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In the world of politics we spend 364 days a year complaining about everything that's wrong with our society. Now, our world leaders are trying to take away the one day of the year where we can reflect on what we are grateful for, Thanksgiving. Some advice: Do NOT let Dr. Fauci's policies ruin your precious time with loved ones.
NEW Exercise Guidelines for Older Adults! with Christina Prevett Want to make sure you stay on top of all things geriatrics? Go to http://PTonICE.com/resources to check out our Free eBooks, Lectures, & the MMOA Digest!
What role does glycogen availability play in cramping and what is the latest research showing us about why cramps happen? Orange Seal Off-Road Team's Alex Wild will join us to dig into this as well as discussing fitness plateaus, endurance athlete guidelines for protein intake and more. Join us live for Episode 340 of the Ask a Cycling Coach Podcast! -------------------------------------------- TOPICS COVERED IN THIS EPISODE 0:15 Intro 4:28 Alex's off-season 10:31 The Hosts' Goals for 2022 24:26 Deep dive into muscle cramps and glycogen 01:12:04 Rapid Fire Questions 1:23:55 Training with too high of an FTP 1:32:40 How Alex avoids fitness plateaus as a pro athlete 1:39:33 Training for extremely long climbs 1:49:10 How much protein should endurance athletes ingest? 1:56:00 More Rapid Fire Questions -------------------------------------------- RESOURCES MENTIONED IN THIS EPISODE - Kawasaki: 'A monkey never cramps' - Serum electrolyte concentrations and hydration status are not associated with exercise associated muscle cramping (EAMC) in distance runners - Cause of Exercise Associated Muscle Cramps (EAMC) — altered neuromuscular control, dehydration or electrolyte depletion? - A Narrative Review of Exercise-Associated Muscle Cramps: Factors that Contribute to Neuromuscular Fatigue and Management Implications - Muscle Cramping in the Marathon: Dehydration and Electrolyte Depletion vs. Muscle Damage - Muscle Cramping During Exercise: Causes, Solutions, and Questions Remaining - Ingestion of transient receptor potential channel agonists attenuates exercise-induced muscle cramps - Exercise-Associated Muscle Cramp-Doubts About the Cause - Skeletal muscle fatigue: cellular mechanisms - Role of glycogen availability on SR Ca2+ kinetics in human skeletal muscle - Effects of Congestive Heart Failure on Ca2+ Handling in Skeletal Muscle During Fatigue - Oxidative stress impairs the function of sarcoplasmic reticulum by oxidation of sulfhydryl groups in the Ca2+-ATPase - The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review -------------------------------------------- TRY TRAINERROAD RISK FREE FOR 30 DAYS! TrainerRoad makes cyclists faster. Athletes get structured indoor workouts, science-backed training plans, and easy-to-use performance analysis tools to reach their goals. Get Started: https://bit.ly/3unoSnx Adaptive Training: What it is, how to use it: https://bit.ly/3dIRClW Build Your Custom Plan: https://bit.ly/3oR8sme Train Together with Group Workouts: https://bit.ly/3fkaYyd -------------------------------------------- LEARN MORE ABOUT ADAPTIVE TRAINING Adaptive Training Video: https://youtu.be/c15eVK29bj0 Adaptive Training: What it is, how to use it: https://bit.ly/3dIRClW How Adaptive Training Makes You Faster: https://bit.ly/2ZNfWLq -------------------------------------------- SUCCESSFUL ATHLETES PODCAST Listen to the Successful Athletes Podcast now!: https://www.TrainerRoad.com/SAP -------------------------------------------- SCIENCE OF GETTING FASTER PODCAST Listen to the Science of Getting Faster Podcast now!: https://www.TrainerRoad.com/SOGF -------------------------------------------- STAY IN TOUCH Facebook: https://www.facebook.com/TrainerRd Instagram: https://www.instagram.com/trainerroad/ Twitter: https://twitter.com/TrainerRoad Strava Club: https://www.strava.com/clubs/trainerroad
Welcome back to Don't Alert the Stans! For this week's episode, an impromptu but comprehensive review of Bruno Mars and Anderson Paak's joint ‘Silk Sonic' project results in a rant from Sope on the rollout and the relative monotony of their sound (00:42:24). In response to Taylor Swift's massive success with the re-recordings of ‘Fearless' and ‘Red', Universal Music have imposed tighter and more restrictive guidelines for artists who would like to follow suit and re-gain control of their artistry after their respective contracts end (01:03:19). Adele's 4th studio album ‘30' is officially out and it's safe to say it was one of the most anticipated releases of the year. Inspiring Eden and Sope to dissect what they call ‘The Adele phenomenon'. Looking at her journey and how she's reached gargantuan levels of superstardom (01:18:00). As the episode rounds down, Eden makes sure to give his condolences to slain rapper Young Dolph who was murdered last week (01:38:00). Not one to miss! Sope's Listens For The Week: Luther Vandross - Make You A Believer + For The Sweetness Of Your Love Aretha Franklin - Jump To It Katy B - Peace & Offerings + Power On Me Lynda Dawn - Roses + At First Light Tania Maria - Brasil With My Soul Maxwell - Of Eden's Listens For The Week: CKay - love nwantiti Amine - TWOPOINTFIVE Silk Sonic - An Evening With Silk Sonic Capella Gray - GYALIS Kings Of Leon - Only By The Night Kings Of Leon - When You See Yourself Nic's Listens For The Week: N/A Remember to RATE, REVIEW AND SUBSCRIBE! Enjoy! ------------------------------------------------------------------------------------------------- Intro Music by: @Jmzofficial ---------------------------------------------------------------------------------------------- Get involved! Don't forget to tweet us your thoughts on the episode at #DATSPOD! Rate and review us on Soundcloud, Apple Music, Spotify and Anchor Follow us on: Twitter - @datspod Instagram - @datspod Anchor – @datspodcast Hashtag - #DATSPOD --- Send in a voice message: https://anchor.fm/datspodcast/message
In this episode, AABP Executive Director Dr. Fred Gingrich is joined by Dr. Justin Kieffer, former chair of the AABP Committee on Pharmaceutical and Biologic Issues (CPBI). Dr. Kieffer led a team of AABP members in the development of the first bovine vaccination guidelines produced by AABP. We discuss the development of this resource document that is available exclusively to AABP members to assist them in developing vaccine protocols for beef and dairy operations. We discuss how veterinarians can consult with producers in optimizing the immune response to vaccines as well as minimize adverse events and what to do if there is an adverse event. Dr. Kieffer updates us on the implementation of the single tier vaccine labeling in 2015 by USDA APHIS. CPBI developed a list of core vaccines for cattle which includes BVD, IBR, BRSV, PI3 and Clostridial pathogens. The vaccine guidelines discuss each pathogen's disease considerations, type of vaccines that are available, outbreak mitigation, and vaccine scheduling notes. The document provides this information for all core and risk-based vaccines that can be considered for cattle. Dr. Kieffer states that veterinarians should inform their producers that no vaccine is completely safe, no vaccine is completely effective and no vaccine is always indicated. AABP recommends that producers utilize the expertise of the veterinarian of record to develop and monitor vaccine protocols to improve the health, welfare and productivity of the cattle in their care. We encourage feedback from members on the guideline by emailing fred@aabp.org. If you are a current AABP member, you can view the vaccine guidelines by going to the AABP Committee Resources page and opening the Pharmaceutical and Biologic Issues section. You will find the guideline as a downloadable PDF at the bottom of the CPBI resources page. The link for the USDA APHIS veterinary biologics product summaries to view vaccine data for the single-tier labeling claim is located here. Practical immunology and beef and dairy vaccine protocolsChris Chase2021 AABP Recent Graduate Conference Proceedings The vaccine guidelines developed by CPBI is an example of AABP providing practical resources for members. If you are not an AABP member and you are working with cattle, we welcome you to join our organization. You can join AABP or renew your dues to become a current member, by going to this link. Have a podcast suggestion or feedback? Email haveyouherd@aabp.org
Contributor: Chris Holmes, MD Educational Pearls: Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours 2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients References Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD ********************* The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award
Credits: 0.25 AMA PRA Category 1 Credit™ CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-251 Overview: Primary care providers should be up to date on the changes to the guidelines for cervical cancer screening to be able to guide patients in shared decision-making about health maintenance. Join us to review the recent changes to cervical cancer screening guidelines as recommended by the American Cancer Society. Episode resource links: Cervical Cancer Screening: Updated Guidelines from the American Cancer Society. Am Fam Physician. 2021 Sep; 104(2):314-315. American College of Obstetricians and Gynecologists. Updated cervical cancer screening guidelines. Practice advisory. April 2021. Accessed September 30, 2021. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-screening-guidelines Fontham, ETH, Wolf, AMD, Church, TR, et al. Cervical Cancer Screening for Individuals at Average Risk: 2020 Guideline Update from the American Cancer Society. CA Cancer J Clin. 2020. https://doi.org/10.3322/caac.21628. Guest: Jillian Joseph, MPAS, PA-C Music Credit: Richard Onorato
The so called elite and their continued covering up for one another is well documented by now and amplified in the Epstein case. In this episode we dive back into so called elite society and how the game is rigged in their favor. (Commercial at 16:44)To contact me:Bobbycapucci@protonmail.comIf you enjoy my content and want to help support the podcast:Source:https://www.fairobserver.com/region/north_america/peter-isackson-alex-acosta-federal-prosecutor-jeffrey-epstein-case-us-american-world-news-79671/
(Gaia House)
(Gaia House)
(Gaia House)
This week, Kate, John, Mark and Henry discuss music to improve sleep and cognition in older adults, lung cancer screening in an organized health system, a comparison of 2 agents for VTE prophylaxis after total knee arthroplasty, and a new pain guideline with a surprising recommendation.
Antimicrobial Stewardship as a strategy to get the right treatment to the right patient at the right time. On this episode of Talking Pediatrics, Dr. Gabi Hester talks with Dr. Christina Koutsari, Pediatric Infectious Diseases pharmacist and co-leader of the Antimicrobial Stewardship committee about growing concerns for antibiotic resistance and ways to combat this potentially lethal situation.
Marni welcomes Licensed Psychotherapist Terri Cole to the Life Check Yourself podcast. Terri is a global relationship and empowerment expert, the author of Boundary Boss: The Essential Guide to Talk True, Be Seen, and (Finally) Live Free, and podcast host. She offers up tips for single ladies who date, how-to say no with ease and grace, and her effective Boundary Blueprint. Key takeaways from this episode: Effective Communication Skills How to Set Personal Boundaries How to Say No with Ease and Grace Dating Red Flags Establishing Healthy Boundaries [2:41] Terri describes boundaries as personal rules of engagement. Guidelines we set to let other people know what is ok and what is not ok with us. They are rules specifically customized around our limits, values, and deal-breakers. They let people know how to treat us. When we were young most of us were told to be good kids and do things for other people whether we wanted to or not. This means, most of us were raised to be self-abandoning, people-pleasing, co-dependents. Almost all of us have disordered boundaries. Terri says boundaries are a language we can learn. We got corrupted data and that creates a twisted sense of self, value, and worth. It is a complicated aspect of our personality. In her book, Boundary Boss: The Essential Guide to Talk True, Be Seen, and (Finally) Live Free she has step-by-step instructions on how to set healthy boundaries. When we do things for others that they can and should be doing for themselves we can become bitter and burnt out. It is absolutely okay to say no without an explanation of why you are saying no. The amount of self-respect, self-love, and self-worth we feel for ourselves sets the bar for every other relationship in our lives. Whether we know it or not. The Boundary Blueprint [15:33] If you don't set boundaries, you will be a martyr only doing things for people out of a corrupted sense of responsibility. You may try to make people feel guilty and you will give corrupted data about yourself to the people in your life so they won't authentically know you. And, how can anyone authentically love you if you don't allow them to authentically know you or you don't authentically know yourself? To get started: Get clear about where you need a boundary, then Do a resentment inventory Make a simple request Don't change the rules Tips for Single Ladies [31:21] Single women should value their time and not get stuck in the pen pal zone when a guy texts but won't ask you out. Ask him to take things to the next level. Who has time to waste? Not empowered single women. Set boundaries in the dating realm, early and often. A woman who has healthy boundaries says something when someone doesn't keep their word. She pushes back when a guy doesn't call when he says he will. She doesn't collude with a guy's twisted sense of reality when he thinks his time is more valuable than she is. Make a Connection: Visit Our Website Join Our Dating Den Facebook Community Here! Learn how to attract your perfect equal...watch our latest training here! Interested in working with us? Book a Breakthrough session at DWDVIP Get a Free Coaching Session with Marni on Our Podcast - Sign up Here to Be a Guest On Our Show Download a Complimentary Copy of our Book - How to Find a Quality Guy Without Going on 200 Dates Boundary Boss
Jay Scott Outdoors Western Big Game Hunting and Fishing Podcast
Join Jay Scott and Brian Rimsza as they discuss OTC Archery Deer hunts-Mandatory Reporting-Hunt Guidelines-Hunt Recommendations You can show support by simply sending an email to azhuntguidelines@azgfd.gov. The two things you need to mention in your email is what model you support and specifically mention that you support moving to mandatory reporting. Threshold Model Continue to issue permits in the same manner we do now. Establish harvest objectives for each unit. These objectives will include an individual season objective along with an annual harvest objective. Utilizing a mandatory harvest reporting system similar to bears/lions requiring successful hunters to report their harvest via telephone, internet, or etag within 48 hours of harvest. Once the season harvest objective has been met in a unit close the season the following Wednesday at sundown. In addition to the harvest reporting also utilize mandatory reporting to collect harvest data from unsuccessful hunters. This option would allow the department to reopen the units that were closed during the 2021 hunt recommendations process. Benefits listed below: No loss of revenue Active management during season eliminating overharvest Ability to evaluate non-resident harvest vs. resident harvest No restriction to non-resident participation azhuntguidelines@azgfd.gov brian.rimsza@hotmail.com Sponsors of the JSO Podcast https://www.gohunt.com/ Cody Nelson "Glassing Guru and Optics Authority" Optics Manager at goHUNT.com Gear Shop-Call Cody directly for info and sales at (702) 847-8747 Ext #2 or email at optics@goHunt.com Use "JayScott" promo code to get discount Now an added incredible value of Desktop Maps and MAPS available on iPhone and Android for no extra cost. Don't miss out on this incredible opportunity. Sign up at https://www.gohunt.com/jayscott and get a $50 goHUNT Gear Shop gift card http://www.kuiu.com/ or http://www.kuiu.com/blog/ https://www.phoneskope.com/ Use the "jayscott21" promo code to get 10% off all orders More on host Jay Scott www.JayScottOutdoors.com Instagram @JayScottOutdoors
The International Olympic Committee (IOC) recently announced controversial new transgender guidelines which could threaten the future of women's sport. But what does the evidence say and why did the IOC ignore the science? Mike Finch and Prof. Ross Tucker explain all. Get bonus content on Patreon See acast.com/privacy for privacy and opt-out information.
Christina Prevett // #GeriOnICE // www.ptonice.com
Accelerate your prophetic training by learning how to position yourself for spiritual promotion. Guest Caleb Wampler speaks about how his time serving under Daniel Kolenda led to him receiving his own platform which reaches millions. You will learn how to go higher in your calling. Go past your spiritual plateau. Understand how living a submitted life is key to unlocking your promotion. In this episode, you will finally have what you need to take a step closer to the ministry God has called you to. “I sat under Daniel Kolenda for three years serving and hardly saying anything. I watched and learned as much as I could. I allowed God to finish His work inside of me before He placed me as a leader” says Caleb Wampler. Jump into this episode. Stay Connected with Caleb and Joshua! Kingdom Encounters International Hunger (Audio Book) Get Connected with Apostles Craig and Colette Toach Follow Apostles Toach! Facebook.com/ToachMinistries Submit Your Question to the Apostles: ToachMinistries.com Join the Ranks of Next Gen Prophets! Prophetic-School.com
An interview with Dr. Leslie Fecher from the University of Michigan Health System, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews considerations for the use of steroids to manage immune-related adverse events in patients treated with immune checkpoint inhibitor therapy in the final episode of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today we're continuing our series on the management of immune related adverse events. I am joined by Dr. Leslie Fecher from the University of Michigan Health System in Ann Arbor, Michigan, author on "Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy. ASCO Guideline Update" and "Management of Immune Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T Cell Therapy, ASCO Guideline." And today we're focusing on considerations for the use of steroids to manage immune related adverse events in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Fecher. LESLIE FECHER: Thank you, Brittany, for this invitation. BRITTANY HARVEY: Great. Then I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with a publication of the guidelines in the Journal of Clinical Oncology. Dr. Fecher, do you have any relevant disclosures that are related to these guidelines? LESLIE FECHER: The details of my disclosures are included in the manuscript, but I'd just like to note that I have received research funding, specifically in the form of clinical trial funding, from companies that do manufacture these immunotherapies. BRITTANY HARVEY: Thank you. Then getting into the content, so steroids are valuable agents in the management of immunotherapy related adverse events. So first, what should clinicians consider pretreatment with steroids? LESLIE FECHER: So I think one of the first things is obviously going back to the traditional history and physical exam, and making sure you understand any preexisting comorbid conditions, such as diabetes, high blood pressure, preexisting cataracts or glaucoma, infections, osteopenia or osteoporosis. It's always good to try and optimize things before getting started on steroids. Additionally, it's typically considered very reasonable to check hepatitis B and C serologies prior to starting immunotherapy treatment. And also consideration of assessment for tuberculosis, if there are specific risk factors, understanding if somebody already carries a diagnosis of HIV, and Understanding the status of that in advanced would be relevant. BRITTANY HARVEY: Those are important considerations. Then in addition to that, how should opportunistic infections be prevented? LESLIE FECHER: So one of the most common infections that we tend to try and prevent is pneumocystis jirovecii pneumonia, or PJP, previously known as PCP pneumonia. And this is one of the more common things that we recommend prevention for. So in patients who have received the equivalent of prednisone dosing of 20 milligrams per day for four or more weeks, or greater than 30 milligrams per day for three weeks or more, that's when it would reasonably be indicated. There are obviously specific institutional guidelines for the preferred regimen, but I think that's important to consider. The role of viral prophylaxis as well as antifungal prophylaxis is a bit less clear, but is something to be considered, especially depending on the duration of the steroid course. And whether or not in the setting of herpes zoster, for example, if the patient has had issues with zoster in the past. BRITTANY HARVEY: OK. and then the use of these steroids is to treat immunotherapy related adverse events. But what are the key recommendations for monitoring both the short term and long term adverse effects from steroids? LESLIE FECHER: So I think being aware of the side effects as well as making sure that the patients and the family members or loved ones that are helping them are aware of them as well. From a short term standpoint, typically we recommend things such as GI prophylaxis, with either a proton pump inhibitor or a histamine 2 antagonist, to reduce or prevent gastric ulcers or duodenal ulcers or gastritis. Given some of the long term effects, such as bone loss as well as steroid myopathies, we encourage exercise as well as physical therapy in some circumstances. But really one of the most important things is to make sure that you're constantly both assessing and eliciting from the patient and family members for any other side effects. So often, common acute short term side effects can be increased risk of infection. So making sure you're asking about it. They may not have the typical manifestations of infection, such as fevers or chills. Insomnia or difficulty with anxiety, irritability, skin changes for sure, or high blood pressure. And then obviously being aware that laboratory evaluation for glucose intolerance is important as well. BRITTANY HARVEY: Definitely. Those are important points for clinicians, patients, and caregivers. So then we've had some of the other authors on this guideline talk about tapering steroids. So what are those recommendations on how clinicians should taper steroids? LESLIE FECHER: So tapering is an art in and of itself in my opinion, and there's lots of different ways to do it. Some general concepts are you want to really try and understand what the side effect is that you are managing, because that will require frequent reassessment. And so when we talk about reassessing patients during the treatment of their toxicities, the management of the toxicities, in my opinion, is almost as important as the management of the immunotherapy itself. And so patients still need to be seen, still need to be assessed, still need blood work done. And so reassessment for the toxicity that you're managing, given that we can see rebounding of symptoms. So for example, if they were getting treated for diarrhea or colitis, having a really good understanding of what their baseline bowel movements were, how bad they got, and then a constant reassessment and making sure that the patient, as well as the family, knows that this should not come back again, if you will, in the midst of the taper. I think the other things to be aware of is that I tend to always reassess before giving the next decrease in dose of the steroids rather than having an automatic decrease. Because again, patients sometimes will follow those, even if their symptoms recur. So ensuring that there's that, again, reassessment. When we're on oral steroids, some of the general concepts we say is that the course should be at least usually about four weeks total, sometimes as long as six weeks or even longer, depending on the toxicity. And we think about, on average, decreasing from a prednisone or prednisolone amount roughly 10 milligrams every three to seven days, depending on the side effect that you're managing. The longer the taper, the slower you might need to go, depending at the end. And also being aware of the risk of adrenal insufficiency towards the end of a long steroid course is also an important thing to assess for. BRITTANY HARVEY: Great. I appreciate you reviewing those considerations. So then in your view, Dr. Fecher, how will these recommendations for the use of steroids in the management of immune related adverse effects impact both clinicians and patients? LESLIE FECHER: I think it will bring ongoing awareness to the physician and their team, as well as the patient and their team. I think that this is obviously really important that everybody is involved and aware. And I use the term engagement from a patient and family member standpoint. It's really critical to have an understanding of the side effects, have an understanding of the prednisone management. And explaining that not only to the physician team and nurses and other people involved in their care, but when patients call in, that they know to look out for rebounding of their symptoms and to report them immediately, as that can impact steroid tapering. I think, again, the awareness and engagement is going to ensure that patients get the best care and best results. BRITTANY HARVEY: Absolutely, and thanks for highlighting both that awareness and engagement. So thank you so much for your work on these guidelines, and for taking the time to speak with me today, Dr. Fecher. LESLIE FECHER: Thank you so much, Brittany. I appreciate your time. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.
An interview with Dr. Marc Ernstoff from the National Cancer Institute, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” He reviews identification, evaluation & management of ocular toxicities in patients receiving ICPis, including uveitis, iritis, and episcleritis in Part 12 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today we're continuing our series on the management of immune related adverse events. I am joined by Dr. Marc Ernstoff from the National Cancer Institute in Bethesda, Maryland, author on "Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy, ASCO Guideline Update" and "Management of Immune Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T Cell Therapy, ASCO Guideline." And today we're focusing on ocular toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Ernstoff. MARC ERNSTOFF: Thank you, Brittany. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Ernstoff, do you have any relevant disclosures that are directly related to this guideline? MARC ERNSTOFF: I have no further disclosures at this time. SPEAKER 1: Great. Thank you. Then let's get into these ocular toxicities. So first, what are the immune related ocular toxicities addressed in this guideline? MARC ERNSTOFF: So the ocular toxicity is addressed in the guidelines represent a relatively uncommon side effect of immune checkpoint inhibition, and represents inflammation of all components of the eye from the superficial component to the internal uveal component. So there is iritis. There's episcleritis and uveitis, are the ones that are usually identified by physical examination and by complaints. BRITTANY HARVEY: Understood. Then so let's start with what are the key recommendations for identification, evaluation, and management of uveitis and iritis. MARC ERNSTOFF: So those are excellent questions. I think that it's important for clinicians to recognize that while most of the eye toxicities are relatively minor, low grade, and can be managed effectively, there are some that are very important to identify, particularly as they may lead to blindness, particularly uveitis or pan uveitis. So identification of these symptoms and signs are important. So evaluation of the patient by asking whether there are any eye symptoms-- dryness or irritation-- is important in your evaluation of the patient's side effects. In addition, looking at the eye, both with a penlight, looking for any inflammatory signs, and doing a ophthalmologic examination to make sure there's no cloudiness or anything identified in the retina is important. BRITTANY HARVEY: Great. And then furthermore, what are the key recommendations for identification, evaluation, and management of episcleritis? MARC ERNSTOFF: So episcleritis can usually be seen by irritation in the superficial areas of the eye. Usually if it's low grade, it can be managed with topical steroids and continuation of the immune checkpoint inhibitor. On the other hand, if it's more bothersome and not responding to topical therapy, evaluation by an ophthalmologist, potentially interruption of immune checkpoint inhibitor, is important. And if it's severe, systemic steroids might be required at that time. BRITTANY HARVEY: Great. Thank you for reviewing how to best identify and manage that particular toxicity. So then in your view, how will these recommendations for the management of ocular toxicities impact both clinicians and patients? MARC ERNSTOFF: So again, I think it's important that both from symptom management, that these, many times, can be managed with topical steroids and tears effectively, and that a patient's therapy can continue, which I believe is important. On the other hand, identifying areas that may be beyond the expertise of an oncologist, would require evaluation by an ophthalmologist, including a slit light examination. It is important to recognize that uveitis can have minimal symptoms and yet be more severe in its condition, requiring intervention and holding of immune checkpoint. And if really severe-- grade 3 or 4-- the interruption and discontinuation of immune checkpoint inhibition is probably going to be required to manage the side effect. Again, if undiagnosed and untreated, it can lead to blindness. So while not quote life-threatening, clearly a major impact in quality of life of a patient that is preventable, if identified. BRITTANY HARVEY: Great. Thank you so much for viewing these recommendations for the management of ocular toxicities, to ensure both the quality of life of patients and the best practices for management of these toxicities. So I want to thank you for your work on these guidelines and for taking the time to speak to you today, Dr. Ernstoff. MARC ERNSTOFF: Thank, you very much, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode.
Dr. Ebell and Dr. Wilkes discuss the POEM titled ' Guidelines for when to consider mortality-reducing treatments for patients with type 2 diabetes '
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An interview with Dr. Pauline Funchain from Cleveland Clinic, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews the recommendations for cardiovascular toxicities in patients receiving ICPis, including overall cardiac toxicities (i.e., myocarditis, pericarditis & arrhythmias), and VTE in Part 11 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today we're continuing our series on the management of immune related adverse events. I am joined by Dr. Pauline Fontaine from the Cleveland Clinic in Cleveland, Ohio, author on "Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy, ASCO Guideline Update," and Management of Immune Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T Cell Therapy, ASCO Guideline." And today we're focusing on the cardiovascular toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Fontaine. PAULINE FONTAINE: Thank you, Brittany, for the invitation. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines, and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Fontaine, do you have any relevant disclosures that are directly related to these guidelines? PAULINE FONTAINE: So I do. My institution receives research funding from Pfizer and Bristol Myers Squibb for clinical trials where I'm a primary investigator. And I have done some consultation work with Eisai. BRITTANY HARVEY: OK. thank you for those disclosures. Then talking about the content of this guideline, what are the immune related cardiovascular toxicities addressed in this guideline? PAULINE FONTAINE: So there are two major categories. One is an overall cardiovascular category. That includes myocarditis, pericarditis, arrhythmias, impaired ventricular function with heart failure, and vasculitis. That's overall. And there's a second category of venous thromboembolism. BRITTANY HARVEY: Great. Then starting with that overall category, what are the key recommendations for identification, evaluation, and management of myocarditis, pericarditis, arrhythmias, impaired ventricular function with heart failure, and vasculitis? PAULINE FONTAINE: So in that overall category, I think it's important to recognize that there are symptoms that are a little bit more general. They may be cardiovascular. They may be pulmonary. But we have to be aware that some of these can be cardiovascular. So that would include worsening fatigue, progressive or acute dyspnea. I think they're generally going to be other things, but you really have to recognize a potential cardiac IRE, as those can have major medical consequences. I mean there are other things that are more obviously cardiac, like chest pain, arrhythmia, palpitations, acute onset peripheral edema. And it is important to note that they can, like every other IRE, happen at any time. In the literature, the median time to onset is 6 weeks, but the range is somewhere between 1.4 to 54, and we know that it can be all over the place with IREs in terms of presentation. Then next would be evaluation. So with evaluation, whenever you see this type of side effect, fatigue, dyspnea, chest pain, it's natural to want to get an EKG troponin. I think that's a great place to start. And I think if there's more concern for cardiac type of IRE, then an echocardiogram, a chest X-ray, I think, are probably the next easiest evaluations to assess for cardiac IRE. One of the important things to note is that cardiac IREs, especially myocarditis, tend to happen along with concurrent myocytis, so it's important to check a CPK to rule that in or rule that out. And typically, then if people need more evaluation, the cardiac MRI is the next step, but things like cardiac catheterization may be involved. And so that's where I think it's really important with management to have cardiology involved early. I mentioned this briefly before, but it's really important to know that myocarditis has a very high fatality rate, up to about 50% in published series. I think as we get better at recognizing myocarditis, that fatality rate will likely go down, but catching a cardiac IRE late can have some very serious implications for our patients. So immediately recognizing that a cardiac workup is necessary, and referring early to cardiology is really important, no matter what grade of cardiac IRE we see. And I do think that with cardiac IREs, it's really, is it an inpatient workup? Does it require immediate cardiac consultation and workup? If there are elevated troponins that are going up, or conduction abnormalities, does that patient need to be in a cardiac unit? I think those are the major things to keep in mind with management. Another thing, I think, that is really important because of the high fatality rate: starting corticosteroids early. So like our other IREs, you can start corticosteroids that 1 to 2 mgs per kg per day. And doing that early has the potential to quickly improve cardiac inflammation, keep people from the very serious and potentially fatal side effects for cardiac IREs. And it really doesn't have that much of a consequence in the short term. So I think in discussions about this guideline, we all felt that if a patient has a Grade 2 or higher IRE-- so that's anything that has a cardiac biomarker that's abnormal plus symptoms of any kind-- it's important to keep in mind early steroids and early cardiac consultation. For very, very severe cases where management with corticosteroids is not improving the patient's status, then we highly recommend considering cardiac transplant rejection doses, which would be methyl pred at 1 gram daily, or adding other immunosuppressants. So there are not as many studies as we would like, but mycophenolate, infliximab, antithymocyte globulin have all been reported. There have also been case reports on abatacept or alemtuzumab, with good outcomes. So those are things to consider, of course, with cardiology input for severe cases. BRITTANY HARVEY: Thank you. Those are important notes for clinicians to keep in mind for management and evaluation. So then, the second category that you mentioned, what are the key recommendations for identification, evaluation, and management of venous thromboembolism? PAULINE FONTAINE: So for identification, most everyone listening to this podcast knows what a venous thromboembolism looks like. That's extremity swelling, extremity pain, sometimes accompanied by fever, pleuritic pain, cough, dyspnea. And the evaluation is the same as what you would see in clinic. That would be venous ultrasounds for any suspected deep vein thromboembolisms. And CT, PE for any suspected pulmonary embolism. And of course, a VQ scan if you can't do that type of CT. And the management is the same as what you would normally do in clinic. So if it's a superficial thrombosis, that would be a grade 1. You would do a warm compress, do supportive care. But importantly, you can continue the immune checkpoint inhibitor per our recommendations. For grade 2, so a symptomatic thrombosis, a deep vein thrombosis, that would require anticoagulation. But again, once anticoagulation has been started, the recommendation is that it is safe to continue the immune checkpoint inhibitor therapy, because at this point, you're protected. Should be, in theory, protected from future embolic events. And then, I think the major thing is that for management in general once there is anticoagulation on board, then there isn't necessarily a reason to hold immune checkpoint inhibitor therapy. I think that the major reasons we would recommend to hold it are life threatening consequences, organ damage. So grade 4 embolic event, where you would have to admit the patient. And then it becomes a risk benefit discussion after an admission. In general, I think the recognition and treatment are the same in terms of venous thromboemboli that are identified in the context of immune checkpoint inhibitor therapy. The major thing is just to know that it exists as a potential side effect, that the incidences appear to be higher, and that there is something about immune checkpoint inhibitor therapy that may put our patients at higher risk for these embolic events. BRITTANY HARVEY: Definitely. That's key to know, and particularly also when to hold or continue ICPI therapy. So then in your view, Dr. Fontaine, how will these recommendations for management of cardiovascular toxicities impact both clinicians and patients? PAULINE FONTAINE: I think the major thing is to know that these exist. The overall cardiac toxicities are less common, so if we're talking about myocarditis, that is a pretty rare event. But it's important to know that this is an event that is potentially fatal, that that fatality happens often, and that myocarditis can occur along with a myositis, and in some cases with myasthenia gravis. So these are three different rare side effects that can happen together, sometimes in pairs, sometimes in triplets, sometimes just one of them. But any one of these three has a higher risk for fatality. So I think just to know that it's out there. So that that is just hanging around in the differential for someone who is tired or out of breath. It may be pulmonary, but also keep in mind that it could be cardiac, and that is serious, and that should be worked up early and treated early. I think that's the major thing that I hope these guidelines do, is put these important but rare side effects out there and potentially save lives. I will say for VTEs, for venous thromboemboli, again, so PE can happen, and it can be fatal. I think this is not as rare, but of course, it's not rare in our patient population either. So these are things that we already look out for. Just, I think, if this podcast and the guidelines can add to the education that immune checkpoint inhibitors will increase the risk of thromboembolism, I think that those are the important takeaways. BRITTANY HARVEY: Absolutely. Recognition of these IREs is a common theme across the affected organ sites that we've heard in many of these podcast episodes. So I want to thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Fontaine. PAULINE FONTAINE: Thank you for having me. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you've enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.
Today is our last installment of our mini-series on Seniors and Nutrition and to finish the series we will be talking about how to prevent and detect malnutrition in the elderly. First, we will discuss what malnutrition is and what it looks like in older adults. Then, we'll cover some of the factors that contribute to malnutrition. Finally, we'll end with ways you can help your loved one avoid poor nutrition, and in turn, malnutrition. Now let's move on to the rest of the show. Good nutrition is important for everyone, regardless of age, but is especially important for older adults. According to the World Health Organization, malnutrition refers to deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions, undernutrition and overweight, obesity and diet-related noncommunicable diseases, such as heart disease, stroke, diabetes, and cancer. Undernutrition includes stunting, which is low height for age, wasting, which is low weight for height, underweight, which is low weight for age, and micronutrient deficiencies or insufficiencies, which are a lack of important vitamins and minerals. Approximately 2.4 billion adults worldwide are experiencing malnutrition, with 1.9 billion being overweight and 462 million being underweight. In some cases, people may be overweight and also exhibiting micronutrient deficiencies or may be underweight and have diabetes. Because there are many types of malnutrition, it can be hard to spot if your loved one is experiencing a form of malnutrition or not. But left unchecked, malnutrition can cause a host of other issues. According to the Mayo Clinic, malnutrition in older adults can cause them to have a weakened immune system, which increases the risk of infections. It also can cause poor wound healing, muscle weakness and decreased bone mass, which can lead to falls and fractures, a higher risk of hospitalization, and an increased risk of death. The Alliance for Aging Research has created a pocket film that covers who is at risk for malnutrition, the debilitating impact it can have on older adults, tips for identifying the condition, and how it can be treated and prevented. We're covering some of the key points of the video, but if you would like to watch the full thing, you can find the link to it in our show notes for today's episode. According to the Alliance for Aging Research, Malnutrition can happen to anyone, but older adults are particularly at risk, as they are more likely to have chronic conditions that put them at risk for malnutrition. Some illnesses and diseases, like cancer and Alzheimer's, can change an older adult's appetite and metabolism and they can also require dietary restrictions that can make eating difficult. When we picture malnutrition, we often picture starving children in third world countries or even the animals on the ASPCA commercials, but malnutrition is everywhere and far more common than we think. Malnutrition doesn't always look like someone is starving. Actually, most malnutrition cases, at least in the US, tend to look like the opposite. What's even more concerning about malnutrition, it can be impossible to see until it's too late. Older adults often experience illnesses, diseases, or accidents that require them to be hospitalized or require them to be in a long-term care facility, both of which lead to a higher risk of malnutrition. As we age, our bodies go through changes that also can lead towards malnutrition, which is another reason that older adults are at a higher risk. As we get older, our sense of smell and taste weakens, and things that we once enjoyed may not taste as good as they once did. Our digestive system can also slow with age, and take longer to digest meals, making us feel fuller throughout the day, but leave us lacking essential calories and nutrients. As we get older, our bodies may not be able to absorb nutrients as well, either. So, your loved one may be eating the same foods that once brought them a lot of energy, but now doesn't have the same effects. According to the American Society for Prenatal and Enteral Nutrition, or ASPEN, malnutrition in seniors often mirrors the signs of aging. Unplanned weight loss, feeling weak or tired, loss of appetite, swelling or fluid accumulation, and being able to eat only in small amounts are all signs that your loved one is malnourished, but they are also signs of aging. If you suspect your loved one may be malnourished, talk to their doctor immediately so they can get the calories and nutrients their body needs. Now that you know what malnutrition is and what it can look like in older adults, let's move on to factors that contribute to malnutrition. Cognitive diseases like Alzheimer's can make it difficult for your loved one to remember to eat. Mobility issues can also make it more difficult for your loved one to shop for their groceries, cook their own meals, and eat on their own. Some treatments and medications can also require dietary restrictions and cause your loved one to have a loss of appetite, leading them to become malnourished. According to ASPEN, the causes of malnutrition in older adults are a complex blend of physical, social, and psychological issues — from the loss of appetite due to depression to the inability to get to the store for groceries. Prompt diagnosis and treatment of malnourished older adults is critical. If it goes on undetected for too long, irreversible damage and even death can occur. Mayo Clinic lists several factors that contribute to malnutrition in older adults. Normal age-related changes in taste, smell and appetite generally decline with age, making it more difficult to enjoy eating and keep regular eating habits. Disease-related inflammation and illnesses can contribute to declines in appetite and changes in how the body processes nutrients. Impairment in ability to eat, like difficulty chewing or swallowing, poor dental health, or limited ability in handling tableware can contribute to malnutrition. Behavioral or memory problems from Alzheimer's disease or a related dementia can result in forgetting to eat, not buying groceries or other irregular food habits. Some medications can affect appetite or the ability to absorb nutrients. Dietary restrictions for managing medical conditions — such as limits on salt, fat or sugar — might also contribute to inadequate eating. Older adults may have trouble affording groceries, especially if they're taking expensive medications. The lack of socialization can also cause malnutrition. Older adults who eat alone might not enjoy meals as before and lose interest in cooking and eating. Adults with limited mobility may not have access to food or the right types of food. Grief, loneliness, failing health, lack of mobility and other factors might contribute to depression — causing loss of appetite. Older adults that suffer from Alcoholism are also at a higher risk of malnutrition, in addition to numerous other health problems. Too much alcohol can interfere with the digestion and absorption of nutrients. Misuse of alcohol may also result in poor eating habits and poor decisions about nutrition. There are several factors that can contribute to malnutrition, as you have just seen, but the list goes on and on. Knowing some of these factors to look out for can make malnutrition easier to spot in your loved one. And it is important to know that just because they are eating, does not mean they are eating well or eating enough. If your loved one seems to be eating regularly, but is losing weight or experiencing low energy levels, they may have a nutrient deficiency and need to be on a special diet, so it is important that you talk to their doctor about any changes in their behavior, and their diet, that you notice, especially if your loved one is unable to notice it on their own. Now that we have discussed what malnutrition is, what it looks like in older adults, and the factors that contribute to malnutrition, we can move on to our final section, how to help your elderly loved one avoid poor nutrition. Mayo Clinic says that as a caregiver or adult child of an older adult, you can take steps to monitor nutritional health, watch for weight loss and address risk factors of malnutrition. You can monitor your loved one's weight by checking their weight at home and keeping a weekly record of it. You can also do a visual check of how their clothes fit, as it can indicate weight loss, as well. Observing their habits is another good way to keep track of their nutrition. You can spend mealtimes together at home — or during mealtime in a hospital or care facility — to observe eating habits and note what kinds of food are eaten and how much. Keeping a record of all medications, the reason for each medication, dosages, treatment schedules and possible side effects can also help your loved one avoid poor nutrition. As we age, many people need medication every day, and those medications can come with side effects that involve loss of appetite or other things that make eating more difficult. When consulting a doctor about poor nutrition, having all of this information on hand can help them determine if your loved one is malnourished faster, resulting in faster treatment that could potentially save their life. Helping your loved one plan healthy meals or preparing meals ahead of time for them can help ensure that they have access to the nutrients they need. Helping them prepare a shopping list or shopping together can also help them make sure that they always have the items they need to make healthy choices at mealtimes. There are many agencies and organizations that exist just to ensure that seniors have access to nutritional meals. Contact your local service agencies that provide at-home meal deliveries, in-home visits from nurses or dieticians, access to food pantries, or other nutrition services to see what help your loved one can be receiving. The local Area Agency on Aging or a county social worker can provide more information about services in your area. If your loved one lives alone and is having trouble eating, they may benefit from social interactions during meals. You could try dropping by during mealtime or invite your loved one to your home for an occasional meal. Going out to eat at a restaurant can be a special treat for them, and they can use their senior discounts. Lastly, daily exercise — even if it's light — can stimulate appetite and strengthen bones and muscles. Encourage your loved one to go on walks if they are able to. Not only can it help stimulate their appetite, but it can help improve their mood. If they are suffering from depression, even a slight mood improvement can increase their appetite, as well. If your loved one needs help improving their nutrition, there are a few things you can do. Before starting anything new, always make sure you discuss the change with their doctor first. When planning meals for your loved, make sure you are including a variety of nutrient-rich foods. A good rule of thumb is to include the rainbow on their plate. Really, all that means is make sure you are including a variety of colored foods, as they all contain different nutrients. Using different herbs and spiced to add flavor to meals can help your loved one improve their interest in eating. Experimenting with these things can help your loved one find a new favorite and cause them to be excited for their next meal. If eating on their own is not enough, you can use supplemental nutrition drinks to help with calorie intake and you can add things like egg whites or whey powder to meals to increase proteins without adding saturated fats. Observing your loved one during mealtimes is the best way for you to prevent and detect malnutrition in your loved one. Actually, being able to see what they eat and don't eat and being able to witness any problems they have with eating can help you determine if your loved one has any problems that their doctor should be aware of. If you notice they are coughing a lot when they are eating and having trouble swallowing, they may have a medical condition that is causing that that if their doctor was aware of, could be fixed. Knowing your loved one's eating habits can also help when shopping or cooking. If your loved one is unable to go to the store or cook their own meals, know what they like and what they are able to eat can help ensure that they eat more, or less if that is the problem. Now, you don't want to make your loved one feel like they have no control over their eating time or like they have lost their independence. We are not suggesting that you stand over them at mealtime. When you take them out to dinner or come visit for lunch, just be aware while you are with them and take note of their habits. It may be useful in the future, and it may not, but it is always better to be safe than sorry. If your loved one is having difficulty eating or you notice any changes in their diet or weight, even if you don't think they are malnourished, talk to their doctor. Malnutrition often goes undetected and undiagnosed until it is too late, so if you have any suspicions, it is always better to tell your doctor sooner rather than later. You may also find you need the help of a nutritionist when figure out what your loved one should be and needs to be eating. Your doctor or your local senior center can give you resources and referrals for nutritionists in your area. Your local senior center may even have a nutritionist on staff that you can meet with. We want to say thank you for joining us here at All Home Care Matters, All Home Care Matters is here for you and to help families as they navigate these long-term care issues. Please visit us at allhomecarematters.com there is a private secure fillable form there where you can give us feedback, show ideas, or if you have questions. Every form is read and responded to. If you know someone who could benefit from this episode, please make sure to share it with them. Remember, you can listen to the show on any of your favorite podcast streaming platforms and watch the show on our YouTube channel and make sure to hit that subscribe button, so you'll never miss an episode. We look forward to seeing you next time on All Home Care Matters, thank you. Sources: https://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/senior-health/art-20044699 https://www.who.int/news-room/q-a-detail/malnutrition https://www.agingresearch.org/campaign/malnutrition/ https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Spotting_Malnutrition_in_Seniors/
In this episode, Tracy Zivin-Tutela, MD, discusses expert guidance on vaccination against shingles.Tracy Zivin-Tutela, MDInfectious Diseases SpecialistDepartment of Infectious DiseasesFountain Valley Regional HospitalLos Alamitos Medical CenterFountain Valley, CaliforniaUsing a case study and the latest expert guidance, this podcast covers topics such as: Counseling patients on benefits and efficacy of vaccination against shinglesVaccine safetyVaccination guidelines for adults with or without previous vaccination with zoster vaccine live or recalled childhood chickenpoxAdministration of vaccination with consideration for other routine vaccines for flu, pneumonia, COVID-19Content based on a CME program supported by an educational grant from GlaxoSmithKlineFollow along with the downloadable slides at: https://bit.ly/3kunxJrLink to full program: https://bit.ly/3o4PB8N
An interview with Dr. Loretta Nastoupil from MD Anderson Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She discusses the identification, evaluation, and management of hematologic toxicities in patients receiving ICPis, including hemolytic anemia among others in Part 10 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at ASCO.org/podcasts. My name is Brittany Harvey. And today, we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Loretta Nastoupil from the University of Texas M.D. Anderson Cancer Center in Houston, Texas, author on Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy, ASCO Guideline Update, and Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy ASCO Guideline. And today, we're focusing on hematologic toxicities in patients treated with immune-checkpoint inhibitor therapy. Thank you for being here, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. I'm happy to be here. BRITTANY HARVEY: Great. Then first I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Nastoupil, do you have any relevant disclosures that are related to these guidelines? LORETTA NASTOUPIL: Yes, Brittany. So I have received honorarium for participation in advisory boards from the following companies, including BMS/Celgene, Genentech, Janssen, Novartis, Merck, MorphoSys TG Therapeutics, and Takeda. And I've also received research funding support from BMS/Celgene, Gilead Kite, Genentech, Janssen, Novartis and Takeda. BRITTANY HARVEY: I thank you for those disclosures. Then let's get into what we're here today to talk about. So what are the immune-related hematologic toxicities addressed in this guideline? LORETTA NASTOUPIL: So it's important to recognize that hematologic toxicities that are immune-related as a result of immune therapy are infrequent occurrences. So it's important to recognize when they do occur and some of the unique workups given that they are so infrequent. So probably one of the most common is hemolytic anemia. It's important to recognize that these are cancer patients. And they may have multiple reasons for the development of acute or new onset anemia, but recognizing if they're on either checkpoint inhibitors or immune therapies, it's important to recognize that it might be spurred on as a result of immune-mediated anemia. We advise in terms of history and workup to consider whether or not they've been exposed to new drugs, whether or not they've had a recent insect or snakebite exposure. The recommended workup includes a CBC with also a peripheral blood smear to look for evidence of hemolysis or macroketosis. In addition, other hemolytic anemia workup includes evaluation for LDH, haptoglobin, reticulocyte count, bilirubin, and free hemoglobin. Other potential diagnoses on the differential include DIC, so a panel, including coags, PT, INR, and PTT, exploring autoimmune serologies, PNH screening, evaluation for infection such as viral or bacterial causes of hemolysis, and also consideration for bone marrow failure syndrome, including evaluation for potentially reversible causes, such as B12, folate, copper, parvovirus, iron, thyroid, infection, et cetera. G6PD level is helpful in the evaluation, as well as exploration as I mentioned of potentially new drugs that might be linked, including ribavirin, rifampin, dapsone, interferon, some of the antibiotics, such as cephalosporins, penicillins, NSAIDs, ciprofloxacin, for instance, et cetera. So as part of the workup, if we have excluded alternative causes and we think that the immune-checkpoint inhibitor might be the underlying cause of the autoimmune hemolytic anemia, then generally we will continue unless they have grade 2 or higher toxicity, which is generally a hemoglobin less than 10. In which case, we would recommend to hold the immune-checkpoint inhibitor, again, with significant anemia. So those with grade 2 or higher, you might consider initiating corticosteroids, including 1.5 to 1 milligram per kilogram per day until improvement. For grade 3 or higher-- so this is more severe anemia So hemoglobin is less than 8. Generally, we're recommending permanent discontinuation of the checkpoint inhibitor and potentially higher doses, including up to 2 milligrams per kilogram per day of prednisone or corticosteroid equivalent to speed up the recovery. In regards to transfusion requirements or consideration, we are suggesting you evaluate or consider your local or regional guidelines. We generally do not transfuse for a target hemoglobin greater than seven to eight. And we also recommend supplementation with folic acid. BRITTANY HARVEY: Great. And then beyond those recommendations for hemolytic anemia, what are the key recommendations for identification, evaluation, and management of acquired thrombotic thrombocytopenia purpura? LORETTA NASTOUPIL: Sure. So fortunately, TTP is quite rare, but, again, something that is worth exploring. Some of the challenges are in the clinical syndrome. And that it can mimic some of the other toxicities that are covered in other sections, particularly the neurotoxicity section. But essentially, for patients who have pretty dramatic change in platelet count, again, they may have additional clinical sequelae such as neurologic toxicity or adverse events. It's important to recognize that TTP might be an underlying cause, again, for patients who are on immune-checkpoint inhibitors. This is where a hematology consult early in the clinical course would be particularly of importance to recognize it and potentially to minimize offending agents. Drug exposure is always important, because many of these patients might have other drugs, in addition to their immune-checkpoint inhibitors, such as chemotherapy, sirolimus, tacrolimus, antibiotics et cetera. And so exploring offending agents is important. An ADAMTS13 level, an inhibitor titer, would be important to send if you're considering TTP, in addition to evaluating the peripheral smear, and the hemolytic anemia workup, as I just mentioned, including LDH, haptoglobin and reticulocyte count. Exploring infectious etiology, including CMV titers or serology, would be particularly helpful, an additional clinical evaluation, such as brain imaging with CT or MRI, echocardiogram, and EKG would be of help. For all grades of TTP, again, even with a clinical suspicion for the diagnosis, in addition to hematology consult, we recommend stabilizing the patient. That might require care in an acute care setting, making sure that they have adequate organ function and that this is stabilized. For grade 1 or higher, we recommend holding the immune-checkpoint inhibitor. And you might consider, again, initiation of corticosteroids with 0.5 to 1 milligram per kilogram per day of prednisone or an equivalent. For grade 3 or higher, we would, again, in addition to holding the checkpoint inhibitor and in conjunction with your hematology colleagues, you might initiate a therapeutic plasma exchange. Again, in accordance with existing guidelines, you may consider higher doses of steroids, including methylprednisolone 1 gram IV daily for three days. You could consider some additional supportive agents, such as rituximab or pembrolizumab if the ADAMTS13 level is less than 10 or less than 10% of normal and an inhibitor or elevated ADAMTS13 IgG has been detected. BRITTANY HARVEY: I appreciate you going through the details for TTP. So then, additionally, this guideline addresses aplastic anemia. So what are the key recommendations for identification, evaluation, and management of aplastic anemia? LORETTA NASTOUPIL: Yeah. So fortunately, again, these are quite rare situations. So with aplastic anemia, similar to what we've discussed in terms of workup of anemia, globally, it's important to explore potentially causes of, again, bone marrow failure syndrome. And aplastic anemia is one of those such causes. Exploration of a bone marrow biopsy in conjunction, again, with your hematology consult would be critically important, and exploring potentially reversible causes, again, such as deficiencies and important nutrients, viral etiologies, in addition to parvovirus, CMV, HHV-6 is important to consider and rule out. But I think the end of the day, a bone marrow biopsy and aspirate is going to be the most helpful assessment to ensure that aplastic anemia has been considered and worked up. In regards to management of aplastic anemia, we're going to hold the immune-checkpoint inhibitor. You may need to provide additional support such as growth factors. And close follow-up, I think is the most critical aspect of this. Sometimes we initiate patients on corticosteroids. We hold the checkpoint inhibitor. And then we may monitor them less frequently. Oftentimes, these patients with high malignancies are going to need to be followed very closely, sometimes weekly or multiple times a week. So in regards to management of aplastic anemia that might be immune mediated as a result of immune-checkpoint inhibitors and in conjunction with your hematology and colleagues, consideration of management might include administration of horse ATG and cyclosporine, but again transfusion support, growth factor support, even consideration for HLA typing and evaluation first. Stem cell transplantation might be appropriate, particularly for a young patient with minimal comorbidities. For grade 3 or higher, in addition to these considerations, we're going to hold the checkpoint inhibitor and monitor weekly for improvement. If no response, you might consider repeating immune suppression with Rabbit ATG plus cyclosporine or cyclophosphamide. And for refractory patients, consider eltrombopag plus best supportive care. BRITTANY HARVEY: Great. Thank you. Those are important notes on the management of aplastic anemia. So then, additionally, what are the key recommendations for the identification, evaluation, and management of lymphopenia? LORETTA NASTOUPIL: Yeah. I think one of the challenges with lymphopenia, it's common for patients who've had cancer-directed therapy, particularly things like chemotherapy. And so understanding whether or not this is a new onset after exposure to checkpoint inhibitors is one of the critical aspects, in addition to considering alternative causes. But for patients in which we do think the lymphopenia is a result of the immune-checkpoint inhibitor, we're not generally advising discontinuation or holding of the immune-checkpoint inhibitor, but it is important to consider best supportive measures, including whether or not patients might benefit from monitoring for reactivation of certain viral etiologies, including CMV and HHV-6, for instance, in addition to potential consideration for prophylactic strategies, such as PJP prophylaxis. Also, zoster reactivation might be something that these patients might indeed be at risk for. So as opposed to holding your checkpoint inhibitor and initiating things like corticosteroids, if we have excluded alternative causes and think lymphopenia is a result of the immune-checkpoint inhibitor or as immune mediated, ensuring that they are receiving best supportive care to mitigate some of their toxicity that may result as the result of the lymphopenia. BRITTANY HARVEY: Understood. And it's important to note for clinicians that management is different from a lot of the management of the other hematologic toxicities. So then the last hematologic toxicity that was addressed in this guideline was acquired hemophilia A. So what are those key recommendations? LORETTA NASTOUPIL: Acquired hemophilia A, again, fortunately is very rare and uncommon, but this is one situation where engagement of a hematologist, who is an expert in management of hemophilia, will be critical. So that would potentially be step one. In terms of laboratory assessment, that would be helpful, in addition to your CBC, where you're assessing things like platelet count, coagulation workup, including fibrinogen, PT, PTT, INR, that would be informative. Patients with acquired hemophilia A will likely have a prolonged activated PTT with a normal PT. So that might be one of the clues. Imaging would be helpful to ensure the patients don't have any signs of spontaneous bleeding or hematoma basis, such as MRI, CT, or ultrasound, if particularly they have any localizing symptoms. Medication review to look for alternative causes would always be helpful. And determination of the Bethesda unit level of inhibitor would be critical. In regards to management, we would hold the checkpoint inhibitor, initiate corticosteroids, transfusion support as indicated, and you want to treat the underlying acquired hemophilia with conjunction of a hematologist. For grade 2 or higher, this may require factor replacement. And the choice is usually based on the Bethesda unit of the titer. Administration of prednisone, in addition to rituximab 375 milligrams per meter squared weekly for four weeks or cyclophosphamide dosed at 1 to 2 milligrams per kilogram per day may be patient specific. And, again, that decision should be made in conjunction with your hematology consult. Prednisone, rituximab, and cyclophosphamide should be given for a minimum of five weeks. And factors should be prescribed to increase the level, particularly during bleeding episodes. And, again, the choice of the factor is based on the presence or absence of an inhibitor. For grade 3 or higher, we advise to permanently discontinue the immune-checkpoint inhibitor. These patients generally will be admitted for stabilization. They do require factor replacement. Bypassing agents may also be required, including factor VII. Caution should be taken in elderly patients and those with coronary artery disease. Corticosteroids, rituximab, and cyclophosphamide should also be considered, transfusion support, if they're having active bleeding. And if worsening or no improvement, you could consider adding cyclosporine or immune suppression to try and stabilize these patients. Again, acquired hemophilia A requires special clinical and laboratory expertise. This would require consult and potentially even transfer to a specialized center, and consultation with a hemophilia center should be initiated as soon as this is considered or confirmed. BRITTANY HARVEY: That's a great summary of these recommendations. The expert panel and you clearly put in a lot of work into these recommendations. So then in your view, how will these recommendations for the management of hematologic toxicities impact both clinicians and patients? LORETTA NASTOUPIL: I think the most important thing are disseminating this information. I think ASCO plays a critical role in helping clinicians first recognize some of the toxicities that are different from what we have traditionally seen with chemotherapy and may have different management strategies. So guidelines, such as this, are critically helpful. Podcasts, such as this, are incredibly helpful to get the information out, recognizing that all of us authors are more than willing to provide additional guidance and are willing to be contacted in this situation where someone's facing one of these unique and rare toxicities and would like some additional guidance in terms of further management. Hematologic toxicities are sometimes hard to distinguish or maybe potentially hard to recognize, given many of these patients may have been on prior chemotherapy agents, and anemia or thrombocytopenia may not be unusual, but recognizing if it's new or more severe than what has been seen previously and that, at least, consideration of an immune-mediated hematologic toxicity, be considered, because the management might be unique. And so I hope that we've outlined today some of the hematologic toxicities that are rare that may be seen with immune therapy and some of the strategies to work up alternative diagnoses and management if it is indeed immune-mediated toxicity. BRITTANY HARVEY: Definitely. And I really appreciate you going through these rare but very important toxicities. So thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune-related adverse events. To read the full guideline, go to www.ASCO.org/supportive care guidlines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. Bianca Santomasso from Memorial Sloan Kettering Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews neurologic toxicities in patients receiving ICPis, such as myasthenia gravis, Guillain-Barre Syndrome, peripheral neuropathy, aseptic meningitis & encephalitis in Part 9 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello and welcome to the ASCO Guidelines Podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey. And today, we're continuing our series on the management of immune related adverse events. I am joined by Dr. Bianca Santomasso from Memorial Sloan Kettering Cancer Center in New York, New York, author on Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy ASCO Guideline Update and Management of Immune Related Adverse Events in patients Treated with Chimeric Antigen Receptor T Cell Therapy ASCO Guideline. And today, we're focusing on nervous system toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Santomasso. BIANCA SANTOMASSO: Thank you for having me. BRITTANY HARVEY: Then I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Santomasso, do you have any relevant disclosures that are directly related to these guidelines? BIANCA SANTOMASSO: Yes, I'd like to disclose that I've served as a paid consultant for Celgene, Janssen Pharmaceutical, and Legend Biotech for advising them on the topics of T cell therapy side effects. BRITTANY HARVEY: Thank you. Then getting into the content of this guideline, what are the immune related nervous system toxicities addressed in this guideline? And what are the overarching recommendations for evaluation of these neurologic immune related adverse events? BIANCA SANTOMASSO: So neurologic immune related adverse events actually encompass a very diverse spectrum of neurologic syndromes that can occur as a complication of treatment with checkpoint inhibitors. So the spectrum that is covered by this guideline includes myasthenia gravis, Guillain-Barre syndrome, polyneuropathy, aseptic meningitis, and encephalitis. And although these are rarer than many of the other immune related adverse event types affecting other organ systems, they're increasingly being encountered due to more patients being treated with novel combinations of immunotherapies. And they're important to recognize, because along with myocarditis, they have generally more morbidity and even more mortality than irAEs affecting other organ systems. So it's important for clinical care providers to have a high index of suspicion for these events. Studies have suggested that these tend to occur in about 3% to 12% of patients, probably between 1% and 2% of patients developing severe events. So they're rare. But again, the events are probably more commonly seen in patients treated with combination checkpoint blockade. And we're increasingly seeing more combinations. So we should be on the lookout for these. Neurologic immune related adverse events can be divided into syndromes that affect the peripheral nervous system, so meaning the peripheral nerves, the neuromuscular junction, and muscle. So that would be Guillain-Barre syndrome, myasthenia gravis, and myositis. And those that affect the central nervous system, such as the brain, spinal cord, or leptomeninges. So those would be aseptic meningitis and encephalitis. The peripheral nervous system irAE appear to be more common than those affecting the central nervous system. And patients can present with a number of different symptoms that kind of relate to these syndromes. That can be as diverse as a headache to numbness, tingling, or focal weakness, such as a foot drop or facial weakness. You may see patients with severe altered mental status or personality changes or gait difficulty, walking difficulty, which could actually mean any number of syndromes. It's generally important to be aware that the timing of onset is generally early, a median of four weeks after the start of treatment, but can range anywhere from one week after the start of treatment to greater than a year. And because we know that cancer can spread to many parts of the nervous system, neurologic toxicity should be considered a diagnosis of exclusion. So that means that as part of the workup for neurologic immune related adverse events, it's imperative to rule out nervous system metastasis, stroke, and infection, which we know can occur at higher rates in patients with cancer. So for most neurologic immune related adverse events, diagnostic workup is similar. It should include MRI brain and/or of the spine, with and without contrast, and often a lumbar puncture for cerebrospinal fluid analysis, including cytology to rule out leptomeningeal metastasis. BRITTANY HARVEY: Thank you for that overview. In addition to those points for evaluation for all nervous system toxicities, what are the key recommendations for identification, evaluation, and management of myasthenia gravis? BIANCA SANTOMASSO: So for myasthenia gravis, presenting symptoms usually include fatiguable or fluctuating muscle weakness. It's generally more proximal than distal. And there's frequently ocular and/or bulbar involvement. So that means either ptosis, like a droopy eyelid, diplopia, or double vision, difficulty swallowing, dysarthria, facial muscle weakness, and/or head drop or neck weakness. Again, for any patient with new neurologic symptoms, an MRI of the brain or spine should be performed depending upon the symptoms to rule out central nervous system involvement by disease or some alternative diagnosis. And similar to idiopathic myasthenia gravis, acetylcholine receptor antibodies can be positive. So these should be checked. This is a blood test. But it's important to note that while these antibodies may be confirmatory, their absence does not rule out the syndrome. The rate of acetylcholine receptor antibody positivity in immune related myasthenia gravis has not been definitively established. So depending on the presentation, one might also consider sending a paraneoplastic panel for Lambert-Eaton myasthenic syndrome. The single most important point I'd like to make regarding suspected immune related myasthenia gravis is that orbital myositis and generalized myositis from immune checkpoint inhibitors can present similarly. For this reason, early neurology consultation and electrodiagnostic testing with repetitive stimulation or single fiber EMG becomes important and helpful to distinguish the two. And to make matters even more complicated, we've learned that there's an overlap syndrome, where patients may develop not only myasthenia gravis, but also myositis and/or myocarditis at the same time. So basically, the neuromuscular junction is affected. But the local muscle and myocardium, which is heart muscle that's kind of related, may be affected all at once. And this overlap of syndromes may increase disease severity and mortality. So they're important to recognize. So what this means is that when you encounter a patient with suspected myasthenia gravis, you should also be checking CPK, muscle enzymes, aldolase to evaluate for myositis, and troponin and electrocardiogram to evaluate for myocarditis. And this should be done even if there are no obvious symptoms. So onto the treatment of myasthenia gravis, this is similar to the management of the idiopathic form. Therefore, it's helpful to have the involvement of a neurologist. The immune checkpoint inhibitor therapy should be held. And patients with mild symptoms are often started on pyridostigmine and corticosteroids. And patients with more severe symptoms should initiate IVIG or plasmapheresis. And patients with more severe symptoms may need to be admitted to the hospital. So that their neurologic and pulmonary status can be monitored closely for improvement. Some patients may require ICU level of monitoring. And considering adding rituximab if symptoms are refractory, and often, as symptoms improve, the steroids can be de-escalated. BRITTANY HARVEY: Understood. Those are all very important points for clinicians to consider. So then following that, what are the key recommendations for identification, evaluation, and management of Guillain-Barre syndrome? BIANCA SANTOMASSO: So Guillain-Barre syndrome, like myasthenia gravis, also presents with weakness. Most often, patients present with a progressive ascending muscle weakness. The syndrome can start with sensory symptoms or neuropathic pain that can be localized to the lower back and thighs. In addition to the classic ascending weakness, there may be facial weakness, double vision, numbness or tingling in the hands or feet, loss of balance, and coordination. And shortness of breath may occur due to respiratory muscle weakness. The autonomic nerves can also be affected and can present as new severe constipation or nausea, urinary problems, or orthostatic hypotension. The reflexes are often reduced or absent, deep tendon reflexes. So again, as for all of the syndromes, early involvement by a neurologist is recommended, if possible. Usually, MRI imaging of the spine is important to rule out spinal cord compression. And it also may show cauda nerve thickening or enhancement, which can occur with this syndrome. And the second aspect is cerebrospinal fluid analysis is important for diagnosis. This is important really for ruling out leptomeningeal metastasis, since that could present similarly. And often, what can be seen in GBS is an elevated protein level in the cerebrospinal fluid. In addition, unlike idiopathic GBS, there can be an elevated white blood cell count in the cerebrospinal fluid. Electrode diagnostic testing can also be helpful for confirmation, and serum tests for antiganglioside antibodies, and a paraneoplastic antibody workup may also be considered. Bedside pulmonary function test and swallowing evaluation should be performed if there's a concern for respiratory or swallowing dysfunction. And some patients do need to have inpatient admission and monitoring if symptoms are severe or if they appear to be progressing from mild. For management, the checkpoint inhibitor therapy should be held. And patients are most often treated with IVIG or plasmapheresis. Corticosteroids can be added to the IVIG or plasmapheresis. These are not usually recommended for idiopathic Guillain-Barre syndrome. However, in immune checkpoint inhibitor related forms, a trial is reasonable. And steroids are usually given at a higher dose for five days and then tapered over several weeks. BRITTANY HARVEY: Understood. I appreciate that overview. So then what are the key recommendations for identification, evaluation, and management of peripheral neuropathy? BIANCA SANTOMASSO: So peripheral neuropathy, or polyneuropathy, is a rare but likely underreported complication of immune checkpoint inhibitor therapy. So in the large databases and meta-analyses, those have really focused on Guillain-Barre syndrome for reporting. But other types of neuropathies, such as painful length dependent sensory and motor axonal neuropathies, or polyradiculopathies or sensory neuropathies do occur after immune checkpoint inhibitors and are probably under-recognized. So evaluation of immune related neuropathy should include neurology consultation to guide the neurology phenotype determination and also the workup. The evaluation primarily relies on a combination of electrodiagnostic studies, serologic tests, and MRI neuroimaging. Because peripheral nervous syndromes can overlap, screening for neuromuscular junction dysfunction with electrodiagnostic testing and myopathy is recommended for any patient who presents with at least motor symptoms that are thought to be peripheral. Serum testing can be helpful for ruling out reversible causes of neuropathy. Spinal imaging is recommended to exclude metastatic disease. And for management, it usually involves holding the checkpoint inhibitor in mild cases, using neuropathic pain medication or steroids in more severe cases. And very severe cases that kind of resembled GBS would be managed as per the GBS algorithm with IVIG or plasmapheresis. BRITTANY HARVEY: Understood. And it's key to look out for those overlapping adverse events. So then following that, what are the key recommendations for aseptic meningitis? BIANCA SANTOMASSO: Right, so now we're getting into the central nervous system toxicity. So aseptic meningitis is an inflammation of the meninges. And it can present with headache, photophobia, neck stiffness. Patients can have nausea, and vomiting, and occasionally fever. The mental status is usually normal. And in patients presenting with headache, which in isolation, could suggest an aseptic meningitis, it's important to evaluate if they have any confusion or altered behavior, which might suggest an encephalitis. And this distinction is important, because suspected encephalitis triggers a different workup, which we'll be discussing later, and also even different management. So the workup for aseptic meningitis includes neuroimaging, usually an MRI of the brain. And on that imaging, we sometimes see abnormal leptomeningeal enhancement. It's important not to assume that this is cancer and to do a lumbar puncture to evaluate cerebrospinal fluid both for inflammation and to exclude other causes of meningeal disease, particularly neoplastic and infectious causes. So cytology, Gram stain, and culture, and other infectious studies should be negative. And it's recommended that empiric antibiotics or antiviral therapy be considered to cover for infectious meningitis until the cerebrospinal fluid results return negative. What's seen in the cerebrospinal fluid in aseptic meningitis is typically reactive lymphocytes, but also neutrophils or histiocytes may be prominent on the cytology. And while the symptoms can be severe, sometimes requiring hospitalization, the management of this entity, these are usually quite treatable. Aseptic meningitis generally responds very well to corticosteroids. So management involves holding the checkpoint inhibitor. And you can often get away with starting a fairly modest dose of corticosteroids, such as oral prednisone, 0.5 to 1 milligram per kilogram or the equivalent. And steroids can usually be tapered over two to four weeks. BRITTANY HARVEY: Great, thank you for reviewing those recommendations. So then you just mentioned the distinction of aseptic meningitis and encephalitis. So what are those key recommendations for identification, evaluation, and management of encephalitis? BIANCA SANTOMASSO: So in encephalitis, the mental status is not normal. It's characterized by, really, an acute or subacute confusion, altered mental status, altered behavior, memory deficits, including working memory and short-term memory. There can be, as associated symptoms, headaches, new onset seizures, psychiatric symptoms, which can include delusions or hallucinations. There could be weakness, sensory changes, imbalance, or gait instability, along with the mental status changes. And so similar to aseptic meningitis, the other central nervous system toxicity, it's important to distinguish encephalitis from other causes of altered mental status, such as CNS metastases, stroke, or infection. And as for the other syndromes, it's very helpful to have neurologic consultation early, if possible. An MRI of the brain is critical. And in addition, MRI of the spine may be obtained to evaluate for inflammatory demyelinating ischemic or metastatic lesions. In immune related encephalitis, MRI brain imaging may reveal T2 flare changes, typical of what can be seen in idiopathic autoimmune or limbic encephalitis. But most often, the MRI imaging is normal. So in this situation, a lumbar puncture for CSF studies to evaluate for evidence of inflammation can be very helpful. You can expect to see either a lymphocytic pleocytosis or an elevated protein, or CSF restricted oligoclonal bands. CSF analysis is also helpful for excluding other causes of encephalitis, particularly viral encephalitis. So HSV, Herpes Simplex Virus, or varicella zoster virus encephalitis should be ruled out and treated with antivirals while the tests are pending. So typically, these entities can be excluded by PCR testing for HSV and VZV. Electroencephalogram, or EEG, can also be helpful for revealing subclinical seizures or status epilepticus, which can occur as a complication of encephalitis or as a cause of persistently depressed sensorium. But these are not specific to encephalitis. Other testing that's done includes screening metabolic tests to look for alternative etiologies. And for this entity, serum and CSF autoimmune antibody evaluation should be sent to assess for malignancy associated neurologic syndromes. And your neurologist can help you with the workup and management, in particular which tests to send. There have been reported cases of antibody positive checkpoint inhibitor related encephalitis. For management, in contrast to aseptic meningitis, these are generally not as steroid sensitive. So you often have to treat with either higher steroid doses, even pulsed steroid doses, along with IVIG or plasmapheresis. If no improvement, escalation to rituximab and cyclophosphamide can be considered, with the assistance of neurology. This management guidance is taken from how to treat autoimmune encephalitities that are not related to checkpoint inhibitors. Unfortunately, these can be difficult to treat. The response may only be partial. So this is one area in need of better understanding of best therapeutics. BRITTANY HARVEY: OK, thank you for reviewing that and pointing out where there's future research needed as well. And I appreciate your reviewing the recommendations for each of these neurologic immune related adverse events. So then to wrap us up, in your view, how will these recommendations for the management of nervous system toxicities impact both clinicians and patients? BIANCA SANTOMASSO: Yeah, so I think this is a daunting list of toxicities. But I'll say that in most situations, the immune checkpoint inhibitor side effects are often manageable and reversible with proper supportive care. They can be serious, and they require close vigilance and prompt treatment and identification. But by knowing what to look for in early identification, that allows early intervention, which is really the key to reversibility and the best outcomes. So having these toxicities on your differential diagnosis is critical. And I think these guidelines really help inform both clinicians, and care providers, and patients on what the possible manifestations are. So we believe this guideline and its recommendations will help members of clinical teams with the recognition and the management of these unique toxicities. And again, it's timely recognition and early intervention that helps patients, really, by increasing their safety with early management. BRITTANY HARVEY: Great, well, thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Santomasso. BIANCA SANTOMASSO: My pleasure. Thank you so much. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast series. Stay tuned for additional episodes on the management of immune related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast. And be sure to subscribe. So you never miss an episode. [MUSIC PLAYING]
2146 Running with Google Project Guideline (Nov. 10, 2021) Show Notes Google's “Project Guideline” is an early stage research project aimed at enabling those with vision loss to run independently. Hosts Nancy and Peter Torpey talk with Bill Ma, director of IT and operations and Jessy DiNapoli, manager of admissions at Guiding Eyes for the … Continue reading 2146 Running with Google Project Guideline (Nov. 10, 2021) →
Today we're talking about your personal brand style guideline. Learn about the elements that go into your personal brand style guide, and how to create one. Brand guidelines are the very beginning branding elements of your business. There are five personal branding elements that are going to go into your personal branding guidelines. We'll talk about each of them today: your logo, your typography, your color palette, professional photos, and your brand voice. HIGHLIGHTS: - Find out what your brand style guidelines are - Know exactly where to start - Discover two atypical guidelines that are vital to your brand QUOTES: "If you're a personal brand, as I've suggested in other lessons, I think a signature is great. You can design that however you want. Beyond your logo, the typography or the font you use is a choice you have to make." "If you're a personal brand, what's different from you and a business is that you are the brand and you need to be the face of it." "When you are having other people that work with you to edit your content (in terms of what you're writing and what you're saying,) what you want is some do's and don'ts." RESOURCES Free Guide: Convert 1 Hour into 1 Month of Content MORE ADVICE AND INTERVIEWS Need A Podcast Coach? CLICK HERE to schedule a chat. If you'd like more content about how to build your personal brand, check out my free Content Marketing Starter Guide. And here are some more of my most popular thought leader interviews! - What Business to Start with John Lee Dumas - Personal Branding Masterclass with Chris Ducker - Built to Serve with Evan Carmichael Don't want to miss the next thought leader interview? - Click here to sign up for free tips each week directly to your inbox! And don't forget to leave a rating and review on iTunes. Talk soon!
As the pandemic continues to alter our expectations for typical respiratory season patterns it has become especially important for patients to have good control and management of their asthma. In today's episode, we are going to discuss the recent asthma guideline updates and how to apply them to your clinical practice. Today I am happy to be joined by my colleagues Dr. Bill Anderson and Dr. Monica Federico. Bill is the Director of the Multidisciplinary Asthma Clinic at Children's Colorado and Assistant Professor of Pediatrics at the University of Colorado School of Medicine. Monica is Medical Director of the Asthma Program and Clinical Alignment for the Breathing Institute at Children's Colorado and is Associate Professor of Pediatrics & Pulmonary Medicine at the University of Colorado School of Medicine. Do you have thoughts about today's episode or suggestions for a future topic? Write to us, Chartingpediatrics@Childrenscolorado.org.
An interview with Dr. Umang Swami from the Huntsman Cancer Institute, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” He discusses the identification, evaluation, and management of renal toxicities in patients receiving ICPis, focusing on nephritis/acute kidney injury in Part 8 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today, we're continuing our series on the management of immune related adverse events. I am joined by Dr. Umang Swami from the Huntsman Cancer Institute at the University of Utah in Salt Lake City, Utah, author on Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy ASCO guideline update, and Management of Immune Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T Cell Therapy ASCO guideline. And today, we're focusing on renal toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Swami. UMANG SWAMI: Thank you, Brittany. And I appreciate the invitation to be here today. BRITTANY HARVEY: Great. Then first, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Swami, do you have any relevant disclosures that are directly related to these guidelines? UMANG SWAMI: No, I do not have any relevant disclosures that are directly related to these guidelines. BRITTANY HARVEY: Thank you. Then let's dive into what we're here today to talk about. So what are these immune related renal toxicities that are addressed in this guideline? UMANG SWAMI: So this guideline focuses on nephritis, or acute kidney injury, as an adverse event due to immunotherapy. Acute kidney injury, or AKI, an uncommon complication of immune checkpoint inhibitor therapy. Just to give a little context before we start, the incidence of any grade AKI around 1% to 2% in patients treated with a single agent immune checkpoint inhibitor, such as ipilimumab, nivolumab or pembrolizumab, and 4.5% in those treated with anti-CTLA-4 for and anti-PD-1 combination of nivolumab plus ipilimumab therapy. The incidence of grade 3 or grade 4 AKI is very low. I will say less than 1% with single agents, and around 1.6% with the combination of nivolumab plus ipilimumab. While initial studies had quoted a small incidence of AKI with immune checkpoint inhibitor use, emerging data now suggests that a higher incidence might be present, which might range between 9.9% to around 29% of AKI with the immune checkpoint inhibitors. However, most of this extra toxicity is grade 1. The median time to onset of renal toxicity with these agents is around 14 weeks, but can range from 6.5 to 21 weeks. BRITTANY HARVEY: Thank you for that background information. I think it's helpful for clinicians to understand how rare or common these adverse events are. So then, what are the key recommendations for identification, evaluation, and management of nephritis or acute kidney injury? UMANG SWAMI: That's a great question. Presenting symptoms related to immune therapy induced renal toxicities may include urinary frequency, dark, cloudy urine, fluid retention, or edema of face, abdomen, extremities. There might be sudden weight gain. There might be associated abdominal or pelvic pain. Patients might have nausea, vomiting, high blood pressure, or they may have a change in mental status such as drowsiness. However, we should remember that a vast majority of them will be asymptomatic at presentation. Therefore, patients should have their renal function, that is, serum creatinine, checked prior to administration of each dose of checkpoint inhibitor therapy. For patients with new elevations in creatinine, one should consider holding checkpoint inhibitor therapy while other potential causes are evaluated. These other causes may include recent IV radiographic contrast administration, dehydration, urinary tract infection, other natural toxic medications, including concurrent chemotherapy, herbals, or other supplements. Patients without their obvious causes or who don't respond to alternative treatment measures should be presumed to have immune related renal toxicity and treated empirically depending on the grade of AKI. Safe treatment of autoimmune component is important. So with regards to the grading of AKI, grade 1 means a creatinine level increase of more than 0.3 milligrams per deciliter, or creatinine 1.5 to two times above baseline. And in this situation, physicians should consider temporarily holding checkpoint inhibitor therapy and evaluating other potential contributing agents in combination regimes, pending consideration of potential alternative pathologies. A change that is still less than 1.5 times of upper limit of normal could be meaningful and should be remembered. For grade 2 AKI, which is creatinine two to three times above baseline, apart from holding immune checkpoint inhibitor and evaluating for alternative causes, nephrology should be consulted. If other ideologies are ruled out, administer 0.5 to 1 milligram per kg per day prednisone or its equivalent. If kidney function worsens or does not improve after one week, increase the dose of prednisone to 1 to 2 milligrams per kg per day or its equivalent, and permanently discontinue immune checkpoint inhibitor. If the AKI improves to grade 1 or less, taper steroids over at least four weeks, otherwise we might see recurrence. If there is no recurrence, a physician might discuss resumption of immune checkpoint inhibitor with patient after taking into account what are the risks and what are the benefits. Resumption of immune checkpoint inhibitor can be considered once steroids have been successfully tapered to 10 milligrams per day or less, or discontinued. However, if elevation persists for more than seven days or worsens, and no cause is found, then the grade 2 AKI needs to be treated as grade 3. Now grade 3 and grade 4 AKI are managed similarly. Grade 3 AKI is defined as creatinine more than three times the baseline, or more than 4 milligrams per deciliter, or when hospitalization is indicated. And grade 4 AKI defined as an AKI associated with life-threatening consequences, when dialysis is indicated, or creatinine six times above baseline. Management includes nephrology consult, evaluation for alternative causes, and permanent discontinuation of immune checkpoint inhibitor. If they are directly implicated in renal toxicity, the administration of corticosteroids in grade 3 or grade 4 AKI is at an initial dose of 1 to 2 milligrams per kg per day of prednisone or its equivalent. If and when the AKI improves to grade 1, corticosteroids can be tapered over at least four weeks. However, if elevation persists for more than three to five days for grade 3 or more than two to three days for grade 4 or worsens, we should consider additional immunosuppression, such as infliximab as a time frame, cyclophosphamide, cyclosporine, or mycophenolate. Usually, reflex renal biopsy is typically not necessary or recommended unless the AKI is refractory to steroids or other immunosuppressive agents. BRITTANY HARVEY: I appreciate your reviewing those details for immune related renal toxicity. So then, in your view, Dr. Swami, how will these recommendations for the management of renal toxicities impact both clinicians and patients? UMANG SWAMI: This guideline presents a concise, up to date, and a stepwise approach to diagnose, grade, and treat this rare, but serious side effect of immunotherapy. In my view, this would be immensely helpful to clinicians in busy practices. Prompt identification and treatment is also expected to help our patients experiencing immune related kidney injury. For patients, it will provide a readily available document to refer to for information regarding side effects of immune checkpoint inhibitor therapy. I applaud the efforts by the ASCO and the authorship team in developing the patient focused version of this guideline. This may allow patients, especially when between clinic visits, to identify this unusual condition and seek medical help in a timely fashion. BRITTANY HARVEY: Great. Thank you for highlighting the importance of this guideline, for all your work you did on this guideline, and for your time today, Dr. Swami. UMANG SWAMI: Thanks so much, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can find many of our guidelines and interactive resources in the free ASCO guidelines app, available on iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
Featuring perspectives from Dr Sara Hurvitz, including the following topics: Introduction (0:00) Case: A woman in her early 40s with metastatic triple-negative breast cancer (TNBC) — Sulfi Ibrahim, MD (12:39) Case: A woman in her mid-40s with oligometastatic TNBC — Ann Partridge, MD, MPH (29:05) Case: A woman in her early 40s with metastatic TNBC and a BRCA2 mutation — Ruth O'Regan, MD (35:44) Beyond the Guidelines (43:36) Journal Club with Dr Hurvitz (53:28) CME information and select publications
In this week's Immigration Law for Tech Startups podcast, I'm joined by my law partner Anita Koumriqian as we discuss DACA and DREAMers, what is going on, and why this matters, not just for the recipients and their families, but also within the tech community. The point of DACA, which stands for Deferred Action for Childhood Arrivals, is to allow peace of mind, comfort, and most importantly, the ability to go to school for undocumented children brought to the United States by their parents from another country. And so, it gives undocumented people the ability to work, if they qualify. Please share this episode with companies, HR and recruiting professionals, startup founders, international talent, or anyone who can benefit from it. Sign up for the Alcorn monthly newsletter to receive the latest immigration news and issues. Reach out to us if we can help you determine the best immigration options for yourself, your company, your employees or prospective employees, or your family whether in the U.S. or abroad. In this episode, you'll hear about: The history of DACA DACA updates under the Biden administration DACA qualification and requirements Grounds for disqualification What permanent injunction means Other bills passed in addition to DACA What companies could do to assist existing DACA employees Guidelines around Advance Parole Don't miss my upcoming conversations with top Silicon Valley venture capitalists, startup founders, professors, futurists, and thought leaders on Immigration Law for Tech Startups. Subscribe to this podcast here or on Spotify, Apple Podcasts, Google Podcasts, or whatever your favorite platform is. As always, we welcome your rating and review of this podcast. We appreciate your feedback! Resources: Alcorn Immigration Law: Subscribe to the monthly Alcorn newsletter Immigration Law for Tech Startups podcast: Episode 13: Show the Love: Family-based Alternatives for Technology Professionals Episode 49: Never Do This in Immigration – Family Episode 68: Update on DACA Immigration Options for Talent, Investors, and Founders Immigration Law for Tech Startups eBook Extraordinary Ability Bootcamp course for best practices for securing the O-1A visa, EB-1A green card, or the EB-2 NIW (National Interest Waiver) green card—the top options for startup founders. Use promotion code ILTS for 20% off the enrollment fee.
Menopause specialist, Dr Sarah Ball, makes a record 4th appearance on the Dr Louise Newson podcast this week, to talk about an important group of women that often feel marginalised when it comes to menopause care and treatment. One in seven women will experience breast cancer, and many more of us have a close relative who has had breast cancer. Thankfully, thousands more women are living longer after breast cancer, but this often means living with the menopause and symptoms of a lack of hormones. The experts discuss the risk factors of developing breast cancer and the complexities of the association between hormones and breast cancer. Dr Sarah Ball has researched the experiences of menopausal women having breast cancer treatment and her findings reveal women are having to endure menopausal symptoms for an average of 7 years before seeking, or being given, help and treatment, and sadly, only 10% of the women surveyed felt they were involved in decisions about their care. Dr Ball and Dr Newson are both passionate about helping women after breast cancer and believe it is essential that these women are listened to, that healthcare professionals discuss in full the treatment options for their menopausal symptoms, and that women feel empowered to make a decision that's right for them, at that time, being aware of all the relevant information. Sarah's 3 tips for women after breast cancer: Don't feel guilty for how you feel about your menopause, you're not complaining, or moaning or being ‘weak'. It's really important that your symptoms are addressed. You are your whole body, not just your breasts. Don't lose sight of the health of your heart, your bones, your skin, your sex life, your mental health and brainpower – these are important too. Symptoms relating to your vagina, vulva and urinary function are treatable by using vaginal estrogen. This is safe to use after breast cancer and is not absorbed by the whole body in the same way as HRT. You can tackle these symptoms successfully, even if you feel you do not want to take HRT. Understand you do have a choice. Guidelines recommend you should be listened to and have a say in decisions about treatments. Tell your healthcare professionals what is most important to you in terms of living your life, treating your menopausal symptoms, and managing the risk of cancer returning. Follow Dr Sarah Ball on Instagram @drsarahmollyball and Twitter @sarahball14 Making decisions around your cancer treatment and menopause is often a complicated and overwhelming process. There is a new factsheet on balance website about making informed decisions about cancer treatments here, and a personal story written by the partner of a woman having worsening menopause symptoms after breast cancer treatment here.
Tips this week include: • New Interworx tutorials are live in the Webmaster Training course • Recipe Video SEO tutorials are almost complete • How to get faster video and post production • Holiday sales are coming soon and where to get first notification • A recap on my first meeting with the new WP Performance team • UpdraftPlus is still having issues for some folks • Fantastic updates to WP Fastest Cache • Super updates to CleanTalk Antispam • A first real look at Full Site Editing • What Google's no-ad subscription survey may mean we'll see in search • How Google overcounted mobile page experience for 4 months • When the new Google Page Experience will come to desktop • Why Twitter previews for Instagram links is so important • What's in the updated Google Video SEO Guideline • Why you may need a dedicated page for video • Why the new YouTube Shorts Report is so exciting • Why livestream shopping for Instagram is so important • TikTok funny for bloggers
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This episode was recorded live at the Fall 2021 Economic Outlook Conference. The 2020 COVID-19 pandemic and associated business disruptions brought unprecedented challenges for companies in the Santa Clarita Valley and across the globe. It's more important than ever for business leaders to arm themselves with vital information and data to make decisions that will impact growth and success in 2021 and beyond. In part four of this series, you'll hear from a panel of business leaders about how they are dealing with supply chain issues and key lessons learned from the pandemic.
An interview with Dr. Maria Suarez-Almazor from MD Anderson Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews identification, evaluation & management of musculoskeletal toxicities in patients receiving ICPis, including inflammatory arthritis, myositis & polymyalgia-like syndrome in Part 7 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at ASCO.org/podcasts. My name is Brittany Harvey, and today, we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Maria Suarez-Almazor from the University of Texas M.D. Anderson Cancer Center in Houston, Texas, author on Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update and Management of Immune-Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. And today, we're focusing on musculoskeletal toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Suarez-Almazor. MARIA SUAREZ-ALMAZOR: Thank you. BRITTANY HARVEY: First I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for the guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Suarez-Almazor, do you have any relevant disclosures that are directly related to these guidelines? MARIA SUAREZ-ALMAZOR: Thank you, Brittany. I don't have any disclosures directly related to the guidelines. BRITTANY HARVEY: Thanks very much. Then getting into the content of this, what are the immune-related musculoskeletal toxicities addressed in this guideline? MARIA SUAREZ-ALMAZOR: There are three major musculoskeletal syndromes covered in this guideline-- inflammatory arthritis, myositis, and polymyalgia rheumatica. BRITTANY HARVEY: Great. Then let's start with that first one that you mentioned. So what are the key recommendations for identification, evaluation, and management of inflammatory arthritis? MARIA SUAREZ-ALMAZOR: The diagnosis of inflammatory arthritis is primarily based on a thorough joint exam to detect the presence of synovitis and how many joints and what joints are actually involved. For this reason, we recommend early referral to a rheumatologist. From a diagnostic perspective, we recommend testing for antinuclear antibodies or ANA, rheumatoid factor, and cyclic citrullinated peptide antibodies or anti-CCP. These are only positive in 10% to 20% of patients but may be indicative of a more persistent disease. As inflammatory arthritis does not have any specific biochemical parameters for follow up, we use inflammatory markers such as sed rate and CRP in conjunction with the clinical exam as indicators of disease activity. For grades 1 and 2, we recommend treatment with nonsteroidal anti-inflammatory drugs or NSAIDs, or low-dose steroids up to 20 milligrams of oral prednisone or equivalent. If there is involvement of only one or two joints, local treatment with steroid injections can be indicated. For grade 3 and higher, the dose of steroids can be increased up to 0.5 to 1 milligram per kilogram of body weight. And if there is no improvement within two weeks or if the steroids cannot be satisfactorily tapered, we recommend early initiation of a disease-modifying antirheumatic drug or a DMARD, such as methotrexate, hydroxychloroquine, or sulfasalazine. We need to understand though that these may take up to two or three months to be effective. Alternatively, we can use biologic agents which have a faster onset of action. Recommended agents include tumor necrosis factor or interleukin 6 receptor inhibitors. In severe cases, immune checkpoint inhibitors may need to be permanently discontinued. But the overall goal is to try to continue therapy while we treat the adverse event. BRITTANY HARVEY: Understood. Appreciate your reviewing that information for inflammatory arthritis. Following that, what are the key recommendations for identification, evaluation, and management of myositis? MARIA SUAREZ-ALMAZOR: Well, myositis is really the most serious of the musculoskeletal toxicities. And it can be life threatening, especially when it's associated with myocarditis and with myasthenia gravis features. It usually presents with proximal weakness of the upper and lower extremities and sometimes with myalgia and even rhabdomyolysis. It usually is very acute in its presentation. Specific testing includes muscle enzymes, creatine kinase and aldolase, and electromyography and muscle biopsy if the diagnosis is uncertain. MRI can be useful as it can show muscle inflammation. And it can also assist in identifying a location for a biopsy if needed. Consultation with rheumatology and neurology should be requested early on. We also recommend that all patients undergo testing of cardiac enzymes such as troponin. And if elevated, a cardiology consultation should be placed right away and further testing performed. For grades 1 and 2, if patient has symptoms, treatment with corticosteroids are 0.5 to 1 milligram per kilogram should be initiated. For patients with grade 3 or 4, checkpoint inhibitors should be discontinued and the patient should be hospitalized. Corticosteroids should be initiated at a dose of 1 milligram per kilogram of prednisone or equivalent. And patients with severe compromise may need intravenous corticosteroid doses at higher doses of 1 or 2 milligrams per kilogram or even higher. For severe disease or if there is myocarditis or concomitant myasthenia gravis, we can consider plasmapheresis. IVIG can also be used, but it has a slower onset of action. And it is important to remember that plasmapheresis can remove immunoglobulins. So if it is to be used, the IVIG should be administered after the plasmapheresis is completed. There are other immunosuppressant therapies such as biologic agents that can also be considered. And sometimes for maintenance, oral immunosuppressants such as azathioprine, methotrexate, or mycophenolate mofetil can also be considered. Patients with severe disease may need to permanently discontinue the checkpoint therapy. BRITTANY HARVEY: OK, those details are helpful for clinicians. So then, for the last category, addressed in this guideline that you mentioned, what are the key recommendations for identification, evaluation, and management of polymyalgia-like syndrome. MARIA SUAREZ-ALMAZOR: Polymyalgia rheumatica syndromes present with marked pain and stiffness of the muscles in the shoulder and hip girdles. But some patients can also present with concomitant inflammatory arthritis. The workup is very similar to that of arthritis. In these patients, it is very important though to obtain a creatine kinase so that the muscle enzyme to be certain that the myalgia is not from myositis, as a treatment would be very different. Although very rare, polymyalgia, in some instances can be associated with giant cell arteritis which, if present, would require more aggressive treatment. For this reason, it is important to ask the patient about symptoms such as headache, visual disturbances, or jaw claudication. The management of polymyalgia-like immune adverse events alone, without any associated vasculitis, is very similar to that of arthritis. So we would use NSAIDs and low-dose steroids for grade 1 and 2. Higher doses of steroids and disease modifying agents, including biologics, might be needed for grades 3 and 4. But overall, very similar management as that of inflammatory arthritis. BRITTANY HARVEY: Great. Thanks for reviewing all of those recommendations for those three different categories. So then, in your view, Dr. Suarez-Almazor, how will these recommendations for the management of musculoskeletal toxicities impact both clinicians and patients? MARIA SUAREZ-ALMAZOR: Thank you, Brittany. For the most common rheumatologic adverse events, such as arthralgia, inflammatory arthritis, or polymyalgia-like syndromes, because they are not life threatening, we may not be as worried. But we need to recognize that they can greatly impair quality of life. So we really hope that these recommendations can assist patients and clinicians in the early recognition of symptoms and also in initiating prompt treatment so our goal to be able to continue checkpoint inhibitor therapy can be achieved by controlling the symptoms that really impair quality of life. Myositis is a much more serious adverse event that can lead to death. Patients may not be able to restart immune checkpoint inhibitor therapy again after they develop myositis. So we hope that these recommendations do highlight the need for very prompt diagnosis, consultation with specialists, and very aggressive treatment early on to control and manage these devastating, life-threatening adverse event. BRITTANY HARVEY: Definitely. Early recognition, treatment, and improved quality of life are key. So I want to thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Suarez-Almazor. MARIA SUAREZ-ALMAZOR: Thank you, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune-related adverse events. To read the full guideline, go to www.ASCO.org/supportive-care-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
Commentary by Dr. Valentin Fuster
Fiona Hill was the top Russia advisor in the Trump administration, serving as Senior Director European and Russian Affairs on the National Security Council from 2017-2019. The daughter of a coal miner and midwife, she grew up in Bishop Auckland in the 60s, moving to the U.S. to escape the class and accent discrimination she faced in the UK. She served as a policy expert on Russia under three presidents but was catapulted to fame for her testimony at the first impeachment inquiry of President Trump. She has written about her experiences in a new memoir, There Is Nothing For You Here: Finding Opportunity In The 21st Century. Hollyoaks star Sarah Jayne Dunn is defending the OnlyFans pictures that led to her exit from the long-running soap. Sarah - who has played the character of Mandy Richardson on the show since 1996 - was reportedly axed after refusing to delete her OnlyFans social media account. The platform is often used as a means for people to sell pornographic photo and video content to paying subscribers. Sarah joins Emma. The National Institute of Clinical Excellence has published new guidelines on the induction of labour for pregnant women with what has been called a u-turn on their original proposals in the summer. Elizabeth Duff, senior policy advisor at the National Childbirth Trust (NCT) and Asma Khalil, Consultant Obstetrician at St George's Hospital in London and spokesperson for the Royal College of Obstetricians and Gynaecologists explain what these changes mean. Presenter: Emma Barnett Producer: Lucinda Montefiore
The Surviving Sepsis Campaign Guidelines have been updated! It's been over five years since the last update and many new studies have redefined the role of several therapies for sepsis. Redeem your CPE or CME credit here! Claim CPE CreditClaim CME CreditNeed a membership?Join for CPE CreditJoin for CME CreditReferences and resources: Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, Critical Care Medicine: November 2021 - Volume 49 - Issue 11 - p e1063-e1143 doi: 10.1097/CCM.0000000000005337Continuing Education Information:Learning Objectives: 1. Discuss the role of corticosteroids in septic shock patients requiring vasopressors2. Discuss laboratory and screening tools to aid in treating septic shock patients0.05 CEU | 0.5 HrsACPE UAN: 0107-0000-21-360-H01-PInitial release date: 11/08/21Expiration date: 11/08/22Complete CPE & CME details can be found here: www.ceimpact.com
In this episode Vivek Kinra really breaks down and explains some of the most important and common things that get denied by insurance companies and how we can avoid or work around these denials. He lets us know how to proceed with the preauthorization. of an implant, why every office should have their own "cheat sheet" that will streamline this process more, and which company Vivek thinks everyone should drop first if they are planning to go fee for service.You can reach out to Vivek Kinra here:Email: vkinra@ppoprofits.comWebsite: https://www.ppoprofits.com/If you want your questions answered on Monday Morning Marketing, ask me on these platforms:Email: michael@thedentalmarketer.siteMy Newsletter: https://thedentalmarketer.lpages.co/newsletter/Ground Marketing Facebook Group: https://www.facebook.com/groups/738965052973156The Dental Marketer Society Facebook Group: https://www.facebook.com/groups/2031814726927041
Episode 545: November 7, 2021 playlist: Hard Feelings, "Sister Infinity" (Hard Feelings) 2021 Domino Patrick Q.Wright and Edward Ka-Spel, "Medusa Of A Thousand Cuts" (The Scarlet Trail of Stinging Tears) 2021 self-released Jake Xerxes Fussell, "Love Farewell" (Good and Green Again) 2022 Paradise of Bachelors Noveller, "Laura Palmer's Theme (Video Edit)" (Wrapped in Plastic) 2021 self-released serpentwithfeet, "Shoot Ya Shot" (DEACON'S Grove) 2021 Secretly Canadian Still, "Ahlam Wa Ish (feat. Winnie Lado)" (KIKOMMANDO) 2021 Pan bela, "Variation 1" (Guidelines) 2021 Editions Appaerent Mark Trecka, "Radiance (feat. Walt McClements)" (Implication) 2021 Whited Sepulchre Crazy Doberman, "as the wind winds tightly 'round the loom" (everyone is rolling down a hill or "the journey to the center of some arcane mystery and the entanglements of the vines and veins of the cosmic and unwieldy millieu encountered in the midst of that endeavor") 2021 Astral Spirits Dear Laika, "Lilac Moon, Reflected Sun" (Pluperfect Mind) 2021 Memorials of Distinction George T and Johnny Aux, "Amsterdam" (Making Excuses For You EP) 2021 Optimo Tara Jane O'Neil, "This Girl's in Love With You" (His Majesty's Request: A Wink O'Bannon Select) 2021 Motorific Sounds Email podcast at brainwashed dot com to say who you are; what you like; what you want to hear; share pictures for the podcast of where you're from, your computer or MP3 player with or without the Brainwashed Podcast Playing; and win free music! We have no tracking information, no idea who's listening to these things so the more feedback that comes in, the more frequent podcasts will come. You will not be put on any spam list and your information will remain completely private and not farmed out to a third party. Thanks for your attention and thanks for listening.
Kimberly Kearney, COTA/L, has been an occupational therapy practitioner since 2003. She has worked in Skilled Nursing, Rehab, Memory Care, Acute Care, Home Health, Community Health, and Early Intervention settings. Most recently, Kim has been working in Home Health in Virginia. She has held licenses in Indiana, Florida, Colorado and now Virginia. Kim has been involved with AOTA serving on the Commission on Practice for over 5 years and assisted with the OTA Forum. She has also presented as a panel member at a few national conferences in these roles. She was involved with the topic of Driving and Community Mobility and worked with the ADED group in Colorado and presented at the Colorado OT Association Conference on the topic. Over the years, Kim has been happy to work with students in various aspects of their OT learning journey as a fieldwork educator. In addition, she views volunteering as a way of life after having worked with American Cancer Society, Girl Scouts, American Red Cross, the MS Society, Medical Reserve Corps, Make A Wish Foundation. She is an advocate for lifelong learning and enjoys a variety of challenges most recently exploring new occupations including meditative drumming, Cricut Maker projects, and solo camping in her teardrop trailer.Recommended resources:Everything is Figureoutable - book by Marie Forleo - https://www.amazon.com/Everything-Figureoutable-Marie-Forleo/dp/0525534997How to Get Involved (AOTA website) - including a link to update your COOL Profile - https://www.aota.org/Education-Careers/Students/Get-Involved.aspxOT-OTA Collaboration in Education - https://www.aota.org/-/media/Corporate/Files/Secure/Governance/RA/Minutes/RA%20Fall%20Online%202017%20Meeting/Importance-of-Collaborative-OT-OTA-Intraprofessional-Education-in-OT-Curricula-FINAL.pdf Guidelines for Supervision in OT Services - https://www.aota.org/-/media/Corporate/Files/Advocacy/State/Resources/Supervision/MSRSOTA.pdfGirl Camper website - https://girlcamper.com/Connect with Kim: Email: OTKimberly@gmail.comIG: @OTKimberlyTwitter: @OTKimberly
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