Open questions, current challenges, and future perspectives in targeting human epidermal growth factor receptor 2-low breast cancer.

Approximately 60% of traditionally defined human epidermal growth factor receptor 2 (HER2)-negative breast cancers express low levels of HER2 [HER2-low; defined as immunohistochemistry (IHC) 1+ or IHC 2+/in situ hybridization (ISH)-]. HER2-low breast cancers encompass a large percentage of both hormone receptor-positive (up to 85%) and triple-negative (up to 63%) breast cancers. The DESTINY-Breast04 trial established that HER2-low tumors are targetable, leading to the approval of trastuzumab deruxtecan (T-DXd) as the first HER2-directed therapy for the treatment of HER2-low breast cancer in the United States and Europe. This change in the clinical landscape results in a number of questions and challenges-including those related to HER2 assessment and patient identification-and highlights the need for careful assessment of HER2 expression to identify patients eligible for T-DXd. This review provides context for understanding how to identify patients with HER2-low breast cancer with respect to sample types, scoring and reporting HER2 status, and testing methods and assays. It also discusses management of important T-DXd-related adverse events. Available evidence supports the efficacy of T-DXd in patients with any history of IHC 1+ or IHC 2+/ISH- scores; however, future research may further refine the population who could benefit from T-DXd or other HER2-directed therapies and identify novel methods for patient identification. Because HER2 expression can change with disease progression or treatment, and variability exists in scoring and interpretation of HER2 status, careful re-evaluation in certain scenarios may help to identify more patients who may benefit from T-DXd.

Cultural transition of international medical graduate residents into family practice in Canada.

OBJECTIVE: To identify the perceived strengths that international medical graduate (IMG) family medicine residents possess and the challenges they are perceived to encounter in integrating into Canadian family practice. METHODS: This was a qualitative, exploratory study employing focus groups and interviews with 27 participants - 10 family physicians, 13 health care professionals, and 4 family medicine residents. Focus group/interview questions addressed the strengths that IMGs possess and the challenges they face in becoming culturally competent within the Canadian medico-cultural context. Qualitative data were audiotaped, transcribed, and analyzed thematically. RESULTS: Participants identified that IMG residents brought multiple strengths to Canadian practice including strong clinical knowledge and experience, high education level, the richness of varied cultural perspectives, and positive personal strengths. At the same time, IMG residents appeared to experience challenges in the areas of: (1) communication skills (language nuances, unfamiliar accents, speech volume/tone, eye contact, directness of communication); (2) clinical practice (uncommon diagnoses, lack of familiarity with care of the opposite sex and mental health conditions); (3) learning challenges (limited knowledge of Canada's health care system, patient-centered care and ethical principles, unfamiliarity with self-directed learning, unease with receiving feedback); (4) cultural differences (gender roles, gender equality, personal space, boundary issues; and (5) personal struggles. CONCLUSIONS: Residency programs must recognize the challenges that can occur during the cultural transition to Canadian family practice and incorporate medico-cultural education into the curriculum. IMG residents also need to be aware of cultural differences and be open to different perspectives and new learning.

Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study.

BACKGROUND: Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting. METHOD: Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis. RESULTS: Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs. CONCLUSIONS: In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.

Reducing enclosed cab drill operator's respirable dust exposure with effective filtration and pressurization techniques.

Many different types of surface mining equipment use enclosed cabs to protect equipment operators from health and safety hazards. The overburden removal and mining process can be extremely dusty and can cause excessive dust exposure. To study this issue, a cooperative research effort was established between the National Institute for Occupational Safety and Health, U.S. Silica Co., Clean Air Filter Co., and Red Dot Corp. in an effort to lower respirable dust levels in an enclosed cab on an older surface drill at a silica sand operation. Throughout this research effort, a number of modifications were incorporated into the drill's filtration and pressurization system, as well as in other areas, to improve its design and performance. An average cab efficiency of 93.4% was determined with gravimetric sampling instruments when comparing the outside with the inside cab dust levels on the final design. Although this study considered just one operation, the goal was to identify cost-effective improvements that could be implemented on all types of enclosed cabs to lower respirable dust concentrations. Two critical components for an effective enclosed cab system are having a properly designed, installed, and maintained filtration and pressurization system, along with a method for maintaining structural cab integrity, which allows the cab to be positively pressurized. Another important component is maintaining cab cleanliness. Although this research was originally directed toward the mining industry, it is also applicable to agricultural or construction equipment.