Valerie Schulz

Methadone in the management of intractable neuropathic noncancer pain.

OBJECTIVE To evaluate the role of methadone in the management of intractable neuropathic noncancer pain. METHODS A case series of 50 consecutive noncancer pain patients who were seen at a tertiary care centre and treated with oral methadone for a variety of intractable neuropathic pain states. RESULTS The mean age was 52.7 years and the mean duration of follow-up was 13.9 months. Post-discectomy nerve root fibrosis, complex regional pain syndrome, peripheral neuropathy and central spinal cord pain syndromes were the most common diagnoses. Over 90% had been treated with one or more tricyclic antidepressants and anticonvulsants and a similar number had received other adjuvant analgesics. All patients had failed treatment with one or more conventional opioid analgesics (mean 2.8) at a mean maximal morphine dose of 384 mg (or equivalents) per day. Twelve patients had failed spinal cord stimulation. Nineteen patients (38%) did not tolerate initial methadone titration or thought their pain was worse on methadone. Five patients (10%) declared initial benefit but required repetitive dose escalation and eventually became non-responders. Twenty-six patients (52%) reported mild (4), moderate (15), marked (6) or complete (1) pain relief and continued on methadone at a mean maintenance dose of 159.8 mg/day for a mean duration of 21.3 months. Fourteen patients (28%) reported improved function on methadone relative to previous treatments. CONCLUSIONS Methadone appears to have unique properties including N-methyl-D-aspartate antagonist activity that may make it especially useful in the management of intractable neuropathic pain. This observation needs to be tested in randomized, controlled trials.

Rules of engagement: residents' perceptions of the in-training evaluation process.

Background In-training evaluation reports (ITERs) often fall short of their goals of promoting resident learning and development. Efforts to address this problem through faculty development and assessment-instrument modification have been disappointing. The authors explored residents’ experiences and perceptions of the ITER process to gain insight into why the process succeeds or fails. Method Using a grounded theory approach, semistructured interviews were conducted with 20 residents. Constant comparative analysis for emergent themes was conducted. Results All residents identified aspects of “engagement” in the ITER process as the dominant influence on the success of ITERs. Both external (evaluator-driven, such as evaluator credibility) and internal (resident-driven, such as self-assessment) influences on engagement were elaborated. When engagement was lacking, residents viewed the ITER process as inauthentic. Conclusions Engagement is a critical factor to consider when seeking to improve ITER use. Our articulation of external and internal influences on engagement provides a starting point for targeted interventions.

NIPPV: prevalence, approach and barriers to use at Canadian ALS centres.

OBJECTIVE The purpose of this study was to evaluate Canadian amyotrophic lateral sclerosis (ALS) centres with respect to: 1) the prevalence of Non-invasive positive pressure ventilation (NIPPV) and invasive mechanical ventilation via tracheostomy (TV) utilization, 2) the approach to NIPPV use, focusing upon the currently employed initiation criteria and 3) the barriers influencing NIPPV administration. METHODS A descriptive survey research design aimed to obtain quantitative data and open-ended responses from an active physician at each of the 15 multidisciplinary Canadian ALS centres. RESULTS The principal findings of this study were: 1) NIPPV and TV are used in 18.3% and 1.5% of patients at Canadian ALS centres, respectively, 2) symptoms of respiratory insufficiency, namely orthopnea (clinical significance rated at 9.00/10 +/- 1.48), dyspnea (8.27 +/- 1.95) and morning headache (7.55 +/- 1.21) are the most significant indicators for NIPPV initiation, 3) the primary barriers to NIPPV utilization are patient intolerance (70% of centres) and inaccessibility of respirologists and ventilation technologists (50% of centres). CONCLUSIONS Variability in NIPPV use has an impact upon the management of Canadian ALS patients. The establishment of more definitive NIPPV initiation criteria, emphasizing respiratory symptoms, and the attenuation of barriers to NIPPV use should be targeted so as to ensure optimal care for all ALS patients.

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

CONTEXT There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

A palliative approach to neurological care: a literature review.

This review assesses the current opinion towards early palliative care in neurology and discusses the existing evidence base. A comprehensive literature search resulted in 714 publications with 53 being directly relevant to the scope of this review. The current literature reflects primarily expert opinion and describes a growing interest in the early introduction of palliative principles into neurological care. Early initiation of palliative interventions has the potential to improve quality of life, enhance symptom management and assist in advance care planning. Further data is required to determine whether this shift in philosophy has a positive impact on patient care.

‘Who is on your health-care team?’ Asking individuals with heart failure about care team membership and roles

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient‐centred care.

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members’ perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team’s collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams’ delivery of care for the complex, chronically ill.

Segmental hyperhidrosis as a manifestation of spinal and paraspinal disease.

BACKGROUND Segmental hyperhidrosis is an uncommon finding which is usually associated with irritation or infiltration of pre-ganglionic sympathetic fibres or the sympathetic chain. METHODS We report two cases of segmental hyperhidrosis with striking clinical features. RESULTS In one case, a mesothelioma produced ipsilateral simultaneous underactivity and overactivity of sympathetic outflow and in the other case a thoracic central disc herniation was probably responsible for a band of sweating which clearly extended beyond the segmental level of injury. CONCLUSION Segmental hyperhidrosis should trigger a search for structural disease in the spinal and paraspinal region.

Cheyne-Stokes Respiration Due to Chronic Heart Failure Abates With Coronary Artery Revascularization

A 78-year-old man presented with dyspnea and mild heart failure with Cheyne-Stokes respiration (CSR). Workup revealed inferolateral ischemia in the setting of significant triple vessel coronary disease, and nil else to adequately explain his dyspnea and eventual respiratory failure. After he underwent surgical revascularization, his ventricular function improved, leading to resolution of his respiratory failure and, of interest, his CSR. CSR is a central sleep apnea common in heart failure patients and has been associated with increased mortality. Here, we present the first English-literature report of CSR abating with surgical coronary revascularization, and briefly review the literature.

Supernumerary phantom limbs in ICU patients with acute inflammatory demyelinating polyneuropathy.

Objective: To explore the previously undescribed phenomenon of phantom limb generation in patients with severe acute inflammatory demyelinating polyradiculoneuropathy (AIDP). Methods: Between April 2011 and January 2014, we encountered 3 patients with AIDP in our intensive care unit who experienced features of self-limited supernumerary phantom limbs (SPLs) during their course. Results: The following case series describes the phenomenon of SPLs in AIDP. Conclusions: This report aims to raise awareness of the possibility of SPLs in the course of AIDP. The pathophysiology and management strategies for this clinical phenomenon are unknown.