Charles A. Odonkor

Connecting the dots: A comparative global multi-institutional study of prohibitive factors affecting cancer pain management

Objective. The goal of this study was to elucidate the attitudes, beliefs, and barriers interfering with cancer pain management, the degree of barrier interference with trainees’ care of patients, and the relationships among prohibitive factors to pain management for physicians in a low–middle-income countries (LMICs) vs high-income countries (HICs). Design and Setting. A multi-institutional cross-sectional survey of physicians in specialties with a focus in pain management training was performed. All surveys were completed anonymously from July 1, 2015, to November 30, 2015. Subjects. One hundred and twenty physicians participated in the survey. Methods. Surveys were based on prior questionnaires published in the literature. Descriptive statistics were calculated, and chi-square (ℵ2) analysis, Fisher’s exact test, and Spearman rank correlation analyses were performed. Results. Compared with their peers in HICs, physicians in LMICs reported less experience with cancer pain management despite seeing more cancer patients with advanced disease (41% vs 15.2%, pu2009<u20090.05). Some barriers were common to both environments, but a few were unique to each setting. Organized by percentage of severity of interference, cultural values/beliefs about pain (84% vs 76%) and lack of training and expertise (87% vs 78%) were significantly more prohibitive for physicians in LMICs than those in HICs; pu2009<u20090.05. Conclusion. There are significant differences in perceived barriers and degree of prohibitive factors to cancer pain management among trainee physicians in low- vs high-resource environments. Understanding these differences may spur further collaboration in the design of contextually relevant solutions, which could potentially help improve the adequacy of cancer pain management

Global cancer pain management: a systematic review comparing trials in Africa, Europe and North America

AIMnDespite the rise in cancer survivorship, few reviews have examined the quality of studies of cancer pain management and practices around the globe. With a void in trials spanning multiple geographical settings, this review evaluates the quality of cancer trials across three continents.nnnMATERIALS & METHODSnA literature review and search of established databases was conducted to identify eligible studies. The Cochrane method, the Jadad Score and a cancer pain-specific ad hoc tool were used to evaluate quality of studies.nnnRESULTSnEighteen studies representing a total of 4693 individuals were included in the review. Study quality correlated positively with study sample size and palliative care index. Trials in all three continents were prone to use opioids for pain management, whereas trials in Europe and North America utilized other adjuvant therapies such as antidepressants and steroids.nnnCONCLUSIONnThis review underscores the need for better multidimensional quality assessment tools for cancer pain trials.

Minding the Gaps in Cancer Pain Management Education: A Multicenter Study of Clinical Residents and Fellows in a Low- Versus High-Resource Setting

Purpose Inadequate pain management training has been reported as a major cause of undertreatment of cancer pain. Yet, past research has not comprehensively compared the quality of cancer pain management education among physicians in training in high-resource countries (HRCs) with those in low-resource countries (LRCs). The purpose of this study was to examine and compare gaps in cancer pain management education among physician trainees in an HRC (United States) versus an LRC (Ghana). Methods A cross section of physicians at four major academic medical centers completed surveys about the adequacy of cancer pain training. Participation in the study was completely voluntary, and paper or online surveys were completed anonymously. Results The response rate was 60% (N = 120). Major gaps were identified in cancer pain management education across the spectrum of medical school training. Training was rated as inadequate (by approximately 80% of trainees), although approximately 10% more trainees in HRCs versus LRCs felt this way; 35% said residency training was inadequate in both settings; and 50% in LRCs versus 44% in HRCs said fellowship training was less than good. On the basis of the lowest group means, the three key areas of perceived deficits included interventional pain procedures (2.34 ± 1.12), palliative care interventions (2.39 ± 1.12), and managing procedural and postoperative pain (2.94 ± 0.97), with significant differences in the distribution of deficits in 15 cancer-pain competencies between LRCs and HRCs (P < .05). Conclusion This study identifies priority areas that could be targeted synergistically by LRCs and HRCs to advance cancer care globally. The findings underscore differential opportunities to broaden and improve competencies in cancer pain management via exchange training, in which physicians from HRCs spend time in LRCs and vice versa.

Poster 381: Gait Symmetry is More Sensitive Than Walking Speed to Assess Function and Recovery After Stroke

being “very relevant”. They indicated a relevance of 46 in spending clinical time with a rehabilitation specialist. Trainees who had rotated with PM&R during medical school were more likely to report a higher level of knowledge (P 1⁄4 .003) in addition to those with awareness of a PM&R department at their institution (P 1⁄4 .04). There was no significant difference in responses between oncology subspecialties. Conclusions: Physician trainees in oncologic subspecialties perceived rehabilitation as a highly relevant service; however, they expressed a low level of knowledge in defining services to patients. Despite the high prevalenceof rehabilitationat their institutions, 19%had receivededucationby a rehabilitation specialist. These findings highlight a need to increase education about rehabilitation among oncology physician trainees. Level of Evidence: Level III

Poster 383: Identification of Novel Wearable-Sensor Derived Gait Features Associated with Physical Activity and Function in Knee Osteoarthritis and Lumbar Stenosis

Disclosures: Charles Odonkor: I Have No Relevant Financial Relationships To Disclose Objective: To objectively measure physical activity using body worn sensors and to establish new gait features which differentiate knee osteoarthritis (OA) and lumbar stenosis (LSS) from healthy controls. Design: Cross-sectional cohort study. Setting: Academic Medical Center. Participants: 30 participants enrolled in the study. Interventions: Not Applicable Main Outcome Measures: Gait features derived from dual feet-sensors and ability to discriminate functional capacity, reported physical activity intensity and mobility limitations in patients with knee OA and LSS vs. healthy controls. Results: Compared to healthy controls, the best novel gait features were: minimum toe clearance, effect size (ES) 1⁄4 0.61, P < .0001 for knee OA; and lift off angle at toe off, ES1⁄4 0.67, P 1⁄4 .006 for LSS. Adjusting for pain localization, the last minute of 6-min walk and self-paced walking tests were more sensitive to functional differences between healthy vs. disease states than the first minute of measured gait cycles, P < .0001. Peak angular velocity, heel-strike angle, respective time ratio of stance, double-support, foot load, push and flat phases were each identified as sensitive markers with ES>0.2, P < .05 for both knee OA and LSS vs. healthy controls. Push-ratio discriminated reported light vs. moderate activity (ES1⁄40.46, P 1⁄4 .0009) while strike-length discriminated reported moderate vs. no activity (ES1⁄40.33, P 1⁄4 .002) on the Stanford brief physical activity score-survey. Adjusting for age, gender, BMI and ethnicity, mean push-ratios were 27.5 (95% CI: 24.4-30.7) and 33.8 (95% CI: 30.6-36.9) for those with reported light vs. moderate activity intensity scores, respectively. With a mean Oswestry-Disability-Index score of 39.6 19.8, ten unique sensor gait features each significantly distinguished LSS patients with zero to minimum disability from those with moderate disability, ES>0.2, P < .05. Conclusions: Sensor-derived spatio-temporal gait-features provide objective markers for discriminating functional status in healthy vs. disease states and hold much promise towards more precise and accurate characterization of physical activity and mobility limitations in people with LSS vs. knee OA. Level of Evidence: Level I

Driving under the influence of cannabis: a framework for future policy

Marijuana is the most widely consumed illicit substance in the United States, and an increasing number of states have legalized it for both medicinal and recreational purposes. As it becomes more readily available, there will be a concurrent rise in the number of users and, consequently, the number of motor vehicle operators driving under the influence. This article examines the cognitive and psychomotor effects of cannabis, as well as current policy concerning driving under the influence of drugs. The authors performed a MEDLINE search on the epidemiology of cannabis use, its cognitive and psychomotor effects, and policies regarding driving under the influence of drugs. Twenty-eight epidemiological studies, 16 acute cognitive and psychomotor studies, 8 chronic cognitive and psychomotor studies, and pertinent state and federal laws and policies were reviewed. These search results revealed that marijuana use is associated with significant cognitive and psychomotor effects. In addition, the legalization of marijuana varies from state to state, as do the laws pertaining to driving under the influence of drugs. Marijuana is a commonly found illicit substance in motor vehicle operators driving under the influence of drugs. Current evidence shows that blood levels of tetrahydrocannabinol do not correlate well with the level of impairment. In addition, although acute infrequent use of cannabis typically leads to cognitive and psychomotor impairment, this is not consistently the case for chronic heavy use. To establish the framework for driving under the influence of cannabis policy, we must review the current published evidence and examine existing policy at state and federal levels.Marijuana is the most widely consumed illicit substance in the United States, and an increasing number of states have legalized it for both medicinal and recreational purposes. As it becomes more readily available, there will be a concurrent rise in the number of users and, consequently, the number of motor vehicle operators driving under the influence. This article examines the cognitive and psychomotor effects of cannabis, as well as current policy concerning driving under the influence of drugs. The authors performed a MEDLINE search on the epidemiology of cannabis use, its cognitive and psychomotor effects, and policies regarding driving under the influence of drugs. Twenty-eight epidemiological studies, 16 acute cognitive and psychomotor studies, 8 chronic cognitive and psychomotor studies, and pertinent state and federal laws and policies were reviewed. These search results revealed that marijuana use is associated with significant cognitive and psychomotor effects. In addition, the legalization of marijuana varies from state to state, as do the laws pertaining to driving under the influence of drugs. Marijuana is a commonly found illicit substance in motor vehicle operators driving under the influence of drugs. Current evidence shows that blood levels of tetrahydrocannabinol do not correlate well with the level of impairment. In addition, although acute infrequent use of cannabis typically leads to cognitive and psychomotor impairment, this is not consistently the case for chronic heavy use. To establish the framework for driving under the influence of cannabis policy, we must review the current published evidence and examine existing policy at state and federal levels.

Poster 483: Immediate vs. Prolonged Pain Relief After Sacroiliac Joint Injection with Anesthetic and Corticosteroid: A Prospective Study

discharge. Among those with a reported psychosocial health related quality of life score, 135 had a score at baseline, 130 at admission, and 64 reported post-discharge. The cohort was between ages 4-21, primarily Caucasian, male, and English speaking. Patient and familyreported physical HRQOL improved significantly from the time of rehabilitation admission to outpatient follow-up (mean score 20.2 to 59.7, P<.001). Psychosocial HRQOL improved, though to a lesser extent (mean score 55.8 to 71.2, P<.001). Conclusions: Patient and family-reported physical and psychosocial HRQOL, which are impacted significantly by new functional impairment, are seen to improve significantly through a course of inpatient rehabilitation. Despite significant loss to follow-up, we were able to determine the magnitude of change was greater than the 10-point decrement previously clinically correlated with an increase in 30-day readmissions and emergency department return visits. Inpatient rehabilitation is associated with important benefits for perceived HRQOL. Level of Evidence: Level III

Poster 104: Development and Design of a Predictive Nomogram for Missed Appointments at an Academic Pain Treatment Center: A Prospective Year-Long Longitudinal Study

Participants: 57 patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first. 21/47 (37%) patients with depression (defined as Zung Depression Scale 33) were included. Interventions: All patients received one or more cervical epidural steroid injections. Main Outcome Measures: Patient reported outcomes including neck disability index (NDI), Numeric Rating Scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and 3-month follow up. Minimal clinically important difference (MCID) were then calculated to provide dichotomous outcomes measures of success. Results: Overall, 24 (42.1% 95%CI 12.8%) and 28 (49.1% 95%CI 13.0%) patients achieved at least 50% improvement in AP and NP respectively. In terms of disability, 25/57 (43.9% 95%Ci 12.9%) patients achieved greater than 13.2-point improvement on NDI overall. In patients with depression, 4/21 (19.0% 95%CI 16.8%) and 5/21(23.8% 95%CI 18.2%) achieved at least 50% improvement on NRS for AP and NP respectively compared to 20 (55.5% 95%CI 16.2%) and 23 (63.9% 95%CI 15.7%) in patients without depression. This difference was statistically significant for both pain measures (non-overlapping 95% CI for both, p <.002 AP, p<.006 NP). Statistically fewer patients, 5/21 (24% 95%CI 18%) with depression achieved at least 13.2 point improvement on NDI compared to 20/36 (55% 95%CI 16%) nondepressed patients (95% CI overlapping, p<.01). There was no difference in outcomes between groups on EQ-5D. Conclusions: Patients with cervical spondylosis and co-morbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared to non-depressed patients at 3 months. Level of Evidence: Level II

Bilateral Intra-Articular Radiofrequency Ablation for Cervicogenic Headache

Introduction. Cervicogenic headache is characterized by unilateral neck or face pain referred from various structures such as the cervical joints and intervertebral disks. A recent study of patients with cervical pain showed significant pain relief after cervical medial branch neurotomy but excluded patients with C1-2 joint pain. It remains unclear whether targeting this joint has potential for symptomatic relief. To address this issue, we present a case report of C1-2 joint ablation with positive outcomes. Case Presentation. A 27-year-old female presented with worsening cervicogenic headache. Her pain was 9/10 by visual analog scale (VAS) and described as cramping and aching. Pain was localized suboccipitally with radiation to her jaw and posterior neck, worse on the right. Associated symptoms included clicking of her temporomandibular joint, neck stiffness, bilateral headaches with periorbital pain, numbness, and tingling. History, physical exam, and diagnostic studies indicated localization to the C1-2 joint with 80% decrease in pain after C1-2 diagnostic blocks. She underwent bilateral intra-articular radiofrequency ablation of the C1-C2 joint. Follow-up at 2, 4, 8, and 12 weeks showed improved function and pain relief with peak results at 12 weeks. Conclusion. Clinicians may consider C1-C2 joint ablation as a viable long-term treatment option for cervicogenic headaches.

Poster 497 Searching for an Oasis in a Physiatry Desert: A Global Survey of the Disability Training and Education Landscape of Healthcare Trainees in West Africa

physician was organized by call frequency, context, number of calls addressed by the handoff, and preventable calls. Setting: Inpatient spinal cord injury center. Participants: Not applicable. Interventions: Not applicable. Main Outcome Measures: Not applicable. Results: The majority of pages were recorded as not addressed by the handoff tool (75% were not addressed compared to 25% addressed). Of those pages not addressed by the handoff 37% were determined to be preventable. The top 3 most frequent pages were equipment failures, critical lab values, and order clarifications. The top 3 clinical pages were equipment failures, medication requests, and gastrointestinal complaints. The top 3 preventable pages that were not addressed by the handoff tool were order clarifications, expired orders, and requests for pre-existing orders. Conclusions: Implementation of a standardized patient handoff has been described in the literature to be important for the transition of patient care and to decrease medical errors; however, no published studies to date have described patient handoff in an inpatient spinal cord injury center. A closer evaluation of the patient handoff may lead to identifying preventable trends within a unique inpatient population, increase patient safety, and allow for more effective communication between health care providers. Level of Evidence: Level V