Rene Claxton

Undertreatment of Symptoms in Patients on Maintenance Hemodialysis

CONTEXT Hemodialysis patients suffer a large symptom burden, and little is known about how effectively symptoms are treated. OBJECTIVES To assess the management of treatable symptoms in hemodialysis patients, we administered a 30-item questionnaire on physical and emotional symptoms to patients receiving outpatient hemodialysis at the University of Virginia. METHODS We asked patients whether they were prescribed therapy for potentially treatable symptoms and assessed who prescribed the therapy. By means of chart review, we also documented whether medications were prescribed for these symptoms. RESULTS We approached 87 patients and enrolled 62 (71%). The most commonly reported, potentially treatable symptoms included bone/joint pain, insomnia, mood disturbance, sexual dysfunction, paresthesia, and nausea. Only 45% of patients with bone/joint pain reported receiving an analgesic medication. Twenty-three percent of patients with trouble falling asleep and 53% of patients with nausea reported receiving a medication to alleviate this symptom. Chart review revealed that 58% of patients who reported the presence of bone/joint pain were prescribed an analgesic, 23% of patients with trouble falling asleep were prescribed a sleep aid, and 42% of patients with nausea received an antiemetic. Primary care providers were more likely than nephrologists to provide for all symptoms except nausea and numbness or tingling in the feet, and this difference was significant for the treatment of worrying (3/3 vs. 0/3, P=0.05) and nervousness (4/5 vs. 0/5, P=0.02). CONCLUSION Potentially treatable symptoms in hemodialysis are undertreated. Pharmacologic therapy, particularly for emotional symptoms, was more commonly prescribed by primary care providers than nephrologists. Additional study of the barriers to symptom treatment and interventions that increase nephrologist and primary care provider symptom management are needed.

Complicated Grief #254

would provide substantial benefit. 2. If anticoagulation is chosen, then determine whether to use oral anticoagulants or LMWH. LWMH does not require routine laboratory testing, has few drug-drug interactions, is not diet-dependent for safe administration, and is more efficacious than warfarin in trials with healthier patients. Warfarin requires frequent laboratory monitoring of the INR and has many drugdrug interactions. In addition, a patient’s INR is highly diet-dependent, and can rise dangerously in patients with diminishing oral intake, which is common for advanced cancer patients. However, LMWH is far more expensive than oral anticoagulation. Warfarin costs approximately

Anti-epileptic drugs for pain #271.

0.11/day compared to

A pilot trial of early specialty palliative care for patients with advanced pancreatic cancer: Challenges encountered and lessons learned.

100/day for enoxaparin. This comparison does not take into account the cost of laboratory tests to monitor a patient’s INR, or the administration costs for patients unable to selfadminister LMWH. Given its high cost, LMWH may not be available for many patients receiving hospice care.

Learning to Learn: The Practical Application of Learning Theory (511)

TCAs, SNRIs, and the AEDs gabapentin and pregabalin are the best adjuvant analgesics for neuropathic pain. For patients who are intolerant to or who experience pain unresponsive to the above medications, one can consider therapy with carbamazepine, oxcarbazepine, valproic acid, topiramate, or lacosamide. However, as these agents are associated with more side effects and lower rates of efficacy, expert consultation is strongly recommended.

Communication skills training in surgical residency: a needs assessment and metacognition analysis of a difficult conversation objective structured clinical examination.

110 Background: Palliative care trials face implementation barriers. We describe challenges encountered in a pilot trial of early specialty palliative care for patients with pancreatic cancer. METHODS We conducted a mixed-methods pilot randomized controlled trial of early specialty physician-led palliative care in advanced pancreatic cancer. Recently diagnosed patients with borderline, locally-advanced, or metastatic pancreatic cancer and their caregivers (total N=60) were recruited from clinic at a comprehensive cancer center and randomized (2:1) to receive monthly specialty palliative care visits for 3 months in addition to standard oncology care vs. standard oncology care alone. Feasibility assessments included enrollment and intervention completion rates. Acceptability and perceived effectiveness were assessed via drop-out rates and semi-structured participant interviews. RESULTS The enrollment target was reached after 50 weeks, with a randomized: approached rate of 27%. Mean patient age was 63 (SD 11) and 50% were male. Mean caregiver age was 62 (SD 12), 47% were male, and 80% were the spouse or partner of a patient. 70% of participants in the intervention group completed at least one specialty palliative care visit and 15% completed 3 palliative care visits within the 3-month time period. Two patients and 3 caregivers withdrew, and 4 patients died prior to 3 months. Enrollment barriers included patients not planning to continue receiving care from a participating oncologist and feeling too overwhelmed at the time of diagnosis to consider research participation. In semi-structured interviews, patients and caregivers noted that long travel times to the cancer center, difficulty scheduling palliative care visits at a convenient time, and lengthy study assessments posed burdens. Oncologists and palliative care physicians recommended more in-person communication between clinicians and tailoring palliative care visit content and schedules to match patient needs. CONCLUSIONS Future palliative care intervention trials must consider implementation challenges related to recruitment, retention, intervention fidelity, and participant burden. CLINICAL TRIAL INFORMATION NCT01885884.

The educational impact of weekly e-mailed fast facts and concepts.

Objectives 1. Describe the steps of the learning cycle. 2. Describe a technique for building on learners’ existing knowledge. 3. Identify and describe three strategies to increase learner involvement in the learning process including no opt out, cold call and ratio. Successful learning relies on gathering information, storing and accessing facts in long term memory and efficiently using working memory. Components of the learning cycle include concrete experience, reflective observation, abstract hypotheses and active testing. Recent educational theory and data focus on applying strategies aimed at different points in the cycle to increase knowledge transfer. Two highlighted techniques are (a) building on previous knowledge and (b) requiring active engagement. Educational techniques that identify and add to learners’ existing neuronal networks maximize information transfer. These techniques include assessing learners’ prior knowledge, asking what new information brings to mind, asking peers to describe connections they have made, and using metaphors/similes/analogies to make connections between the familiar and new. Active participation increases learning. These techniques include no opt out, cold calling and ratio. No opt out guards against unwilling or unknowledgeable learners and encourages learners to participate in the learning cycle by repeating the correct answer even if he/she first responded, ‘‘I don’t know.’’ Through cold calling, educators ask a question and, regardless of raised hands, call on someone. This systematic and scaffolded (easier followed by harder questions) technique requires all learners to go through learning cycle. Ratio requires the teacher consider the amount of work the student must do to arrive at an answer. Educators maximize the learner/teacher effort ratio by using half-statements which require learners to finish, feigning ignorance or asking for supporting evidence. In this session, participants will apply educational precepts to teaching palliative care. This will be done using the following methods: (a) brief didactic description of advances in education that stress the importance of integrating new information into prior learning and active engagement in the learning process, (b) description of techniques that master educators use to operationalize these precepts, (c) watching videotapes of master educators, and (d) practicing these techniques.