John B. Taylor

Cancer and Leukemia Group B 90206: A Randomized Phase III Trial of Interferon-α or Interferon-α Plus Anti-Vascular Endothelial Growth Factor Antibody (Bevacizumab) in Metastatic Renal Cell Carcinoma

The majority of sporadic clear cell renal cell carcinoma (RCC) is characterized by loss of heterozygosity of the von Hippel-Lindau (VHL) tumor suppressor gene and somatic inactivation of the remaining VHL allele. The resulting VHL gene silencing leads to induction of hypoxia-regulated genes including vascular endothelial growth factor (VEGF). Thus, therapeutic inhibition of VEGF holds promise for treatment of this historically refractory malignancy. An antibody to VEGF (bevacizumab, Avastin) has demonstrated a significant prolongation of time to disease progression compared with placebo in patients with metastatic RCC. Interferon-α (IFN-α) is a standard initial cytokine therapy in RCC with a modest response rate and a survival advantage demonstrated in randomized trials. We hypothesized that the addition of anti-VEGF therapy to IFN-α would prolong survival in untreated metastatic RCC patients. A Phase III trial is now being conducted randomizing untreated, metastatic clear cell RCC patients to IFN-α alone or IFN-α plus Avastin.

Men's Eating and Living (MEAL) study (CALGB 70807 [Alliance]): recruitment feasibility and baseline demographics of a randomized trial of diet in men on active surveillance for prostate cancer

To assess the feasibility of performing national, randomized trials of dietary interventions for localized prostate cancer.

The therapeutic discharge: An approach to dealing with deceptive patients

OBJECTIVE Patients with factitious disorder or malingering behaviors pose particular problems in acute care settings. We sought to describe a manner to effectively discharge these patients and keep further harm, iatrogenic or otherwise, from being inflicted. METHOD Once an indication has been identified, the therapeutic discharge can be carried out in a stepwise fashion, resulting in a safe discharge. We outlined how to prepare for, and execute, the therapeutic discharge, along with preemptive consideration of complications that may arise. RESULTS Consequences for the patient, physicians, and larger healthcare system are considered. CONCLUSION The therapeutic discharge is a safe and effective procedure for patients with deception syndromes in acute care settings. Carrying it out is a necessary element of psychiatric residency and psychosomatic medicine fellowship training.

Behavioral Health Integration: Challenges and Opportunities for Academic Medical Centers

Leaders of academic medical centers (AMCs) are simultaneously pursuing the goal of behavioral health integration in their healthcare systems while finding ways to incorporate behavioral health integration into their undergraduate and graduatemedical curricula and clinical training. In addition, academic leaders need to foster and conduct research that elucidates which models of integrated care are most effective and demonstrates the impact of integration on clinical and cost outcomes. In this commentary, we identify some of the key dimensions around which behavioral health integration may be conceptualized.We believe that clarity in each of these areas is a necessary step to planning and implementing integrated care in AMCs, teaching the current and next generation of clinicians who will be at the forefront of leading and practicing in integrated settings, and guiding the research that evaluates the impact of specific treatments and treatment models.

Qualitative radiology assessment of tumor response: does it measure up?

Our purpose was to assess whether a simpler qualitative evaluation of tumor response by computed tomography is as reproducible and predictive of clinical outcome as the Response Evaluation Criteria in Solid Tumors (RECIST) and World Health Organization (WHO) methods. This study was a two-reader retrospective evaluation in which qualitative assessment resulted in agreement in 21 of 23 patients with metastatic colorectal carcinoma (91.3%, kappa=0.78; 95% CI, 0.51-1.00). Hepatic metastases were classified as increased, decreased, or unchanged, compared with agreement in 20 of 23 patients (87.0%) for RECIST (kappa=0.62; 95% CI, 0.23-1.00) and WHO (kappa=0.67; 95% CI, 0.34-1.00) methods. Patients were placed into partial response, stable disease, and disease progression categories. Time to progression of disease was better predicted qualitatively than by RECIST or WHO. Our pilot data suggest that our qualitative scoring system is more reproducible and predictive of patient clinical outcome than the RECIST and WHO methods.

Predictors of Disruptions in Breast Cancer Care for Individuals with Schizophrenia

BACKGROUND Patients with schizophrenia experience markedly increased breast cancer mortality, yet reasons for this disparity are poorly understood. We sought to characterize disruptions in breast cancer care for patients with schizophrenia and identify modifiable predictors of those disruptions. MATERIALS AND METHODS We performed a medical record review of 95 patients with schizophrenia and breast cancer treated at an academic cancer center between 1993 and 2015. We defined cancer care disruptions as processes that interfere with guideline-concordant cancer care, including delays to diagnosis or treatment, deviations from stage-appropriate treatment, and interruptions in treatment. We hypothesized that lack of psychiatric treatment at cancer diagnosis would be associated with care disruptions. RESULTS Half of patients with schizophrenia experienced at least one breast cancer care disruption. Deviations in stage-appropriate treatment were associated with breast cancer recurrence at 5 years (p = .045). Patients without a documented psychiatrist experienced more delays (p = .016), without documented antipsychotic medication experienced more deviations (p = .007), and with psychiatric hospitalizations after cancer diagnosis experienced more interruptions (p < .0001). Independent of stage, age, and documented primary care physician, lack of documented antipsychotic medication (odds ratio [OR] = 4.97, 95% confidence interval [CI] = 1.90, 12.98) and psychiatric care (OR = 4.56, 95% CI = 1.37, 15.15) predicted cancer care disruptions. CONCLUSION Disruptions in breast cancer care are common for patients with schizophrenia and are associated with adverse outcomes, including cancer recurrence. Access to psychiatric treatment at cancer diagnosis may protect against critical disruptions in cancer care for this underserved population. IMPLICATIONS FOR PRACTICE Disruptions in breast cancer care are common for patients with schizophrenia, yet access to mental health treatment is rarely integrated into cancer care. When oncologists documented a treating psychiatrist and antipsychotic medication, patients had fewer disruptions in breast cancer care after adjusting for age, cancer stage, and access to primary care. Addressing psychiatric comorbidity at breast cancer diagnosis may increase the likelihood that patients with schizophrenia receive timely, stage-appropriate cancer treatment. Comanagement of schizophrenia and breast cancer at cancer diagnosis may be one key strategy to decrease inequities in cancer treatment and improve cancer survival in this underserved population.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population

OBJECTIVE This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation

OBJECTIVE The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable. METHOD After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge. RESULTS Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge. CONCLUSION While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of ones identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.

Continuous Quality Improvement for Psychiatry Residency Didactic Curricula

The field of psychiatry is rapidly evolving, and residency didactic curricula must also evolve in order to remain up-to-date and relevant to the learner. However, ensuring continuous revision of educational content can be a significant challenge for residency programs. Curriculum revision is a complex process that requires input from faculty for planning, implementation, and monitoring, as well as feedback from learners themselves [1]. It can be difficult to obtain consistent and meaningful feedback about each didactic and to interpret the feedback to inform curriculum changes. Administrative resources for gathering and interpreting feedback are scarce, resident comments may be overly reactionary in the immediate post-didactic period, and faculty may be resistant to suggested changes. In the absence of specific constructive feedback, didactic instructors may deliver the same session year after year. Though the importance of ongoing curricular revision has been emphasized [2, 3], to our knowledge, there are no models described in the literature to guide residency programs in systematically reviewing and revising a psychiatry didactic curriculum on an ongoing basis to ensure high-quality teaching and up-to-date content. At the Massachusetts General Hospital (MGH)/McLean Hospital Adult Psychiatry Residency, a large program with two primary teaching campuses, the entire didactic curriculum (defined as any formal scheduled teaching, discussion-based lessons, or experiential learning-based seminars) was systematically revised in 2012 [4]. Following the launch of the new curriculum, program leadership developed a process for ongoing review and improvement of the didactic content and teaching methodologies in the curriculum. This educational case report provides a description of a novel continuous quality improvement (CQI) process for residency didactic curricula that engages residents as key participants in the process. CQI processes are systematic approaches to improving quality, often using the plan-do-study-act cycle, by identifying quality improvement opportunities (plan), implementing change (do), collecting feedback (study), and monitoring ongoing revision of the process (act). CQI has been used successfully in multiple areas of healthcare delivery [5]. The CQI process for residency didactic curricula described in this manuscript consists of three components: (1) soliciting feedback from residents, (2) creating resident-driven curriculum subcommittees to review and summarize feedback and recommend curricular changes, and (3) utilizing a curriculum committee to recommend curricular changes and deliver feedback to faculty. The Associate Program Director (APD), with support and guidance from the Program Director, is primarily responsible for overseeing and implementing this process.

Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine?

BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APMs journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APMs vision and mission statements and to practitioners of psychosomatic medicine.