Caring for Patients Receiving 177Lu-DOTATATE,Lutathera®: A Treatment of Hope for Patients With Gastroenteropancreatic Neuroendocrine Tumors

Lutathera^®, the trademark for lutetium 177Lu-DOTATATE registered to Advanced Accelerator Applications SA, is a peptide receptor radionuclide therapy used to treat gastroenteropancreatic neuroendocrine tumors positive for hormone receptor somatostatin. Lutathera specifically targets known tumor receptors and has been shown to decrease both tumor growth and spread. While available in Europe for many years, the Federal Drug Administration approved the use of 177Lu-DOTATATE in the United States in January 2018. 177Lu (lutetium) is a radioactive isotope with special precautions and considerations for safe administration of this treatment. When nuclear medicine, radiation safety, nursing, and the physicians work together as a team, the safe administration of Lutathera provides patients with another treatment option to battle cancer.     

Cognitive Deficits in Patients With Depression

Cognitive impairment in patients with depression is often overlooked because cognitive deficits and symptoms of depression often overlap. Understanding the neurobiological aspects of cognitive deficits is important, because cognition evolves as a therapeutic target in treating depression. Cognitive symptoms can precede or linger after symptoms of depression, such as sleep, appetite, and affective symptoms, improve. Emerging literature on medications targeting cognition in patients with depression should be considered when clinical decisions are made. Residual cognitive symptoms have been identified as a predictor of poor outcomes when treating depression. Referral to psychiatry should be considered in patients with residual symptoms where diagnosis is unclear.     

Management of Patients With Aortic Valve Stenosis

With increased life expectancy and aging of the population, aortic stenosis is now one of the most common valvular heart diseases. Early recognition and management of aortic stenosis are of paramount importance because untreated symptomatic severe disease is universally fatal. The advent of transcather aortic valve replacement technologies provides exciting avenues of care to patients with this disease in whom traditional surgical procedures could not be performed or were associated with high risk. This review for clinicians offers an overview of aortic stenosis and updated information on the current status of various treatment strategies. An electronic literature search of PubMed, MEDLINE, EMBASE, and Scopus was performed from conception July 1, 2016, through November 30, 2017, using the terms aortic stenosis, aortic valve replacement, transcatheter aortic valve replacement (TAVR), transcatheter aortic valve insertion (TAVI), surgical aortic valve replacement, aortic stenosis flow-gradient patterns, low-flow aortic valve stenosis, natural history, stress testing, pathophysiology, bicuspid aortic valve, and congenital aortic valve disease.     

Smokeless Tobacco and Cigar and/or Pipe Are Risk Factors for Barrett Esophagus in Male Patients With Gastroesophageal Reflux Disease

Objective

To investigate the effect of smokeless tobacco (ST), cigar and/or pipe smoking (CP) on the development of Barrett esophagus (BE) in white male patients with gastroesophageal reflux disease (GERD).

Pediatric Patients With Graves’ Disease: Difficult Diagnosis During Puberty

Graves’ disease is an autoimmune disease, characterized by goiter, hyperthyroidism, and ophthalmopathy. Many symptoms resemble typical transient childhood illnesses, and providers can miss subtle clues or attribute them to adolescent developmental aging. The variation in clinical management and lack of specific treatment guidelines for pediatric and adolescent patients requires careful consideration and partnership with affected patients and referral sources. This complex disease requires astute diagnostic reasoning in the primary care setting, ongoing patient and family support, and coordination of multidisciplinary health care providers. This case highlights adolescent Graves’ disease presentation in the primary care setting and the nurse practitioner role.     

Foot Function Index: A Promising Questionnaire for Individuals With Charcot-Marie-Tooth Disease Type 1A

ObjectiveTo evaluate in a preliminary methodologic study, the Foot Function Index (FFI), a 3-subscale (pain, disability, and activity restriction) foot disability assessment questionnaire, in patients with Charcot-Marie-Tooth disease type 1A (CMT1A).DesignMonocentric exploratory cross-sectional study with 2 identical evaluations by the same physical medicine and rehabilitation physician at 14-day intervals (test-retest) according to international guidelines for validating health-related patient-reported outcomes, the Consensus-based Standards for the Selection of Health Measurement Instruments Criteria.SettingPhysical medicine and rehabilitation and neurology departments in a French academic hospital.ParticipantsPatients with CMT1A confirmed by molecular biology (N=26).InterventionThe FFI and a health-related quality-of-life questionnaire (Medical Outcomes Study Short Form 36 [SF-36] with mental and physical composite scores) combined with quantitative walk analysis by instrumental gait analysis and evaluation of isokinetic quadriceps and hamstrings peak torque by isokinetic dynamometer.Main Outcome MeasuresFFI score and its dimensions.ResultsAcceptability was satisfactory, with less than 5% missing data and good distribution of results. Internal consistency was very satisfactory, with Cronbach α of 0.95. Reproducibility was very satisfactory, with Lin concordance coefficient 0.82. External consistency was satisfactory, with expected correlation coefficients: the FFI was significantly correlated with the SF-36 physical composite score and gait parameters (cadence) (r=-0.58 and r=-0.52; P<.005) but not with peak torque or SF-36 mental composite score.ConclusionsThis study confirms the very good metrologic properties of the FFI in patients with CMT1A. The FFI could be a promising questionnaire to assess foot-related disability in a neurologic disease. Complementary studies are still needed to confirm these promising preliminary results.     

Alzheimer’s Disease

Alzheimer’s disease is the most prevalent form of dementia. There are significant efforts underway to elucidate the pathogenesis of this disease and to find ways to lessen the impact of the symptoms. This paper summarizes current knowledge regarding the diagnosis and treatment of the disorder.     

Examination of Factors Related to the Effect of Improving Gait Speed With Functional Electrical Stimulation Intervention for Stroke Patients

Background

Functional electrical stimulation (FES) for patients with stroke and foot drop is an alternative to ankle foot orthoses. Characteristics of FES responders and nonresponders have not been clarified.

Update on Treatments for Cognitive Decline in Alzheimer’s Disease

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder and a leading cause of dementia in the elderly. AD initially presents as mild cognitive impairment (MCI); later, as AD progresses, memory and cognition are destroyed, preventing the ability to carry out activities of daily living. The primary care provider may be the first to suspect MCI, and screening tests can help with diagnosis. Development of drugs for cognitive decline in AD has been slow; however new therapies are in the pipeline and discovery of biomarkers make early diagnosis and future treatment of AD hopeful.     

Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study

Objective

To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials.

What Do Medical Students Do and Want When Caring for “Difficult Patients”?

Phenomenon: Medical students, like physicians, experience negative emotions such as frustration when interacting with some patients, and many of these interactions occur for the first time during clinical clerkships. Students receive preclinical training in the social and behavioral sciences, often including learning about “difficult patient” interactions, yet little is known about their desire for training during clinical education. We explored students’ strategies in these difficult clinical interactions, whether they felt prepared by the curriculum, and what support they would have liked. These data inform proposed strategies for supporting clinical learning. Approach: We interviewed 4th-year students about interactions with patients toward whom they felt negative emotions and sought to identify strategies and supports needed in these interactions. Interviews ended when theoretical sufficiency was achieved. We used qualitative content analysis to organize strategies into themes about areas benefiting from curricular supports. We mapped students’ desired curricular support examples to cognitive apprenticeship teaching methods—modeling, coaching, reflection, scaffolding, exploration, and articulation—and aligned them with traditional pedagogical techniques. Findings: We interviewed 26 medical students (44 volunteered/180 invited). Their strategies formed five themes: finding empathy (with a subtheme of focusing on social determinants of health), using learned communication approaches, anticipating challenging interactions, seeking support, and considering it an opportunity for more responsibility. Students described ideal clinical teaching, including postinteraction debriefs with an emphasis on validating their emotional reactions and challenges. Students mentioned all cognitive apprenticeship teaching methods, most prominently modeling (observing supervisors in such interactions) and supported oral reflection. They also identified a need for faculty and resident development to enact these teaching methods. Insights: Although students use some learned strategies in interactions in which they feel negative emotions toward patients, they desire more preparation and support during their clinical rotations. Their desires map to traditional pedagogical techniques and to methods of cognitive apprenticeship. Our findings point to the need to use these techniques to enhance clinical learning for students who experience emotionally challenging patient interactions.     

Blowin’ in the Wind – Another Study Reporting Shortfalls in Caring for Our Transgender Patients

The factors that contribute to persistent health disparities faced by the transgender community, such as lack of practitioner training and electronic health record deficiencies, are well documented. Yet, health-care leaders across settings and disciplines have not enacted the guidance provided almost a decade ago by organizations such as The Joint Commission to address the issues. This article summarizes a recent survey conducted by Goldberg, Moy, and Rosenkrantz (2018) which reported on policies and practices at breast-imaging facilities across the United States. In addition to summarizing the article that was published in the Journal of the American College of Radiology, this article discusses the relevance of Goldberg et al.’s findings. This commentary calls on health-care leaders to take action to address the festering shortfalls in care which contribute to the health disparities faced by the transgender community across all settings including radiology practices.