PERSPECTIVES OF UNDER-RESOURCED PATIENTS ABOUT THE MEDICARE ANNUAL WELLNESS VISIT

The Medicare Annual Wellness Visit (AWV) involves a personalized risk assessment and prevention plan to help prevent disease and disability among older adults. Though studies have shown that AWV uptake is suboptimal, little is known about the perspectives and experiences of patients completing it. Family medicine physicians are conducting AWVs at a Rhode Island pilot teaching clinic participating in the GWEP's Age-Friendly Health Systems Initiative. To evaluate perspectives of the clinic's under-resourced patients, 20 qualitative telephone interviews were conducted following their AWV. Interview recordings were analyzed for content and themes. Few patients recognized the term ‘Annual Wellness Visit’ or recognized it was significantly different from other visits: “I noticed it was a bit different, but not that different. I’m usually not covered for a visit like that by Medicare.” Mental health, mobility and medications were discussed at most of the AWVs. Some patients noticed that a physician did the medication review instead of the nurse. Patients had varying experiences of how advance directives were discussed, and some thought it unnecessary since a family member knows their preferences. A few patients were dissatisfied that their physician did not focus on their chronic or acute health problems. However, most patients “trusted” their physicians to do “whatever is necessary” for them, and were glad to have had the AWV because “instead of talking about being sick all the time, talking about how to stay well”. Recommendations for patient education to improve understanding and the experience of the AWV will be offered.

Adopting and Adapting a Falls Prevention Program: Lessons Learned From Implementing a Model From a Different Context

Geriatric Workforce Enhancement Programs (GWEPs) are ideally suited to develop and implement educational programs to transform the geriatric care system. They link academic programs, clinical partners, and community-based organizations to bridge care system gaps to improve the health and social care of older adults. Such a collaboration is especially important in falls prevention, where primary care assessments generate referrals to community programs that enroll older adults to reduce their risk of falling. However, exporting an evidence-based model developed in one context for implementation in another is not without its perils and pitfalls. This paper explores the challenges of applying a model developed elsewhere to the Rhode Island context, including the need to understand how structural differences in academic, primary care, and community-based systems require flexibility, innovation, and persistence in overcoming the networking challenges in these different settings. Recommendations for implementing program models in a variety of settings are explored.

A Novel Interprofessional Palliative Care and Geriatrics Curriculum for Nephrology Teams

Background:

The population of older adults with chronic kidney disease (CKD) is increasing and nephrologists need education on the principles of geriatrics and palliative care to effectively care for this population.

Objectives:

Our objective was to develop and deliver a curriculum to interprofessional clinicians caring for older adults with CKD. The aim of this curriculum would be to improve knowledge of the principles of geriatrics and palliative care.

Design:

We have previously developed a curriculum on geriatrics and palliative care targeted toward primary care teams. In this project, we used an interdisciplinary steering committee to modify the curriculum for nephrology teams.

Setting:

This curriculum was delivered in a live grand rounds setting and was recorded and made available via online platform for virtual learning.

Participants:

The 6-session curriculum was delivered to 611 live and online learners between January 2018 and April 2019, with more than half of the participants (n = 317) completing more than 1 session. Participants came from a variety of disciplines including medicine, nursing, pharmacy, and social work.

Results:

Participants had a high rate of agreement with the statement that the curriculum met learning objectives, with live participants having stronger agreement. Participants reported that the activity would change their practice behavior by calling palliative care earlier, as well as improving their communication skills.

Conclusion:

Interprofessional collaboration can result in improved learning around the management of patients with CKD or end-stage kidney disease.

THE RESOURCE EXCHANGE NETWORK: A MODEL FOR TRANSFORMATIVE CHANGE IN GERIATRIC CARE

Transformational efforts to redesign the care system for older adults call for the development of novel partnership models incorporating academic institutions, primary care networks, and community-based organizations. The Rhode Island Geriatric Workforce Enhancement Program (RI-GWEP) has utilized the “resource exchange model” to develop innovative, interdisciplinary, and integrated projects combining educational resources, clinical expertise, programmatic experience, and impact evaluation. With particular emphasis on the challenges of developing interprofessional education spanning the traditional gaps between disciplines and departments, this presentation emphasizes the critical conditions, components, and capacities of such a collaborative network. These include: (1) mission dominance, (2) barter exchange, (3) partnership investment, and (4) interpersonal relationships. RI-GWEP’s experience provides insights into the conceptual foundation of geriatrics networks and specific, concrete examples of projects incorporating these principles. Implications for the development of networks in other settings include consideration of particular: (1) projects, (2) people, (3) places, (4) personalities, and (5) possibilities.

A Pilot Study of Autism-Specific Care Plans During Hospital Admission

BACKGROUND AND OBJECTIVE

Hospital admissions can be difficult for patients with autism spectrum disorder (ASD). We created an autism-specific care plan (ACP) to help improve the hospital experience for patients with ASD, and we tested feasibility and acceptability and compared the experience of care for children with and without an ACP.

METHODS

We performed a nonrandomized, retrospective chart review of all patients with ASD and a hospital admission from January 2013 to December 2013 (n = 142) to determine feasibility of the intervention. We then mailed surveys to all 142 families to measure experience with the ACP and to compare experience of care in those who did and did not have an ACP. Using multivariable linear regression we assessed the association of experience of care with ACP use while adjusting for covariates.

RESULTS

The ACP was well tolerated by parents and used frequently by staff. Compared with parents who did not use the ACP, parents who used the ACP reported a better experience relating to their general hospital experience (B = 1.48, P < .001) and staff attention to their child's ASD-specific needs (B = 3.07, P < .001).

CONCLUSIONS

According to this pilot study, care plans are feasible and hold promise to improve the experience of care for children with ASD and their families in the hospital setting.

A method for counting monosodium urate crystals in synovial fluid

This study was aimed to standardize the technique for counting monosodium urate (MSU) crystals in the synovial fluid (SF) of patients with gout. A total of 52 SF specimens were examined under a polarized light microscope. The amount of SF ranged between 0.1 and 45 mL (median 3 mL). MSU crystals were counted in four areas with the same size at 400x magnification. Cytological examination of the same specimens was also performed. Median leukocyte count was 400 cells/mm3 (range 50-14,000 cells/mm3), with a median percentage of polymorphonuclear leukocytes of 9% (range 0%-98%). Median crystal count was 179.5 (range 3-1600). Inter- reader and intra-reader agreement in crystal counting were good with a weighed k of 0.89 [95% confidence interval (CI) 0.85-0.94] and 0.89 (95% CI 0.84-0.93), respectively. Our data indicate that the SF MSU crystal count is a feasible and highly reliable technique.

Low rates of depressed mood and depression diagnoses in a clinic review of children and adolescents with autistic disorder

OBJECTIVES

The purpose of this study was to investigate the prevalence of depression diagnoses and related clinical data in an outpatient sample of youth with autistic disorder.

METHODS

Records of 123 psychiatrically referred children and adolescents with a Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) diagnosis of autistic disorder were examined. Mood disorder diagnoses and chief complaints along with family mood disorder history were the primary variables analyzed.

RESULTS

Four subjects (3%) presented with depressed mood. Irritability complaints were frequent (n=78, 63%). Six subjects (5%) received a mood disorder diagnosis; all with mood disorder, not otherwise specified. No subjects received a depressive disorder diagnosis. Family history of mood disorders was common.

CONCLUSIONS

Findings raise questions about the appropriate characterization and potential misdiagnoses of depression in youth with autistic disorder.

Brief report: Asperger's syndrome and sibling birth order

Prior investigations suggest that birth order position may be associated with the risk for developing a pervasive developmental disorder. This retrospective chart review examined the birth order status of 29 psychiatrically-referred patients with Asperger's Syndrome (AS). Eighty-six percent of the subjects were first born. The finding was statistically significant when compared to an expected random distribution of AS subjects χ(2) (1, N = 29) = 9.18, p < 0.01. The reasons for such an association are unclear though birth stoppage, obstetric complications, and immunological mechanisms may play a role.

[The role of nailfold videocapillaroscopy in Raynaud's phenomenon monitoring and early diagnosis of systemic sclerosis]

Several connective tissue diseases, in particular systemic sclerosis (SSc), have Raynaud's phenomenon (RP) as their first clinical manifestation. Primary RP represents a benign condition often observed in otherwise healthy subjects, especially women: it is due to an exaggerated response to the physiological cold-induced vasospasm, whereas the secondary form of RP is typically associated with connective tissue diseases, especially SSc. Nailfold videocapillaroscopy (NVC), particulary after the recent technological advances, is a safe and reliable method to observe the microvascular structure and its early changes, especially during the transition from primary to secondary RP. In case of SSc, by considering validated patterns and scoring systems, NVC is the main tool that rheumatologists can rely on, besides the presence of specific auto-antibodies, to perform a very early diagnosis of the disease. This implies the possibility of early treatment of SSc, with an eye of predicting and preventing its major clinical complications.

Intrahepatic cholangiocarcinoma: An international, multi-institutional analysis of prognostic factors and lymph node assessment

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Background: Intrahepatic cholangiocarcinoma (ICC) is a rare and poorly understood primary liver cancer. The role of routine lymphadenectomy at the time of surgical resection remains poorly defined. We sought to identify factors associated with outcome following surgical management of ICC and examine the impact of lymph node (LN) assessment on survival.

Methods: 411 patients who underwent curative intent surgery for ICC between 1973-2010 were identified from an international multi-institutional database. Clinical and pathologic data were evaluated using uni- and multivariate analyses.

Results: Median tumor size was 6.5 cm. Most patients had a solitary tumor (55%) and no evidence of vascular invasion (64%). Resection involved ≥hemi-hepatectomy (74%) and margin status was R0 (82%). Overall median survival was 28 months and 5-year survival was 32%. Factors associated with adverse prognosis included positive margin status (HR=3.11; p<0.001), multiple lesions (HR=2.16; p=0.007) and vascular invasion (HR=2.13; p=0.01). Tumor size was not a prognostic factor (HR=1.05; p=0.08). Lymphadenectomy was performed in 233 (57%) patients; 87 (37%) had LN metastasis. LN metastasis was associated with worse outcome (median survival: N0 39 months vs. N1 21 months; p=0.02). Preoperative factors such as tumor size, number, and morphologic subtype did not predict presence of LN metastasis (all p>0.05); however, vascular invasion did (OR=2.24; p=0.003).

Conclusions: While tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis were associated with survival. Presence of LN metastasis cannot be predicted using preoperative tumor features. Lymphadenectomy should be routinely performed for ICC as up to one-quarter of patients will have LN metastasis.

No significant financial relationships to disclose.

Pancreatic neuroendocrine tumors: Can the WHO staging system be simplified

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Background: The current World Health Organization (WHO) classification system for well-differentiated pancreatic endocrine neoplasms (PENs) is complex, and incorporates both stage- and grade-specific information. The aim of this study was to compare separately the prognostic value of stage and grade in a large single institution study of PENs. Methods: A prospectively maintained database from a single institution identified 183 patients who underwent operative treatment for a PEN between 1982–2005. Tumors were staged (<2 cm primary, =2 cm primary, metastatic disease) and graded (Low: no necrosis and <2 mitoses/50 high-power fields - HPF. Intermediate: presence of necrosis and/or =2 mitoses/50 HPF) with a simplified schema. The influence of tumor stage and grade on disease recurrence and disease-specific survival (DSS) was assessed. Results: Median age of the 183 patients was 56 years and 53% were women. Median length of follow-up was 44 months. At the time of presentation 35 patients (19%) had tumors <2 cm without evidence of metastatic disease (<2 cm), 96 patients (52%) had tumors =2 cm without metastases (=2 cm), and 52 patients (29%) were found to have nodal or distant metastatic disease (mets). Size of the primary tumor was not associated with the presence of nodal metastases (mean diameter: N0, 4.8 cm vs. N1, 4.7 cm: p=0.96) and 5/19 patients with tumors =2 cm had positive nodes. Grade was determined in 98% of patients (n=180). Low-grade tumors were present in 102 patients (56%) and intermediate grade tumors in 78 patients (42%). Earlier stage tumors were more likely to have low grade disease (% Low grade: <2 cm, 83%; =2 cm, 61%; mets, 28%: p <0.001). For all patients, tumor stage and grade were associated with survival (5-yr DSS: Stage: <2 cm, 100%; =2 cm, 90%; mets, 70%: p<0.001. Grade: Low, 98%; Intermediate, 70%: p<0.001). For patients with tumors =2 cm or with mets, grade was associated with survival within each sub-group (5-yr DSS =2 cm: Low 97% vs. Intermediate 80%: p<0.001, Mets: Low 93% vs. Intermediate 62%: p=0.05). Discussion: Stage and grade are important independent prognostic factors in patients with PENs. More accurate prognostic information can be provided by combining tumor size and metastases with simple grading information based on necrosis and mitotic rate.

No significant financial relationships to disclose.

Gemcitabine in pre-treated advanced renal carcinoma: a feasibility study

Eigtheen patients affected by metastatic renal cell carcinoma, 16 which were assesable, were treated with 1 g/m2 of Gemcitabine (GCB) on days 1, 8 and 15 of a 28-day treatment cycle up to a maximun of ten cycles. All patients in neoplastic progression were treated with chemo- and immunotherapy (5 FU, IL-2, IFN alpha d 13-cis-retinoic acid.) Out of the 16 assessable patients, 5/16 (31%) showed overall response (ICR, 4 PR), 5 (31%) stable disease (SD) and 6 (38%) progression of disease (PD). Toxicity was limited to WHO grades I only, primarily hematological.

Mutagenesis of the human transferrin receptor: two cytoplasmic phenylalanines are required for efficient internalization and a second-site mutation is capable of reverting an internalization-defective phenotype

Site-specific mutagenesis has been used to define the sequences required for efficient internalization of the human transferrin receptor. It has previously been shown that the sole cytoplasmic tyrosine, at position 20, is required for efficient internalization. When two other cytoplasmic aromatic residues, the phenylalanines at positions 13 and 23, are substituted with alanines internalization is also reduced. The phenylalanine 23 mutation decreases the internalization rate constant approximately threefold, and mutation of phenylalanine 13 decreases it by approximately twofold. The mutation at position 23 has as serious an effect on internalization as substitution with a nonaromatic amino acid for the single tyrosine. These results demonstrate the importance of several aromatic amino acids in maintaining efficient internalization of the transferrin receptor. Substitution of a tyrosine at a second site, for a serine at position 34, within the cytoplasmic domain of a transferrin receptor with a nonaromatic amino acid at position 20, results in a complete reversion of the internalization-defective phenotype. This reversion is completely dependent upon a tyrosine, as phenylalanine substituted at position 34 does not revert the internalization-defective phenotype. This result demonstrates that a tyrosine placed outside of its native context can still function in the internalization of the transferrin receptor, suggesting a flexibility in surrounding sequences required for efficient internalization.