Management of Symptomatic Refractory Hypoglycemia at the End of Life in a Nondiabetic Patient With Metastatic Urothelial Carcinoma.

Patients with advanced cancer can develop symptomatic hypoglycemia at the end of life which can be associated with significant distress. We report the case of a man with metastatic urothelial carcinoma who developed acute-onset, recurrent, and symptomatic hypoglycemia concerning for non-islet cell tumor hypoglycemia (NICTH). Hypoglycemic episodes were physically and emotionally distressing and refractory to glucose tablets and a low concentration of dextrose infusion. Based on symptom burden and goals of care, treatment was escalated to a concentrated dextrose infusion requiring a central venous line, oral corticosteroids, and subcutaneous somatotropin. He was transferred to the inpatient palliative service, and on this treatment regimen, did not have additional distressing hypoglycemia. For patients with metastatic cancer and symptomatic hypoglycemia, applying a palliative-based framework with discussion of prognosis, values, and goals will lead to goal-concordant care at the end of life that can include aggressive maintenance of euglycemia to relieve suffering.

Hoigne Syndrome Secondary to Intravenous Lidocaine in a Woman with Metastatic Ewing Sarcoma.

Introduction: Palliative care providers are increasingly using lidocaine infusions for refractory cancer pain. Hoigne syndrome (HS) is a rare psychiatric reaction that has been reported after local anesthetic usage, but has not been described in the palliative care setting. Case Report: We report a case of a young woman with metastatic Ewing sarcoma who developed HS days after starting a lidocaine infusion. Given the improvement in her pain since initiation of lidocaine, the decision was made to continue the infusion and medically manage her HS. She had improvement with the addition of benzodiazepines and lowering the lidocaine infusion rate. Discussion: Palliative care providers should be aware of HS as a possible side effect of lidocaine infusions and the unique challenges in managing it in patients near the end of life.

"Tell Me More": Students Can Practice and Self-Evaluate Primary Palliative Care Skills in a Large, Multistate Internal Medicine Clerkship.

Background: Experts recommend integrating palliative care throughout the four-year medical school curriculum, including in required clerkships such as internal medicine (IM). Objective: The aim of this study was to determine whether third-year medical students could gain meaningful experience in primary palliative care during their IM clerkship with observation and feedback from internists and/or IM residents or fellows. Design: We implemented two clinical exercises: (1) perform advance care planning with a patient and (2) participate in the delivery of important news. Students self-reported aspects of their experience in a confidential online survey. Setting/Subjects: Third-year medical students enrolled in a required IM clerkship. Measurements: Students reported the setting in which they completed the exercises, their level of independence, and their level of comfort with advance care planning after completing the exercise. We performed a qualitative analysis of open-ended comments to determine domains, themes, and subthemes and a separate analysis to determine the extent to which the comments suggested learning relevant to the stated learning objectives for each exercise. Results: The majority of students completed both exercises without palliative care specialists present, 76% (196/258) for the advance care planning exercise and 75% (195/259) for important news. Fifty-one percent (132/258) of students completed advance care planning with a significant level of independence, and 70% (182/258) reported being comfortable or very comfortable with advance care planning after completing the exercise. Qualitative analyses of student comments found that the majority of students described learning something related to the stated learning objectives for each exercise and suggested that they gained an appreciation of the complexity of patient-provider interactions around serious illness and palliative care. Conclusion: We found it feasible to integrate clinical exercises in advance care planning and delivering important news into an IM clerkship.

Primary Palliative Care Education in U.S. Residencies and Fellowships: A Systematic Review of Program Leadership Perspectives.

Background: More medical residents and fellows outside of palliative care (PC) will need to be trained in primary PC (PPC) to meet an increasing patient need. Objective: To systematically review surveys of program leadership in postgraduate medical training programs and their respective PPC curricula. Methods: This review included all studies of program leadership surveyed about their PPC curricula in U.S. graduate medical education programs, published in English, and listed on MEDLINE, CINAHL, and EMBASE through January 2020. Results: Data were extracted from eight studies that met the selection criteria out of 221 reviewed texts. PC domains of communication, symptom management, and end-of-life care were taught in all medical specialties most commonly through didactics and PC rotations. Program leadership supported expanding PPC curriculum, with lack of time being the most common barrier. There were differences by specialty in which trainees were exposed to PPC education, with most programs not using a formal curriculum. Conclusions: Generally, there are positive attitudes about PPC education, but there remain significant numbers of trainees with no exposure, and heterogeneity in the content and delivery of PPC education across specialties. PPC Education in U.S. Residencies and Fellowships: A Systematic Review of Program Leadership Perspectives.

Restricted interests and anxiety in children with autism.

A preoccupation with restricted interests (RI) is a core symptom of autism spectrum disorders (ASD). Engagement in RI is commonly observed in this population and impacts social, adaptive, and emotional functioning. The presence of anxiety disorders and overlap in symptom expression with RI, such as obsessive compulsive disorder (OCD), in children with ASD suggests a possible link between anxiety and the RI manifestation. RI play a multidimensional role in ASD and have been described as being expressed in multiple forms, such as fact collection or the enactment of RI through play. However, there is little research exploring in more detail the possible relationship between RI expression and anxiety. To explore the association between RI expression and anxiety, the current study examined the association between the various modes of RI expression and anxiety disorder symptoms in 68 elementary-aged children diagnosed with high-functioning ASD. Findings indicated that symbolic enactment of RI in the form of play, rather than information collection or time engaged in RI, was significantly linked with the increased presence and severity of anxiety symptoms. The conceptualization of RI as possible maladaptive coping responses to negative emotional experiences is discussed.

Brief report: effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism.

This pilot study tested the effect of cognitive behavioral therapy (CBT) on parent-reported autism symptoms. Nineteen children with autism spectrum disorders and an anxiety disorder (7-11 years old) were randomly assigned to 16 sessions of CBT or a waitlist condition. The CBT program emphasized in vivo exposure supported by parent training and school consultation to promote social communication and emotion regulation skills. Parents completed a standardized autism symptom checklist at baseline and posttreatment/postwaitlist and 3-month follow-up assessments. CBT outperformed the waitlist condition at posttreatment/postwaitlist on total parent-reported autism symptoms (Cohen's d effect size = .77). Treatment gains were maintained at 3-month follow-up. Further investigation of this intervention modality with larger samples and broader outcome measures appears to be indicated.