The growing number of older adults in America will result in an increasing demand for psychotherapists familiar with their psychological needs. To treat this population in an ethical manner, practitioners need to be aware of the unique characteristics of the aging process, especially in regards to age-related vulnerabilities, such as cognitive decline. Unfortunately, recent research has shown that those currently in practice do not have sufficient knowledge of the aging process and age specific issues of older adults. To address these deficits the American Psychological Association published a report outlining six general concepts: attitudes, general knowledge about adult development, clinical issues, assessment, intervention, and education. These concepts are described. Furthermore, this article extends the current thinking on ethical issues regarding older adults by addressing their vulnerabilities. In addition, ethical issues such as informed consent, confidentiality, and elder abuse are addressed as they apply to both clinical and research situations. In addition, methods of resolving these important issues are suggested throughout the article. A depiction of the ethical issues of psychologists working with older adults is provided and practical procedures to help psychologists perform with high ethical standards of care for this age group are offered.
At the onset of the COVID-19 pandemic, based on BSG guidelines, all patients undergoing endoscopic surveillance for Barrett's Oesophagus (BE) were indefinitely postponed. As well as the potential for missed progression to dysplasia, the negative impact on patients' quality of life is immeasurable. The Cytosponge® is a minimally invasive cell sampling device which to date has been researched in screening for BE. We describe the first use of the Cytosponge® outside of a clinical trial to support the triage of BE surveillance patients.
Methods
Consecutive patients with non-dysplastic BE (NDBE) or those deemed to be low risk after previous treatment for BE-related dysplasia, DBE, with no prior history of stenosis were invited to have the Cytosponge®. The sample was analysed for TFF3 (a marker of intestinal metaplasia), cellular atypia and p53.
Results
To date, 153 patients (mean age 66 years, 126 male) have undergone the Cytosponge® procedure. The median maximal length of BE was 3cm (1-15cm). Three patients were unable to swallow the device and 19 (12%) needed a repeat procedure as no columnar cells were present. 87 patients (80%) with NDBE had a either a low-risk result (TFF3 positive only – 62) or required a repeat Cytosponge® routinely (TFF3/atypia/p53 negative – 25). The remaining 21 patients (20%) needed an endoscopy within 3 months of the Cytosponge®. 17 of these patients have since had an endoscopy of which 4 had a new diagnosis of dysplasia (low grade dysplasia, indefinite, INDEF 2, LGD – 1; intramucosal, IMC - 1) and 2 a new diagnosis of cancer. 18 patients in the low-risk ND-BE cohort have undergone follow-up endoscopy (ND-BE 17/18, HGD 1/18). of the 23 patients in the post-treatment cohort, only 1 patient had a high-risk result and subsequent endoscopy confirmed HGD (Table 1). Over-expression of p53 appeared to be the most sensitive marker (p - 0.01).
Conclusions
Cytosponge® has proved to be a useful non-endoscopic tool for patients with BE under surveillance. Preliminary data are promising to detect dysplasia and triage patients to endoscopy early. Further large scale, longitudinal endoscopic follow-up is needed.
INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS: In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated. RESULTS: Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02). DISCUSSION: Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.
Inflammatory bowel disease [IBD] is associated with high rates of post-colonoscopy colorectal cancer [PCCRC], but further in-depth qualitative analyses are required to determine whether they result from inadequate surveillance or aggressive IBD cancer evolution.
Pathogenic germline exonuclease domain (ED) variants of POLE and POLD1 cause the Mendelian dominant condition polymerase proof-reading associated polyposis (PPAP). We aimed to describe the clinical features of all PPAP patients with probably pathogenic variants. We identified patients with a variants mapping to the EDs of POLE or POLD1 from cancer genetics clinics, a colorectal cancer (CRC) clinical trial, and systematic review of the literature. We used multiple evidence sources to separate ED variants into those with strong evidence of pathogenicity and those of uncertain importance. We performed quantitative analysis of the risk of CRC, colorectal adenomas, endometrial cancer or any cancer in the former group. 132 individuals carried a probably pathogenic ED variant (105 POLE, 27 POLD1). The earliest malignancy was colorectal cancer at 14. The most common tumour types were colorectal, followed by endometrial in POLD1 heterozygotes and duodenal in POLE heterozygotes. POLD1-mutant cases were at a significantly higher risk of endometrial cancer than POLE heterozygotes. Five individuals with a POLE pathogenic variant, but none with a POLD1 pathogenic variant, developed ovarian cancer. Nine patients with POLE pathogenic variants and one with a POLD1 pathogenic variant developed brain tumours. Our data provide important evidence for PPAP management. Colonoscopic surveillance is recommended from age 14 and upper-gastrointestinal surveillance from age 25. The management of other tumour risks remains uncertain, but surveillance should be considered. In the absence of strong genotype-phenotype associations, these recommendations should apply to all PPAP patients.
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