Hepatitis B Virus and B-cell lymphoma: evidence, unmet need, clinical impact, and opportunities

Nearly a billion people worldwide are infected with the hepatitis B Virus (HBV) and about a third of them have chronic infection. HBV is an important cause of morbidity and mortality, including acute and chronic hepatitis and hepatocellular carcinoma (HCC). Screening and control of primary HBV infection through vaccination represent a major advance in global public health, but large sections of the world population, in both developed and underdeveloped countries, remain unscreened and unvaccinated. In addition to being a global cause of liver disease, an important role of HBV in lymphoma has also emerged. First, the high risk of HBV reactivation in previously infected patients receiving chemo-immunotherapy necessitates the systematic evaluation of HBV serological status in all non-Hodgkin's lymphoma (NHL) cases and preemptive antiviral therapy for those who may have chronic or occult HBV infection. Second, HBV has been shown to infect lymphocytes, namely B-cells, and has been associated with a higher risk of developing B-cell lymphoma, most clearly in countries where HBV is endemic. While the risk of HBV reactivation with chemoimmunotherapy in NHL is well known, the role and the impact of HBV as a global lymphoma risk factor and potential oncogenic driver in B-cells are very poorly understood. Here, we review the clinical and scientific evidence supporting an association between HBV and B-cell lymphoma, with a particular focus on diffuse large B-cell lymphoma (DLBCL) and provide an overview of the estimated impact of HBV infection on the biology and clinical course of DLBCL. We also discuss ways to gain a better insight into the unmet need posed by HBV in lymphoma and whether assessing immune responses to HBV, measuring viral loads, and detecting the presence of HBV-encoded proteins in tumor tissue could be integrated into the molecular and clinical risk stratification of patients with DLBCL

Hepatitis B Virus and B-cell Lymphoma: Evidence, Unmet Need, Clinical Impact, and Opportunities

Nearly a billion people worldwide are infected with the hepatitis B Virus (HBV) and about a third of them have chronic infection. HBV is an important cause of morbidity and mortality, including acute and chronic hepatitis and hepatocellular carcinoma (HCC). Screening and control of primary HBV infection through vaccination represent a major advance in global public health, but large sections of the world population, in both developed and underdeveloped countries, remain unscreened and unvaccinated. In addition to being a global cause of liver disease, an important role of HBV in lymphoma has also emerged. First, the high risk of HBV reactivation in previously infected patients receiving chemo-immunotherapy necessitates the systematic evaluation of HBV serological status in all non-Hodgkin\u27s lymphoma (NHL) cases and preemptive antiviral therapy for those who may have chronic or occult HBV infection. Second, HBV has been shown to infect lymphocytes, namely B-cells, and has been associated with a higher risk of developing B-cell lymphoma, most clearly in countries where HBV is endemic. While the risk of HBV reactivation with chemoimmunotherapy in NHL is well known, the role and the impact of HBV as a global lymphoma risk factor and potential oncogenic driver in B-cells are very poorly understood. Here, we review the clinical and scientific evidence supporting an association between HBV and B-cell lymphoma, with a particular focus on diffuse large B-cell lymphoma (DLBCL) and provide an overview of the estimated impact of HBV infection on the biology and clinical course of DLBCL. We also discuss ways to gain a better insight into the unmet need posed by HBV in lymphoma and whether assessing immune responses to HBV, measuring viral loads, and detecting the presence of HBV-encoded proteins in tumor tissue could be integrated into the molecular and clinical risk stratification of patients with DLBCL

Intolerance of Uncertainty and Attitudes Towards Persons Living with Disabilities in Medical Students: Is There a Correlation?

INTRODUCTION: Patients living with a disability experience an illness trajectory that may be uncertain. While navigating clinical uncertainty has been well-researched, health professionals\u27 intolerance of uncertainty for patients living with disabilities has yet to be explored. We examined the relationship between medical students\u27 intolerance of uncertainty with their attitudes towards people living with disabilities to better inform curricular efforts. METHODS: We employed a survey-based design consisting of the Intolerance of Uncertainty Scale (IUS) and Disability Attitudes in Healthcare (DAHC) Scale to medical students upon completion of core clerkships (end of third-year of training). Data were de-identified. Mean DAHC and IUS scores were compared with published values RESULTS: Response rate was 97% (268/275 students). Mean IUS score did not differ from previously cited medical student scores, but mean DAHC score was significantly higher than previously cited scores. We observed a statistically-significant relationship between IUS and DAHC scores. Students with greater intolerance of uncertainty had lower scores for disability attitudes [ CONCLUSION: We identified a weak negative correlation between IUS and DAHC scores in medical students. Further research is needed to clarify findings and identify best practices that equip trainees with skills to care for patients with uncertain illness trajectories and patients living with disabilities

I Don\u27t Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department

Introduction: Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations. Methods: This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer. Results: Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum. Discussion: This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable

Self-Compassion Predicts Intolerance of Uncertainty: A New Construct to Prepare Students for Clinical Uncertainty

Learning Objectives: Managing uncertainty represents a significant source of stress for clinicians and trainees. Self-compassion is a strategy to help individuals cope with stress. The objective of this study is to determine the relationship between intolerance of uncertainty and self-compassion in medical students.Background: For clinicians, higher scores on the Intolerance of Uncertainty Scale (IUS) have been linked with failure to comply with evidence-based guidelines and higher likelihood of burnout. In contrast, higher self-compassion scores are correlated with decreased stress and burnout. A negative correlation between self-compassion and intolerance of uncertainty has been demonstrated in college students and general population. This relationship has not been examined in medical students and provides a possible curricular aim for addressing stress as they transition to clinical learning environments during clerkships.Objectives: The goal of our study is to determine if there is a correlation between intolerance of uncertainty and self-compassion in medical students.Methods: Third-year medical students (n=273) completed the IUS short version and the Self-Compassion Short Form (SCSF) through an online survey. Data was de-identified and a linear regression analysis was conducted to predict IUS based on SCSF. Pearson correlation was also calculated.Results: Response rate was 95% (259/273). IUS and SCSF scores were treated as continuous variables and analyzed parametrically. Mean scores for IUS and SCSF in medical students did not differ from previously reported means (p=0.14 and p=0.43 respectively). A significant regression equation was found (F(1,256) = 48.372, p<0.0001) with an R2 of 0.159. Pearson correlation was calculated at r = 0.399 (moderate effect size).Conclusion: A significant negative correlation was found between intolerance of uncertainty and self-compassion (p<0.0001). While findings suggest that self-compassion predicts intolerance of uncertainty, future studies should examine its implications on the role of curriculum in preparing learners for clinical uncertainty

Preparing for Discharge: A Workshop on Communicating Diagnostic Uncertainty

Learning Objectives: Demonstrate a workshop designed to teach third year medical students how to communicate diagnostic uncertainty.Background: Diagnostic uncertainty abounds in medicine. Effectively communicating that uncertainty is critical to high-quality patient care. There is a gap in training preparing medical students for communicating diagnostic uncertainty. The Uncertainty Communication Checklist (UCC) is a framework to effectively communicate diagnostic uncertainty to emergency department patients at discharge.Educational Objectives: We developed a workshop to address a curricular gap in preparing medical students to communicate diagnostic uncertainty to patients. Its objectives were to introduce learners to diagnostic uncertainty, discuss the importance of effective communication during times of diagnostic uncertainty, describe key steps for effectively communicating uncertainty, and practice communication through peer role-play.Curricular Design: We designed a workshop leveraging the UCC and role-play scenarios for third-year medical students. The virtual workshop was conducted at the conclusion of their core clerkships. Prework included reflection prompts and an interactive online module. The workshop began with a didactic lecture to reinforce these materials. Students completed a peer role-play in which a provider must discharge a patient from the Emergency Department with an uncertain diagnosis. The session concluded with small group faculty facilitated debrief sessions.Impact: Anonymous post-session survey data (76% response rate; 202/265) indicated that most (82%; 152/185) students felt more comfortable with communicating diagnostic uncertainty after the workshop. A majority (83%; 166/201) indicated it was useful, and most (81%; 149/184) felt it should be included in the curriculum in the future. Further studies are needed to identify students’ comprehension and application of uncertainty communication training

Intolerance of Uncertainty and Self-Compassion in Medical Students: Is There a Relationship and Why Should We Care?

Managing the uncertainty of clinical practice represents a significant source of stress for clinicians, including medical students transitioning into the clinical workplace. Self-compassion, a strategy to better cope with stress and burnout, may represent a skill that can be leveraged to better prepare learners for the uncertainty inherent in clinical practice. A negative correlation between intolerance of uncertainty and self-compassion has been demonstrated in undergraduate students and in the general population. An examination of this relationship in medical students may help inform future curricular development for addressing burnout in undergraduate medical education. We electronically administered the Intolerance of Uncertainty Short Scale and the Self-Compassion Short Form to 273 third-year medical students from a single institution and analyzed data via regression. A significant negative correlation was found between intolerance of uncertainty and self-compassion (p \u3c 0.0001). Students with higher levels of self-compassion showed lower levels of intolerance of uncertainty. This is consistent with findings in other populations. Our findings offer a starting point for designing training experiences that strengthen student self-compassion to enhance their ability to reconcile the uncertainty they will encounter in clinical practice