Survival outcomes for older adults with acute lymphoblastic leukemia (ALL) are poor and optimal management is challenging due to higher-risk leukemia genetics, comorbidities, and lower tolerance to intensive therapy. A critical understanding of these factors guides the selection of frontline therapies and subsequent treatment strategies. In addition, there have been recent developments in minimal/measurable residual disease (MRD) testing and blinatumomab use in the context of MRD-positive disease after therapy. These NCCN Guidelines Insights discuss recent updates to the NCCN Guidelines for ALL regarding upfront therapy in older adults and MRD monitoring/testing in response to ALL treatment.

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To determine practicing physicians' strategies for diagnosing and managing uncomplicated urinary tract infection, we surveyed physicians in general internal medicine, family practice, obstetrics and gynecology, and emergency medicine in four states. Responses differed significantly by respondents' specialty. For example, nitrofurantoin was the antibiotic of first choice for 46% of obstetricians, while over 80% in the other specialties chose trimethoprim-sulfamethoxazole. Most surveyed said they do not usually order urine culture, but the percentage who do varied by specialty. Most use a colony count of 10 5 colony-forming units or more for diagnosis although evidence favors a lower threshold, and 70% continue antibiotic therapy even if the culture result is negative. This survey found considerable variation by specialty and also among individual physicians regarding diagnosis and treatment of urinary tract infection and also suggests that some of the new information from the literature has not been translated to clinical practice. H ow physicians diagnose and treat uncomplicated urinary tract infection (UTI) can affect patient care and health care costs. Because UTI is a frequent complaint, even small variations in charges for diagnosis and treatment can account for large differences in expense when aggregated over millions of cases. Surveys have found that physicians vary in their approach to UTI. [1][2][3] Despite its importance, there is little information on what strategies physicians in the United States use in working up suspected UTI in women. KEY WORDS: urinary tract infectionResearch over the past 15 years has introduced new information regarding the diagnosis and management of UTI. Stamm and colleagues, for example, showed that a lower colony count than previously thought predicts bladder bacteriuria in symptomatic women. 4,5 Investigators have demonstrated the effectiveness and safety of shorter courses of treatment for acute cystitis, 6 and have developed convenient dipstick tests for pyuria and bacteriuria. 7 Investigators have increasingly questioned the need for culture and sensitivity of the urine in uncomplicated cases. 6,8 In addition, there is evidence that diagnostic strategies are changing, driven in part by mandates to reduce unnecessary costs. 9 To develop a broader understanding of physicians' diagnostic and management strategies and to determine whether these new advances have found their way into practice, we surveyed practicing physicians in several states and compared their strategies by possible sources of variation such as specialty, date of medical training, and practice location. METHODSWe developed an 88-item survey that was based on a review of the literature and interviews with generalist physicians. The 4-page survey asked about the value of clinical finding, tests, and strategies in the diagnosis and management of a 30-year-old nonpregnant woman with uncomplicated UTI with dysuria of recent onset.We surveyed physicians in specialties likely to be primary providers for adult w...

BackgroundMammography screening for women under the age of 50 is controversial. Groups such as the US Preventive Services Task Force recommend counseling women 40–49 years of age about mammography risks and benefits in order to incorporate the individual patient’s values in decisions regarding screening. We assessed the impact of a brief educational intervention on the knowledge and attitudes of clinicians regarding breast cancer screening.MethodsThe educational intervention included a review of the risks and benefits of screening, individual risk assessment, and counseling methods. Sessions were led by a physician expert in breast cancer screening. Participants were physicians and nurses in 13 US Department of Veterans Affairs primary care clinics in Alabama. Outcomes were as follows: 1) knowledge assessment of mammogram screening recommendations; 2) counseling practices on the risks and benefits of screening; and 3) comfort level with counseling about screening. Outcomes were assessed by survey before and after the intervention.ResultsAfter the intervention, significant changes in attitudes about breast cancer screening were seen. There was a decrease in the percentage of participants who reported that they would screen all women ages 40–49 years (82% before the intervention, 9% afterward). There was an increase in the percentage of participants who reported that they would wait until the patient was 50 years old before beginning to screen (12% before the intervention, 38% afterward). More participants (5% before, 53% after; P<0.001) said that they would discuss the patient’s preferences. Attitudes favoring discussion of screening benefits increased, though not significantly, from 94% to 99% (P=0.076). Attitudes favoring discussion of screening risks increased from 34% to 90% (P<0.001). The comfort level with discussing benefits increased from a mean of 3.8 to a mean of 4.5 (P<0.001); the comfort level with discussing screening risks increased from 2.7 to 4.3 (P<0.001); and the comfort level with discussing cancer risks and screening preferences with patients increased from 3.2 to 4.3 (P<0.001). (The comfort levels measurements were assessed by using a Likert scale, for which 1= not comfortable and 5= very comfortable.)ConclusionMost clinicians in the US Department of Veterans Affairs ambulatory practices in Alabama reported that they routinely discuss mammography benefits but not potential harms with patients. An educational intervention detailing recommendations and counseling methods affected the knowledge and attitudes about breast cancer screening. Participants expressed greater likelihood of discussing screening options in the future.

The clinical breast exam (CBE) is an important tool in the care of women. However, the utility of the screening CBE has been called into question. This article discusses the importance of the CBE as a physical diagnosis tool. Recommendations regarding screening with CBE are reviewed, and evidence surrounding breast cancer screening using CBE is briefly summarized. Clinicians should strive to provide high quality CBEs as part of the general clinical exam for women, particularly those who present with breast complaints, and for patients who choose to have CBE screening. In conclusion, there is a role for the CBE in the care of women, and clinicians should be proficient at performing these exams. Simulation teaching technologies are now available at Department of Veteran Affairs (VA) facilities to enable clinicians to improve their CBE skills. T he clinical breast exam (CBE) is an important tool in the care of women. It is utilized for the evaluation of breast complaints and, more controversially, in breast cancer screening. The Department of Veteran Affairs (VA) Women's Health Services Office has recently coordinated the distribution of breast exam simulation equipment to VA facilities in order to enhance CBE competency training for VA providers. Since the utility of the screening CBE has been called into question, 1 the issue may be raised as to whether this training is pertinent. The following summary will provide rationale that the CBE is an important physical diagnosis skill that should not be discarded, and that simulation equipment is a helpful tool in training clinicians.Clearly, the CBE is required for the evaluation of patients with breast complaints, particularly those with a breast lump. In one study of primary care clinics, 11 % of women complaining of a breast lump and 4 % of women with any breast complaint were found to have a malignancy. 2 In addition, a significant number of patients with breast cancer present with a palpable breast mass. Haakinson et al. 3 reported that 34 % of women with invasive breast cancer initially presented with a palpable lesion. 13 % of the women with a palpable breast mass who were found to have invasive cancer had a normal mammogram within the previous year. Likewise, a large study of diagnostic mammograms reported that the sensitivity of mammography in women with a self-reported breast lump was 87.3 %. 4 This suggests that approximately 13 % of clinically evident breast cancers may be missed by mammography imaging. Therefore, identifying these tumors by palpation is a pertinent clinical issue, and providers should be proficient at discerning abnormal breast findings.The more divisive issue is whether the clinical breast exam should be used in conjunction with mammography for breast cancer screening in asymptomatic patients. The US Preventive Services Task Force (USPSTF) states that there is insufficient evidence to recommend for or against routine screening with the CBE. 1 However, the American Cancer Society 5 and the American College of Obstetricians and Gynecologist...