Citations

Effective delivery of cancer care via telehealth requires a planned care system that accounts for myriad patient, provider, and practice/cancer center resources before, during, and after the care episode. Telehealth is broadly defined as a method to have virtual, bidirectional communication between patients and providers. Telehealth can include methods such as audio-only, video-consultation, and tele-monitoring, which can occur in a synchronous, asynchronous, or blended format. The purpose of this review is to present common foundational principles for providing clinical cancer care via telehealth, followed by an overview of three distinct examples of comprehensive telehealth programs that have been developed to meet the needs of patients and families across the cancer trajectory, including survivorship, rehabilitation, and palliative care phases. The programs described are exemplars that were developed and implemented prior to the coronavirus pandemic, so they reflect many years of planning and evidence. Lessons learned include the need for ongoing patient support, clinician training, and cancer health system/practice programmatic considerations such as billing, scheduling, reimbursement, software, and hardware/platform security. Although the COVID-19 pandemic produced an explosive shift in regulations and implementation, sustainability of these changes may not be long-term. Nevertheless, a permanent shift in cancer care to include telehealth is likely here to stay.

Introduction: Studies have found that smaller brain volumes, cerebral infarcts, and white matter abnormalities are associated with dementia and mild cognitive impairment. However, these studies have been limited by short follow-up precluding a strong establishment of temporality. Therefore, it is unknown whether brain imaging findings are preceded by long-term changes in cognition. We sought to address this gap by examining brain imaging and two decades of cognitive changes in and a large, representative population-based cohort of older adults of black and white race. Hypothesis: We hypothesized that 22-year declines in global cognitive factor scores (GCFS) would be associated with a pattern of smaller total brain and temporal lobe meta region of interest (likely to be affected by Alzheimer’s disease) volumes, larger white matter hyperintensity volumes, and greater odds of ≥1 lacunar infarct and elevated brain β-amyloid deposition. Methods: ARIC participants with brain imaging data, complete cognitive factor score, and not missing key covariates were included. GCFS were collected at three visits across 22 years (1990-2013), and brain MRI and florbetapir PET imaging were collected in 2011-13; PET in subset of n=327. Mixed effects models with random intercepts and slopes predicted individual change in GCFS. Outcomes of interest were total brain volume (cc), temporal lobe meta region volume, log 2 (white matter hyperintensity volume), ≥1 lacunar infarct, and elevated brain β-amyloid deposition (SUVR >1.2). Multivariable linear and logistic regression was used to relate outcomes to GCFS slopes after adjusting for confounders, including vascular risk factors. As appropriate, models were also adjusted for total intracranial volume. Results: Among 1957 with complete brain MRI imaging, 1830 were included in the study, 60% (n=1096) women and 26% (n=480) black. At the first visit, the mean (SD) baseline age was 55 (5.2) yrs. The mean (SD) observed GCFS at the three visits were 0.16 (0.79), 0.05 (0.75), and -0.78 (0.86). After adjustment, a 1-SD larger decline in GCFS was significantly associated with a smaller brain volume by 1.6% [95%CI: 1.3, 1.8] relative to mean brain volume, a smaller temporal lobe meta region volume by 2.4% [2.1, 2.8] relative to the mean volume, a 15% [11, 19] larger volume of white matter hyperintensities, 1.3-fold [1.2, 1.4] higher odds of having ≥1 lacune, and 1.8-fold [1.4, 2.4] higher odds of elevated brain β-amyloid deposition. Associations remained significant after further adjustment for first or last GCFS. Conclusions: Greater declines in long-term cognitive functioning were significantly associated with smaller brain volumes and dementia-related brain characteristics and were independent of last visit GCFS. This suggests long-term changes in cognition may precede late-life brain morphology and outperform cross-sectional cognitive measures.

INTRODUCTION: Urinary neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in differentiating acute tubular necrosis (ATN) from other types of acute kidney injuries (AKIs) in cirrhosis, particularly hepatorenal syndrome (HRS). However, NGAL is not currently available in clinical practice in North America. METHODS: Urinary NGAL was measured in a prospective cohort of 213 US hospitalized patients with decompensated cirrhosis (161 with AKI and 52 reference patients without AKI). NGAL was assessed for its ability to discriminate ATN from non-ATN AKI and to predict 90-day outcomes. RESULTS: Among patients with AKI, 57 (35%) had prerenal AKI, 55 (34%) had HRS, and 49 (30%) had ATN, with a median serum creatinine of 2.0 (interquartile range 1.5, 3.0) mg/dL at enrollment. At an optimal cutpoint of 244 μg/g creatinine, NGAL distinguished ATN (344 [132, 1,429] μg/g creatinine) from prerenal AKI (45 [0, 154] μg/g) or HRS (110 [50, 393] μg/g; P < 0.001), with a C statistic of 0.762 (95% confidence interval 0.682, 0.842). By 90 days, 71 of 213 patients (33%) died. Higher median NGAL was associated with death (159 [50, 865] vs 58 [0, 191] μg/g; P < 0.001). In adjusted and unadjusted analysis, NGAL significantly predicted 90-day transplant-free survival ( P < 0.05 for all Cox models) and outperformed Model for End-Stage Liver Disease score by C statistic (0.697 vs 0.686; P = 0.04), net reclassification index (37%; P = 0.008), and integrated discrimination increment (2.7%; P = 0.02). DISCUSSION: NGAL differentiates the type of AKI in cirrhosis and may improve prediction of mortality; therefore, it holds potential to affect management of AKI in cirrhosis.

Abstract Background: Accurate interpretation of laboratory values with sex-specific reference ranges presents a challenge in transgender individuals on gender affirming hormone therapy (GAHT). Creatinine (Cr), the most common marker used for kidney function, varies significantly with body mass and composition. Both Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) equations account for sex in estimating glomerular filtration rate. GAHT can effect Cr values in 2 potential ways: 1) by causing changes in muscle mass and body fat redistribution as early as 3 months after GAHT initiation and 2) by direct effects of sex hormones on kidney function. Previous studies have shown Cr values approaching affirmed gender identity as early as 6 months when on GAHT without mention of sex steroid levels. In this study we sought to describe the changes in serum Cr after initiation of GAHT in an effort to better understand expected changes and interpretation of lab data in TG individuals. Methods: A retrospective chart analysis on all adult TG patients initiated on GAHT at our institution from January 2011 to 2020 was completed. We reviewed demographics, baseline health information, body mass index, and lab values including Cr, sex hormone levels, A1C, and fasting blood glucose. Lab values were obtained prior to GAHT, at the start of GAHT, at 3, 6, and 12 months after GAHT. Matched pair testing was conducted with sex steroid levels and Cr values in transgender men (TM) on testosterone and transgender women (TW) on estradiol in order to compare the median pre GAHT Cr to median Cr levels at 3, 6, and 12 months. Results: 84 TW with a median age of 30 and 24 TM with a median age of 23 were included for analysis. TW and TM had a low rate of existing kidney disease (4.9%, 0%), diabetes mellitus (4.8%, 0%), and hypertension (10.8%, 4.5%) respectively. TW on GAHT achieved a goal estradiol level (≥100 pg/ml) at a rate of 37.3%, 51.7%, and 71.1% and suppressed testosterone to a goal level (&lt;60ng/ml) at a rate of 44.4%, 54.7%, and 76.5% at 3, 6, and 12 months respectively. There was no significant change in Cr values at 3 months, but significantly decreased on average by -0.07 (p&lt;0.001) at 6 months, and by -0.09 (p&lt;0.001) at 12 months. TM on GAHT achieved a goal testosterone level (≥240 ng/dl) at a rate of 64.3%, 80.0%, and 72.3% at 3, 6, and 12 months respectively. Cr values increased significantly on average by 0.14 (p=0.036) at 3 months, by 0.21 (p=0.004) at 6 months, and by 0.15 (p=0.003) at 12 months. Conclusions: In TW on GAHT, clinicians can consider using affirmed gender Cr reference ranges as early as 6 months. Similarly in TM on GAHT, affirmed gender Cr reference ranges can be used as early at 3 months. It remains to be seen whether changes in Cr levels reflect changes in sex steroid levels or sex steroid direct effects. Additionally, research is needed to determine if change in Cr levels reflect true changes in GFR.