Delirium documentation in hospitalized pediatric patients with cancer.

OBJECTIVE: Screening tools for delirium are being used more consistently in pediatric critical care. However, screening is not universal, and delirium may be underdiagnosed, misdiagnosed, or undocumented in hospitalized patients. We evaluated the identification and documentation of delirium in pediatric oncology and bone marrow transplant patients. METHOD: A retrospective chart review on all hospitalized pediatric oncology and bone marrow transplant patients admitted to an Academic Cancer center between 2013 and 2016. Patients aged less than 21 years of age with active cancer were included. Patients with major psychiatric conditions, developmental delays, or autism were excluded. Data were collected to characterize documentation concerning the identification and diagnosis of delirium. RESULTS: Of 201 hospitalization records, 54 (26.9%) admissions from 109 unique patients had documentation of delirium. The overall documented incidence of delirium was 3.2% of hospitalizations or 8.2% of unique patients. Patients prescribed opioids and benzodiazepines were more likely to have documentation of delirium. ICD coding under-reported delirium while physician documentation was inaccurate in 26% (53/201) when compared with the chart review. SIGNIFICANCE OF RESULTS: Delirium was frequently undocumented or miscoded. Implementing a validated, universal screening tool for delirium may improve identification and clinical outcomes.

Oral adherence in adults with acute myeloid leukemia (AML): results of a mixed methods study.

INTRODUCTION: The incidence of AML is increasing, in part due to an aging population. Since 2017, eight novel agents have been introduced, 6 of which are oral: midostaurin, enasidenib, ivosidenib, gilteritinib, glasdegib, and venetoclax. With an increase in oral medications (OMs), patients face associated side effects that accompany OMs, which often decreases adherence. We aimed to identify and summarize adherence to OMs in this population. METHODS: Our mixed method design used focus groups (FG) and patient surveys. After IRB approval, 11 patients and 4 caregivers participated in 4 FGs. Themes from the FGs were used to develop a 37-item OMs adherence needs assessment. Participants were recruited and consented at three cancer centers to complete surveys (online, at the clinic, hospital, or from home). RESULTS: A total of 100 patients completed OMs survey. The number of pills to be taken was the most frequent and troublesome challenge. The most frequently reported interventions that would improve patient adherence were smaller pills, easier packaging, and scheduling assistance. Nearly 33% of patients indicated they skip OMs dose altogether when they forget to take it. Younger patients (< 65 years) were more accepting of taking oral compared with intravenous medications (p = .03). CONCLUSION: This study represents the first assessment of OMs adherence in adults with AML. Findings provide the basis for further exploration of interventions to enhance and increase adherence to OMs regimens.

Combination therapy with methadone and duloxetine for cancer-related pain: a retrospective study.

BACKGROUND: A comprehensive approach to pain management often requires multimodal therapy and a combination of medications. Oncology patients may be prescribed methadone and duloxetine as single agents or in combination for cancer-related pain, particularly neuropathic pain. Duloxetine is also prescribed for depression or anxiety in patients with cancer. METHODS: A retrospective chart review on patients with cancer-related pain prescribed duloxetine and methadone combination therapy at the Virginia Commonwealth University supportive care clinic (SCC) between 2012 and 2019. Edmonton Symptom Assessment System (ESAS) scores reported by patients on monotherapy were compared to scores after they started combination therapy. Of 131 patients identified on combination therapy, 43 met study criteria (2 with incomplete ESAS scores). RESULTS: ESAS total and subscores after combination therapy were lower than on monotherapy. Combination therapy decreased total, pain, and emotion subscores by 5.6 (SD =17.3, dz =-0.32, P=0.046), 0.9 (SD =3.0, dz =-0.30, P=0.052), and 1.8 (SD =5.1, dz =-0.36, P=0.023), respectively. On combination therapy, 28% of patients reported at least a two-point reduction in pain scores. All study participants reported cancer pain with neuropathic components; most had mixed pain syndromes comprising nociceptive and neuropathic components. Adherence rates were high as 81% of patients with follow-up appointments continued therapy. CONCLUSIONS: These results suggest the combination of duloxetine and methadone reduces cancer-related pain and emotional symptom burden compared to either medication as a single agent.

Feasibility of Delivering an Avatar-Facilitated Life Review Intervention for Patients with Cancer.

Background: Life review, a narrative-based intervention, helps individuals organize memories into a meaningful whole, providing a balanced view of the past, present, and future. Examining how the content of memories contributes to life's meaning improves some clinical outcomes for oncology patients. Combining life review with other modalities may enhance therapeutic efficacy. We hypothesized a life review intervention might be enhanced when combined with a kinetic, digital representation (avatar) chosen by the patient. Our goal was to determine the feasibility of an avatar-based intervention for facilitating life review in patients with advanced cancer. Methods: We conducted an observational, feasibility trial in a supportive care clinic. Motion capture technology was used to synchronize voice and movements of the patient onto an avatar in a virtual environment. Semistructured life review questions were adapted to the stages of child, teenager, adult, and elder. Outcome measures included adherence, recruitment, comfort of study procedure, patients' perceived benefits, and ability to complete questionnaires, including the Edmonton Symptom Assessment System (ESAS) and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). Results: Seventeen patients were approached, with 11/12 completing the intervention. The total visit time of a single intervention averaged 67 minutes. The post-intervention survey found all patients agreed or strongly agreed (Likert Scale 1-5) they would participate again, would recommend it to others, and found the experience beneficial. After one month, ESAS scores were either unchanged or improved in 80% of patients. Conclusion: An avatar-facilitated life review was feasible with a high rate of adherence, completion, and acceptability by patients. The findings support the need for a clinical trial to test the efficacy of this novel intervention. Clinical Trial Number NCT03996642.