urine toxicology was found to be positive for methamphetamines. Following medical clearance, the patient was admitted for acute inpatient psychiatric stabilization. During hospitalization, her psychosis rapidly resolved with only the use of two emergency treatment injections containing antipsychotic medication. This case presents an interesting differential diagnosis between a brief psychotic disorder with peripartum onset and a substance-induced psychosis, and allows for further discussion in the differentiation and clinical treatment of these diagnoses.

The relationship between neurocognitive decline and the heart-lung machine.

Surgery involving the use of cardiopulmonary bypass (CPB) has long been associated with cerebral changes and may also contribute to adverse neurocognitive outcomes. However, there is a debate as to whether bypass itself is responsible for these changes. We conducted a systematic literature review on PubMed, supplementing our work with recent articles from other sources to examine the current evidence on neurocognitive decline associated with CPB. While surgeries involving CPB appear to be associated with cerebral changes and potentially with neurocognitive decline, it is unclear as to whether decline is related to the procedure itself. It is possible that the impacts of CPB can be more readily observed among individuals with preoperative cognitive impairment. It is thus important to screen for subtle and more apparent preoperative cognitive impairment as a risk factor for adverse outcomes. Further research, comparing on-pump and off-pump cohorts and involving intensive screening of preoperative cognitive decline, is indicated to elucidate the true neurocognitive consequences of the heart-lung machine.

Cancer and the LGBTQ Population: Quantitative and Qualitative Results from an Oncology Providers' Survey on Knowledge, Attitudes, and Practice Behaviors.

BACKGROUND: Despite growing social acceptance, the LGBTQ population continues to face barriers to healthcare including fear of stigmatization by healthcare providers, and providers' lack of knowledge about LGBTQ-specific health issues. This analysis focuses on the assessment of quantitative and qualitative responses from a subset of providers who identified as specialists that treat one or more of the seven cancers that may be disproportionate in LGBTQ patients. METHODS: A 32-item web-based survey was emailed to 388 oncology providers at a single institution. The survey assessed: demographics, knowledge, attitudes, and practice behaviors. RESULTS: Oncology providers specializing in seven cancer types had poor knowledge of LGBTQ-specific health needs, with fewer than half of the surveyed providers (49.5%) correctly answering knowledge questions. Most providers had overall positive attitudes toward LGBTQ patients, with 91.7% agreeing they would be comfortable treating this population, and would support education and/or training on LGBTQ-related cancer health issues. CONCLUSION: Results suggest that despite generally positive attitudes toward the LGBTQ population, oncology providers who treat cancer types most prevalent among the population, lack knowledge of their unique health issues. Knowledge and practice behaviors may improve with enhanced education and training on this population's specific needs.

Contraception: the Need for Expansion of Counsel in Adolescent and Young Adult (AYA) Cancer Care.

Little is known about oncology provider recommendations regarding best practices in contraception use during cancer treatment and through survivorship for adolescent and young adult (AYA) cancer patients. This review examined the literature to identify related studies on contraception recommendations, counseling discussions, and methods of contraception in the AYA oncology population. A literature review was conducted using PubMed, including all peer-reviewed journals with no publication date exclusions. A systematic review of the literature was conducted using combinations of the following phrases or keywords: "oncology OR cancer" AND "contraception, family planning, contraceptive devices, contraceptive agents, intrauterine devices OR IUD, vaccines, spermatocidal agents, postcoital, immunologic, family planning, vasectomy, tubal ligation, sterilization" AND "young adult OR adolescent" AND "young adult AND adolescent". Reviewers assessed articles using the "Quality Assessment Tool for Quantitative Studies" which considers: (1) selection bias; (2) study design; (3) confounders; (4) blinding; (5) data collection methods; and (6) withdrawals and dropouts. A total of five articles were included and all studies were quantitative. Results showed no consistent recommendations among providers, references to guidelines, or methods of contraceptive types. Provider guidelines for discussions with AYA patients should be expanded to provide comprehensive, consistent, and quality cancer care in the AYA population.

Patient Perspectives on Deep Brain Stimulation Clinical Research in Early Stage Parkinson's Disease.

The FDA has approved a multicenter, double-blind, Phase III, pivotal trial testing deep brain stimulation (DBS) in 280 people with very early stage Parkinson's disease (PD; IDE#G050016). In partnership with The Michael J. Fox Foundation for Parkinson's Research, we conducted a survey to investigate motivating factors, barriers, and gender differences among potentially eligible patients for participation in a trial testing DBS in early PD compared to standard medical treatment. The majority of survey respondents (72%) indicated they would consider learning more about participating. Early PD patients are therefore likely to consider enrolling in trials of invasive therapies that may slow symptom progression and help future patients.