Guy Maytal

Quality of Life Implications of Bisphosphonate-Associated Osteonecrosis of the Jaw

PURPOSE Potentially debilitating, osteonecrosis of the jaw (ONJ) is an emerging complication of bisphosphonates. However, its effect on quality of life (QoL) is unknown. We determined the ONJ-related QoL decline in a cancer patient cohort. PATIENTS AND METHODS Thirty-four cancer patients with bisphosphonate-associated ONJ completed a telephone survey (October 2007 through May 2008). The Oral Health Impact Profile 14 (OHIP) retrospectively assessed participant oral health-related QoL before and after ONJ. Standardized ONJ descriptions were developed in a multidisciplinary, iterative process and were evaluated with three frequently used preference-based QoL measurement methods on a 0 (death) to 1 (perfect health) scale: Visual Analogue Scale (VAS), Time Trade-Off (TTO), and EQ-5D. RESULTS ONJ significantly (p < .001) increased OHIP scores (worse QoL) for additive (3.56-16.53) and weighted (7.0-17.5) methods. Seven individual OHIP items significantly increased (Bonferroni correction p < .0035): pain, eating discomfort, self-consciousness, unsatisfactory diet, interrupted meals, irritability, and decreased life satisfaction. Mean preference-based QoL values significantly decreased (p < .001) with worsening ONJ stage (VAS, TTO, and EQ-5D): no ONJ (0.76, 0.86, 0.82), ONJ stage 1 (0.69, 0.82, 0.78), ONJ stage 2 (0.51, 0.67, 0.55), and ONJ stage 3 (0.37, 0.61, 0.32). As ONJ worsened, EQ-5D domain scores significantly increased (p < .001). Pain/discomfort and anxiety/depression contributed most to declining QoL. CONCLUSIONS ONJ significantly affects QoL, a detriment that increases with worsening ONJ. QoL impairments for ONJ stages 2 and 3 are similar to other treatment side effects that influence decision-making. Bisphosphonate-associated ONJ QoL is an important consideration for patients, clinicians, and policy makers.

Aripiprazole-related tardive dyskinesia.

The low prevalence of extrapyramidal symptoms associated with atypical antipsychotics has led to their widespread use during the past decade. Aripiprazole, the newest medication in this class, has been associated with extrapyramidal symptoms (eg, akathisia) and with improvement of tardive dyskinesia (TD), but to date it has not been associated with the development of TD. We report a case of TD associated with the use of aripiprazole 15 mg/day for 18 months for refractory depression. Symptoms of TD resolved within several weeks of discontinuation of aripiprazole.

Patient–Physician Boundaries in Palliative Care Training: A Case Study and Discussion

Abstract The subject of patient-physician boundaries has been most extensively explored in the psychiatric literature, but to date, little has been published about this concept within the realm of palliative care. Some palliative care physicians may be particularly susceptible to boundary crossings due to the intensity and intimacy of the bonds that form with patients at the end-of-life. We illustrate the concept of boundary crossings and violations in palliative care using the case of a palliative care trainee who experiences difficulties in maintaining boundaries with a dying patient. We discuss the nature of the patient-physician relationship using role theory and discuss how the formation of dual roles can be detrimental to the patient-physician relationship. Finally, we explore why palliative care practitioners and trainees are particularly vulnerable to crossing boundaries and how to recognize and manage these crossings when they occur.

Case records of the Massachusetts General Hospital. Case 17-2015. A 44-year-old woman with intractable pain due to metastatic lung cancer.

Dr. Lecia V. Sequist: A 44-year-old woman with metastatic (stage IV) non–small-cell lung carcinoma was seen in the outpatient cancer center of this hospital because of intractable pain. The patient had been well until approximately 1 year before this evaluation, when pain in her right shoulder and scapula developed, followed by cough and an episode of hemoptysis. A chest radiograph that was obtained at another hospital reportedly showed findings suggestive of pneumonia. Antibiotic agents were administered, but the pain and radiographic abnormalities persisted. Nine months before this evaluation, computed tomography (CT) of the chest revealed an irregular mass (3.5 cm by 3.7 cm by 5.0 cm) in the anterior right upper lobe, along with multiple pleural nodules (most <1 cm in diameter) in the right hemithorax and mediastinal and right hilar lymphadenopathy (with nodes ≤12 mm in diameter). 18F-fluorodeoxyglucose positron-emission tomography and CT (PET–CT) reportedly revealed two indeterminate foci in the first and fifth lumbar vertebrae. Flexible bronchoscopy and mediastinoscopy with biopsy were performed. Dr. Mari Mino-Kenudson: Examination of a pretracheal lymph node–biopsy specimen revealed that multiple lymph-node fragments had been almost completely replaced by metastatic tumor deposits (Fig. 1A through 1D). There was a solid growth of tumor cells with infrequent and incomplete gland formation, a finding consistent with poorly differentiated adenocarcinoma. Immunohistochemical staining for thyroid transcription factor 1 was positive in the tumor cells, a finding consistent with adenocarcinoma of the lung. Because the patient had never smoked tobacco, genetic testing of tumor tissue for a mutation of the epidermal growth factor receptor gene (EGFR) was performed and revealed a deletion of 15 bp in exon 19 (Fig. 1E). A frameshift deletion mutation in exon 19 is known to confer sensitivity to EGFR tyrosine kinase inhibitors. Dr. Sequist: Therapy with erlotinib hydrochloride (150 mg daily) was begun 7 months From the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Massachusetts General Hospital; and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Harvard Medical School — both in Boston.

Case 17-2015

Dr. Lecia V. Sequist: A 44-year-old woman with metastatic (stage IV) non–small-cell lung carcinoma was seen in the outpatient cancer center of this hospital because of intractable pain. The patient had been well until approximately 1 year before this evaluation, when pain in her right shoulder and scapula developed, followed by cough and an episode of hemoptysis. A chest radiograph that was obtained at another hospital reportedly showed findings suggestive of pneumonia. Antibiotic agents were administered, but the pain and radiographic abnormalities persisted. Nine months before this evaluation, computed tomography (CT) of the chest revealed an irregular mass (3.5 cm by 3.7 cm by 5.0 cm) in the anterior right upper lobe, along with multiple pleural nodules (most <1 cm in diameter) in the right hemithorax and mediastinal and right hilar lymphadenopathy (with nodes ≤12 mm in diameter). 18F-fluorodeoxyglucose positron-emission tomography and CT (PET–CT) reportedly revealed two indeterminate foci in the first and fifth lumbar vertebrae. Flexible bronchoscopy and mediastinoscopy with biopsy were performed. Dr. Mari Mino-Kenudson: Examination of a pretracheal lymph node–biopsy specimen revealed that multiple lymph-node fragments had been almost completely replaced by metastatic tumor deposits (Fig. 1A through 1D). There was a solid growth of tumor cells with infrequent and incomplete gland formation, a finding consistent with poorly differentiated adenocarcinoma. Immunohistochemical staining for thyroid transcription factor 1 was positive in the tumor cells, a finding consistent with adenocarcinoma of the lung. Because the patient had never smoked tobacco, genetic testing of tumor tissue for a mutation of the epidermal growth factor receptor gene (EGFR) was performed and revealed a deletion of 15 bp in exon 19 (Fig. 1E). A frameshift deletion mutation in exon 19 is known to confer sensitivity to EGFR tyrosine kinase inhibitors. Dr. Sequist: Therapy with erlotinib hydrochloride (150 mg daily) was begun 7 months From the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Massachusetts General Hospital; and the Departments of Anesthesia, Critical Care, and Pain Medicine (M.M.K.), Palliative Care (M.M.K., K.P.D., T.J.R.), Medical Oncology (L.V.S.), Psychiatry (G.M.), Radiology (E.J.F.), and Pathology (M.M.-K.), Harvard Medical School — both in Boston.

Unimaginable Loss: Contingent Suicidal Ideation in Family Members of Oncology Patients

Background Family members of patients with cancer may reveal to the medical team that they are considering suicide after their loved one dies. No literature is available indicating how to assess risk and to intervene with these individuals. Objective The authors describe various alerting signs and seek to improve awareness and approaches to suicide prevention. Method The authors present five cases of potential contingent suicide. Results Family members struggling with anticipatory grief challenge the clinical team at several points of decision-making. Conclusion Close coordination among members of the patients treatment team and psychiatric consultants is crucial for helping vulnerable family members move safely into adequately supported bereavement.

Patient-Clinician Boundaries in Palliative Care Training: Identifying and Managing Boundary Crossings (517)

life for our patients suffering with advanced illness and their families, and as a result of successful published AICCP outcomes (Am JManag Care. 2009;15(11):817e825). Those successes include improvements in communication and care delivery advanced planning with increased formulation of advance directives and decreases in inpatient utilization. The AICCP is designed to assist patients and families to optimally manage living with advancing illness. The progam is based on a model that includes three componentsdnon-directive health counseling, education, and care coordination. Presenters hail from two different regionsdnorthern California and Coloradodand are of two distinct disciplinary backgroundsdRNand LCSWdand will share very real experiences with AICCP implementation,maintenance, andmonitoring. Additionally, there will be heart-tugging case studies information regarding the original study definitions of palliative care components of the model and AICCP’s place in the continuum of care. Our hope is that you will join us in sharing the passion wehave about theAICCP inmeeting thepalliative needs of our patients and their families.