A Curriculum for Psychiatry R2s - Psychiatry Residency - University

1

Inpatient Consult-Liaison Psycho-Oncology A Curriculum for Psychiatry R2s

Ryan Kimmel MD

Mitch Levy MD

Suzanne Murray MD

Jennifer Seibert MD

Kjersti Braunstein MD

University of Washington

Department of Psychiatry

Seattle Washington

Corresponding Author

Ryan Kimmel

rjkimmeluwedu

University of Washington Medical Center

Box 356073

Seattle WA 98195-6073

206-598-6111 (fax)

206-598-7543 (phone)

2

Table of Contents

Introduction and Problem Identificationhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 3

Needs Assessment Methods and Results Summary 3

Goals and Objectiveshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4

Educational Strategies and Objective Measurementhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4

Faculty Curriculum Guide

Didactic 1 Medical Overview of Stem Cell Transplantationhelliphellip 6

Didactic 2 Cancer and Depressionhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 8

Didactic 3 Resiliencehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 10

Didactic 4 At-The-Bedside Supportive Psychotherapy of Demoalizationhellip 11

Didactic 5 Common Psychopharmacology Dilemmashelliphelliphelliphelliphelliphelliphelliphellip 12

Didactic 6 Neuropsychiatric Sequelae of Cancer Medicationshelliphelliphelliphelliphellip 14

Appendix

1 Didactic 1 Powerpoint Slides and Poster Imagehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 16

2 Didactic 2 Powerpoint Slideshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 24





7 Needs Assessment Survey Questionshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 63

8 Needs Assessment Survey Results for Quantitative Questionshelliphelliphelliphelliphellip 65

3

Introduction and Problem Identification

The Seattle Cancer Care Alliance (SCCA) is the collaborative treatment arm for the

Oncology Departments at the University of Washington Seattle Childrenrsquos and the Fred

Hutchinson Cancer Research Center The SCCA has carved out several floors at the

University of Washington Medical Center (UWMC) to create a hospital-within-a-

hospital This focus has significantly increased the number of cancer inpatients seen by

the inpatient Consult-Liaison Psychiatry Service at the UWMC Of the three hospitals

where UW residents rotate the UWMC has the greatest number of patients actively

undergoing stem cell transplantation

The American Psychosocial Oncology Society (APOS) developed online psycho-

oncology training tools (httpwwwapos-societyorgprofessionalsmeetings-

edwebcastsaspx) and has also articulated recommended topics for a two-year psycho-

oncology curriculum (httpwwwapos-societyorgprofessionalstools-

resourcesteachingaspx) There are excellent books that tackle the broad field as for

example Hollandrsquos Psycho-Oncology 2nd

Edition Oxford Press 2010 To our

knowledge however there exists no published psycho-oncology curriculum geared

towards psychiatry residents much less residents on inpatient consult-liaison rotations

The core psychiatry consult-liaison attendings at the UWMC have diverse interests both

psychologic and psychopharmacologic As this core group rotates months on the

inpatient psychiatry consult-liaison service we recognized that no single attending had

available the grouprsquos cumulative knowledge Moreover the R2s on the service were not

privy to the cumulative psycho-oncology teaching of the core attending group

Needs Assessment

The R2s who rotate on our inpatient consult-liaison service already spend two half-days

of the week off the service in didactics outpatient clinics and outside supervision The

consult-liaison clinical service needs are significant and it would be difficult to carve out

more significant swaths of time Therefore the authors postulated that over the course

of resident rotation six 20-minute didactics done at the start of rounds would be

manageable

To get the resident perspective we enlisted the help of an R4 Dr Braunstein The

authors then brainstormed potential didactic topics We took the APOS Fellowship

Curriculum topics identified inpatient-specific subjects and then grouped the topics

together into overarching foci of basic stem-cell transplant biology cancer-specific

psychopharmacology psychiatric symptoms of paraneoplastic syndromes psychiatric

side effects of cancer medication resilience and supportive therapy for demoralization

We constructed a 10-question anonymous Catalyst Web survey that sought to confirm

or refute our assumptions about prior psycho-oncology training the palatability of the 20-

minute didactic schedule and resident overall comfort with and understanding of each

proposed topic (see Appendix 7) We also asked for recommendations for other topics

The purpose of our survey was not only did we want to test our assumptions but also

4

make the residents feel like they were a part of the process and to look forward to the

didactics

Out of 66 Seattle-based residents in our program 36 responded to the survey including

12 of 16 R2s to whom the didactic series is directed (see Appendix 8) Six residents

reported attending a prior didactic in psycho-oncology citing a single lecture during the

regular psychiatry residency series Thirty-four of 36 respondents approved of the

proposed format Of the topics proposed by the authors the preponderance of responders

rated their understanding or comfort with the material as ldquopoorrdquo or ldquodecentrdquo In fact

only one resident responded to any question with an indication of satisfactory knowledge

This R2 noted that they were already comfortable with at-the-bedside supportive

psychotherapy for demoralization

Resident-suggested topics that could be included were spirituality death and dying and

palliative care Facets of these were subsequently included in the didactics The authors

also confirmed that these topics were going to be covered in more detail as part of the

general residency didactic schedule

Goals and Objectives

Residents completing the curriculum will have specific data to answer common consult

questions have a clearer understanding of biopsychosocial sequelae of cancer and its

treatment and feel more comfortable interacting with patients on our oncology wards

Course Objectives are as follows

Upon completing the curriculum the residents will

Have a rudimentary knowledge of stem-cell biology

Be able to identify common cancer treatment-specific issues with standard

psychopharmacology

Be able to identify common neuropsychiatric sequelae of paraneoplastic

syndromes and chemotherapy agents

Recognize depression demoralization and interventions resulting in resilience in

oncology inpatients

Feel more comfortable engaging in at-the bed supportive psychotherapy

Have access to important articles for further reading on the presented topics

Educational Strategies and Objective Measurement

The topics we chose have a broad range of quantitative and experiential themes

Moreover the residents as well as the attendings have a broad range of learning styles

We therefore set about to use multiple educational methods We included diagrams to

help teach the stem-cell biology interactive problem-based learning for

psychopharmacology and neuropsychiatric syndrome presentations reflective discussion

regarding resilience and role-playing for supportive psychotherapy

5

The didactics were initially presented by each author in front of the other authors and a

group of R2s One 20-minute didactic was done each week The length of the didactic

was intended to be non-intrusive The timing first thing in the morning was designed so

as not to be a distraction once the work of seeing patients and documenting encounters

was initiated for the day

Given that the didactics were brief the presentations were embedded with important

journal references and recommendations for more in-depth reading Moreover we will

refer to the didactics during actual cases we see on the CLP rotation during the month

Trainee knowledge will be evaluated via demonstrated practice during the CLP rotation

At the completion of their consult rotation residents will be asked to evaluate the

didactics and whether the objectives had been met This data will be collected over the

course of an academic year and will be used to further enhance the curriculum

6


Didactic 1 ndash Medical Overview of Stem Cell Transplantation

This is a didactic to provide information about the process involved in stem cell

transplantation It includes an interactive review of hematopoiesis and details the steps

involved in transplantation We also explore possible scenarios requiring psychiatric

consultation-liaison team involvement in the care of the stem cell transplant patients

Objectives

At the end of the session the resident will be able to

1 Recognize the general process involved in stem cell transplantation

2 Identify specific phases of stem cell transplantation during which psychiatric

symptoms may become more prominent and thus prompt psychiatric consultation

Overview

First we introduce the terminology encountered in literature as well as medical

documentation regarding stem cell transplantation clarifying some acronyms and

distinguishing between hematopoetic and embryonic stem cells We also introduce the

general outline of the stem cell transplantation process each step of which is discussed in

more detail below

Review of Hematopoiesis

The most interactive portion of this lecture we spend a few minutes reviewing

hematology with a sort of matching game the group of learners is given an envelope

containing different cell types and they are asked to arrange these correctly on a large

board that contains an outline of the hematopoetic cascade

Myeloablation

We discuss the chemotherapeutic regimens as well as XRT as methods of ablating

marrow in preparation for transplant

Stem Cell Infusion

The process of bone marrow stimulation stem cell harvesting as well as infusion is

discussed mentioning the intricacy of the actual protocols for this infusion

Engraftment

The final stage of the stem cell transplant process is engraftment The prolonged time

course of this is discussed as are the methods of speeding immune reconstitution

Graft vs Host DiseaseGraft vs Tumor Effect

The balance between myeloablation (to minimize GVHD) and preservation of the

beneficial graft vs tumor effect is explored We review and define GVHD and graft vs

tumor effect as well as discuss the treatment of GVHD including steroids and other

immunomodulating medications

Common Times for Psychiatric Consultation

Transitioning from discussion of the prolonged immunosuppression that can result from

delayed engraftment as well as GVHD treatment we explore the learnerrsquos ideas about

common times that our services as psychiatric consultants are required We create a list

of possible psychiatric symptoms prompting consultation during times of a)

immunosuppressant use b) chemotherapy complications such as mucositis c) delayed

engraftment and d) relapse

7

References

Chang G et al Mental Status Changes After Hematopoietic Stem Cell Transplantation

Cancer 2009 Oct 1115(19)4625-35

Peccatori J and Ciceri F Allogeneic stem cell transplantation for acute myeloid leukemia

Haematologica Vol 95 Issue 6 857-859 doi103324haematol2010023184

Websites

httpwwwcancergovcancertopicsfactsheetTherapybone-marrow-

transplant

httpwwwcancergovcancertopicsunderstandingcancerStemCellspage

1

httpwwwmayocliniccomhealthstem-cell-transplantMM00787

8

Didactic 2 ndash Assessment of Depression in Patients with Cancer

This didactic is based a single vignette interspersed with didactic information It focuses

on the assessment of depression as well as creating comfort in discussing mood in the

context of difficult medical treatment It is designed so that the lecturer can pause at

several points to solicit ideas from residents who have prior experience or knowledge in

this area Some of the references provided offer practical advice for residents who want

to learn more

Objectives


1 Discuss the challenges in diagnosing depression in a patient with cancer

including patient family and provider biases

2 List common worries of cancer patients and proposed screening questions to

assist in identifying patients who need further evaluation for depression and

suicidality

3 List the pain sleep and other neurovegetative symptoms that are more greatly

correlated with depression in a patient than with typical cancer-related

symptoms

4 Understand the emerging evidence for psychosocial treatments in depressed

cancer patients with awareness of the limits of the evidence base in this area

Case

The case illustrates a fairly typical scenario of ambiguity over time about the presence of

depressive symptoms in a patient undergoing active cancer treatment The case is halted

at several points along the way to elicit discussion and teaching in the following areas

Diagnostic Challenges

There are several diagnostic challenges in determining depression in this patient

population as well as biases about the diagnosis of which residents should be

aware This section also offers proposed screening symptoms that would suggest

further depression assessment of a patient being treated for cancer

Topics for Initial Assessment

Residents can familiarize themselves with the common worries of cancer patients

useful questions to use with patients to elicit discussion of their mood anxiety

and suicidality and with particular symptom patterns likely to be associated with

depression rather than cancer-related

Epidemiology of Depression in Cancer

Despite an increased prevalence of depression in patients with cancer than for

those in outpatient primary care depression is not inevitable

Psychosocial Treatments in Cancer

9

The best evidence is for medications plus supportive or cognitive behavioral

therapy however the overall evidence for the efficacy of psychosocial

interventions is minimal and equivocal

References

Akechi T Okuyama T Onishi J Morita T Furukawa TA Psychotherapy for depression

among incurable cancer patients Cochrane Database Syst Rev 2008 Apr

16(2)CD005537

Fisch M Treatment of Depression in Cancer J Natl Cancer Inst Monogr 2004(32)105-

11

Jacobsen PB Jim HS Psychosocial Interventions for Anxiety and Depression in Adult

Cancer Patients Achievements and Challenges CA Cancer J Clin 2008 Jul-

Aug58(4)214-30

Krishnan KR Delong M Kraemer H Carney R Spiegel D Gordon C McDonald W

Dew M Alexopoulos G Buckwalter K Cohen PD Evans D Kaufmann PG Olin

J Otey E Wainscott C Comorbidity of depression with other medical diseases in

the elderly Biol Psychiatry 2002 Sep 52(6)559-88

Roth AJ Modi R Psychiatric issues in older cancer patients Crit Rev Oncol Hematol

2004 Nov48(2)185-97

Spoletini I Gianni W Repetto L Bria P Caltagirone C Bossu P Spalletta G Depression

and cancer An unexplored and unresolved emergent issue in elderly patients Crit

Rev Oncol Hematol 2008 Feb65(2)143-55

Weinberger MI Bruce ML Roth AJ Breitbart W Nelson CJ Depression and barriers to

mental health care in older patients Int J Geriatr Psychiatry 2011 Jan26(1)21-6

10

Didactic 3 ndash Resilience

Cancer diagnoses and issues with terminal illness often elicit strong and sometimes

inappropriately negative reactions from healthcare providers This is an interactive and

informational didactic that helps learners identify their immediate and characteristic

responses to the topic of cancer There is an increasingly rich literature reviewing those

factors associated with successful and adaptive coping with cancer and other challenges

The didactic summarizes known resilience factors for cancer and briefly covers some

interventions that have enhanced resilience and successful coping in cancer patients

Objectives

1 Learners will display awareness of their biases and attitudes towards

cancer diagnoses

2 Learners will demonstrate understanding of at least 3 general resilience

factors associated with coping with medical illness and cancer

3 Learners will be familiar with research suggesting the role of interventions

to improve coping in cancer patients

4 Learners will demonstrate an attitude of compassion for patientsrsquo

existential struggles and suffering with illness and appreciate possible

resilience factors in coping as demonstrated by observed in their case

formulation or observed interviews by attending physicians on their CL

rotations

A description of this didactic is contained in the notes on the Powerpoint slides in

Appendix 3

References

Cimprich B Janz NK Northouse L Wren PA Given B Given CW Taking CHARGE

A self-management program for women following breast cancer treatment

Psychooncology 2005 Sep14(9)704-17

Nezu AM Nezu CM Felgoise SH McClure KS Houts PS Project Genesis assessing

the efficacy of problem-solving therapy for distressed adult cancer patients J

Consult Clin Psychol 2003 Dec71(6)1036-48

Antoni MH Lechner S Diaz A Vargas S Holley H Phillips K McGregor B Carver CS

Blomberg B Cognitive behavioral stress management effects on psychosocial and

physiological adaptation in women undergoing treatment for breast cancer Brain

Behav Immun 23580-91 2009

Parry C ldquoEmbracing uncertainty the experiences of childhood cancer survivorsrdquo

Qualitative Health Research 2003

Lipsman et al ldquoThe attitudes of brain cancer patients and their caregivers towards death

and dying a qualitative study ldquo BMC Palliative Care 2007

Stewart and Yuen lsquoA Systematic Review of Resilience in the Physically Illrsquo

Psychosomatics 2011 52199 ndash209

Coolbrandt and Grypdonk ldquoKeeping courage during stem cell tranplantation a

qualitative researchrdquo European Journal of Oncology Nursing 2010

11

Didactic 4 ndash At-The-Bedside Supportive Psychotherapy for Demoralization

Coping with terminal illness and dying are fundamental challenges for patienst and

providers The term lsquodemoralizationrsquo has been coined to describe a failure of coping with

existential threats such as cancer and end of life Authors have sought to define

demoralization and formulate clinically applicable interventions as far back as 30 years

ago Griffith and Gaby (Psychosomatics 2005) articulated 7 pairings of ldquoexistential

postures vulnerability and resilience to illnessrdquo These pairings include confusion and

coherence isolation and communion despair and hope helplessness and agency

meaninglessness and purpose cowardice and courage and resentment and gratitude

These pairings allow a framework and organization with which to pursue bedside


Residents in psychiatry on consultation liaison services may have training in treatment

via psychotherapy or pharmacotherapy for major depression They may have had little

exposure to interventions for demoralization or disorders of adjustment This is an

experientially-based intervention focused on introducing learners to the concepts of

demoralization and existential postures as described by Griffith and Gaby They are then

presented with sample cases from the Griffith article and challenged to identify postures

of demoralization and role-play interventions with a partner to move their client toward a

position of greater strength and more adaptive coping Ultimately the goal for this

module is to then identify and intervene therapeutically with appropriate cases with

attending supervision on the consultation-liaison service

Objectives

1) Learners will understand 3 key differences between depression and

demoralization

2) Learners will demonstrate understanding of postures of existential

demoralization and their counterparts (remoralization)

3) Learners will demonstrate the ability to role-play identification and

intervention with a sample case involving a demoralized patient

3) Learners will employ strategies for synthesizing understanding of

demoralization in as demonstrated in their clinical formulationassessment

of acase during their CL rotation


Appendix 4

References

bull Griffith James L Gaby Lynne Brief Psychotherapy at the Bedside Countering

Demoralization From Medical Illness Focus 2010 8 143-150

bull Slavney PR Diagnosing demoralization in consultation psychiatry

Psychosomatics 1999 40325ndash329

12

Didactic 5 - Common Psychopharmacology Dilemmas

This is a vignette-based didactic with examples cases the Psychiatry CL Service gets

several times a year Feel free to engage the residents after the case presentation just to

see if anybody happens to know the data or has gotten this question in real life The

second slide of each case summarizes the data and provides a journal reference should

residents want to read more Some of the cases have a third slide with ldquoClinical Bottom

Linerdquo recommendations

Objectives


1 Recognize the timeframe when oral mucositis is most likely how to pro-

actively anticipate the challenges that mucositis presents in drug delivery and

how to adapt medication formulations after mucositis appears

2 By the end of the didactic each resident will know that certain antidepressants

may render tamoxifen less effective and cancer more likely

3 By the end of the didactic residents will understand the role of stimulants for

depression and cancer-related fatigue

4 By the end of the didactic residents will understand the unique pros and cons

of mirtazapine

Case 1

The first case involves the unusual circumstance of regarding data suggesting that several

common antidepressants inhibit the metabolism of tamoxifen thereby making breast

cancer recurrence more likely While there is not an absolute consensus there is enough

evidence for specific recommendations

Case 2

The second case addresses our use of mirtazapine for depressionnauseaappetite

stimulationsleep In truth there are better hypnotics and better anti-emetics than

mirtazapine The rare bone marrow suppression associated with mirtazapine (frequency

perhaps in the range of Clozaril) should be a bit alarming One could still justify

mirtazapinersquos use if for example the risk from intractable nausea outweighed the

marrow suppression risk

Case 3

The third case addresses the use of methylphenidate for depression and cancer-related

fatigue This comes up during consults on Physical Medicine and Rehabilitation as well

You might convey how the quick results and short half-life of methylphenidate make it

an easy trial in appropriate cases Residents have often heard that it is an appetite

suppressant though our clinical experience is that lethargic patients may be too tired to

eat and that methylphenidate can actually improve caloric intake for some patients

Provigil has also been used in many types of medical fatigue and information on this can

be found in Jean-Pierre Cancer 2010

13

Case 4

Mucositis during chemo induction is something that residents may only see on our

rotation but using Prozac for SSRI withdrawal is a good trick for other situations too

References

Case 1

Kelly CM Juurlink DN Gomes T Duong-Hua M Pritchard KI Austin PC Paszat LF

Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving

tamoxifen a population based cohort study BMJ 2010 Feb 8340

Cronin-Fenton D Lash TL Soslashrensen HT Selective serotonin reuptake inhibitors and

adjuvant tamoxifen therapy risk of breast cancer recurrence and mortality Future Oncol

2010 Jun6(6)877-80

Case 2

Flanagan RJ Dunk L Haematological toxicity of drugs used in psychiatry Hum

Psychopharmacol 2008 Jan23 Suppl 127-41

Case 3

Candy M Jones L Williams R Tookman A King M Psychostimulants for depression

Cochrane Database Syst Rev 2008 Apr 16(2)CD006722

Minton O Richardson A Sharpe M Hotopf M Stone P Drug therapy for the

management of cancer-related fatigue Cochrane Database Syst Rev 2010 Jul 7(7)

Hardy SE Methylphenidate for the treatment of depressive symptoms including fatigue

and apathy in medically ill older adults and terminally ill adults Am J Geriatr

Pharmacother 2009 Feb7(1)34-59

Case 4

Benazzi F Fluoxetine for the treatment of SSRI discontinuation syndrome

Int J Neuropsychopharmacol 2008 Aug11(5)725-6 Epub 2008 Feb 1

14

Didactic 6 Neuropsychiatric Sequelae of Cancer and Cancer Treatments

This is a vignette-based didactic with example cases based on patients encountered on

our CL service The cases are examples of psychiatric symptoms occurring due to

cancer treatments andor cancer itself Some of these are rare but come up in the

differential frequently on our service Similar to Didactic 5 the cases are meant to bring

out discussion amongst the residents and students perhaps revealing an already strong

knowledge base for some and a deficit in others The subsequent slides include basic

data known about the topic with references followed by several journal references for

those who want to read more on the topic The final slide is the objectives of the session

These were purposely not revealed at the start to avoid giving the diagnosis away in the

clinical vignettes

These topics are very large and the planned time for this session is only 20 minutes The

purpose of this session is to cover the very basics and refer the learners to the literature

for a more complete understanding

Objectives

1 Identify neuropsychiatric effects associated with chemotherapy agents

2 Identify neuropsychiatric sequelae of PRES as well as list causes of PRES

3 List symptoms of paraneoplastic syndrome cancers associated with

paraneoplastic syndromes and differentiate these symptoms from a

primary psychiatric illness

Case 1

The first case is a patient who develops psychotic and manic symptoms after prednisone

was given for his prostate cancer Faculty should present the case then facilitate a

discussion with the group about steroid induced neuropsychiatric treatments Discussion

should include symptoms that occur incidence risk factors and options for treatment

The next several slides summarize what is the literature tells us about incidence onset

and risk factors of steroid induced psychiatric symptoms

Case 2

The second case is an example of someone with Posterior Reversible Encephalitis

Syndrome (PRES) from immunosuppressive therapy Once again the case should

facilitate discussion of a differential and clinical course of PRES but may quickly lead to

the slides that follow which include presenting symptoms typical imaging findings

etiologies and basic pathophysiology of PRES Slides are followed by references for

further reading as well as a slide with list of chemotherapy agents that can cause

neurotoxicity

Case 3

The final case is to represent paraneoplastic syndromes The case itself is an example of

Anti-NMDA encephalitis (which is often but not always cancer mediated) It opens up

discussion of the paraneoplastic process seen in many types of cancer A facilitated

15

discussion should occur including neuropsychiatric symptoms that occur with

paraneoplastic syndromes the cancers that are typically linked to paraneoplastic

syndromes and the recommended treatments for the syndrome Pertinent references are

included for further reading

References

Case 1

Kenna HA Poon AW de los Angeles CP Koran LM Psychiatric complications of

treatment with corticosteroids review with case report Psychiatry Clin Neurosci 2011

Oct65(6)549-60

Warrington TP Bostwick JM Psychiatric adverse effects of corticosteroids Mayo Clin

Proc 2006 Oct81(10)1361-7

Wada K Yamada N Sato T Suzuki H Miki M Lee y Akiyama K Kuroda S

Corticosteroid-induced psychotic and mood disorders diagnosis defined by DSM-IV and

clinical pictures Psychosomatics 2001 Nov-Dec42(6)461-6

Stiefel FC Breitbart WS Holland JC Corticosteroids in cancer neuropsychiatric

complications Cancer Invest 19897479-491

Case 2

Hinchey J Chaves C Appignani B Breen J Pao L Wang A Pressin MS Lamy C Mas

JL Caplan LR A reversible posterior leukoencephalopathy syndrome N Engl J Med

1996 334494-500

Aranas RM Prabhakaran S Lee VH Posterior reversible encephalopathy syndrome

associated with hemorrhage Neurocrit Care 2009 10(3)306-12

Ni J Zhou LX Hao HL Liu Q Yao M Li ML Peng B Cui LY The clinical and

radiological spectrum of posterior reversible encephalopathy syndrome a retrospective

series of 24 patients J Neuroimaging 2011 Jul21(3)219-24

Case 3

Kayser MS Kohler CG Dalmau J Psychiatric manifestations of paraneoplastic

disorders Am J Psychiatry 20101671039-1050

Foster AR Caplan JP Paraneoplastic Limbic Encephalitis Psychosomatics 200950108-

113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION

Slide 2 CONDITIONS TREATED BY STEM

CELL TRANSPLANT AmegakaryocytosisCongenital Thrombocytopenia

Amyloidosis

Aplastic AnemiaRefractory Anemia

Germ Cell Tumors (Testicular Cancer)

Paroxysmal Nocturnal Hemoglobinuria

Hodgkins Disease

Acute Leukemias

Chronic Lymphocytic Leukemia

Familial Erythrophagocytic Lymphohistiocytosis

Non-Hodgkin Lymphoma

Multiple Myeloma

Osteopetrosis

Myelodysplastic SyndromeOther Myelodysplastic Disorders

Solid Tumors

Wiskott-Aldrich Syndrome

17

Slide 3 GENERAL PROCESS

Myeloablation ndash days to weeks

Stem Cell Infusion - hours

Engraftment ndash months to years

Goal

Ablate marrow enough to kill tumor and

minimize GVHD but not so much as to

eliminate the useful graft vs tumor

effect

So seems relatively simple as a concept not too far off from what wersquove learned about BMT

Slide 4 TERMINOLOGY (ALPHABET SOUP)

PBSCT Peripheral Blood Stem Cell Transplant

HSCT Hematopoeitic Stem Cell Transplant

ACBSCT Autologous Cord Blood Stem Cell Transplant

Autologous self

Syngeneic Identical twin

Allogeneic Unrelated but HLA-matched

A B and DR most important

So herersquos where it gets complicated hellip 43 yo F 6 d sp PBSCT for CML

Slide 5 EMBRYONIC STEM CELLS

VERY different

hESC

Eggs fertilized via IVF

Pre-implantation embryonic cells plated and

cultured

NIH funding for hESC restricted for nearly 8

years

No limits on PBSCHSC

Stem Cells are a dirty word in some circles

18

Slide 6 HEMATOPOEISIS

Letrsquos take couple of minutes to review which cells wersquore talking about transplanting You have 90 seconds using the cells you have in front of you arrange the cells on the board here in the proper configuration to demonstrate the hematopoetic process hellip GO





Goal


minimize GVHD but not so much as to eliminate

the useful graft vs tumor effect

Slide 8 STEM CELL TRANSPLANTATIONPROCESS

Myeloablation

ChemotherapyMultiple regimens

Less intense conditioning regimens emerging

age of patients receiving SCT now into 70s

lower transplant-related mortality but no survival benefit less intense conditioning = more relapse

RadiationTotal Body

Tomotherapy

Now letrsquos break down the steps of the stem cell transplant a bit further first step 1 Myeloablation Regimens vary with type of cancer molecular subtypes patient comorbidities etc

19





Goal



eliminate the useful graft vs tumor effect

Slide 10 STEM CELL TRANSPLANTATION

PROCESSHarvesting Cells

Induction of donor marrow

G-CSF injections 1-5 days prior to harvest

Increases stem cells in periphery 10-100-fold

Apheresis

4-6 hours

2-4 cycles to gather appropriate amount of

circulating stem cells

Central line

G-csf and sometimes chemotherapeutic agents like cyclophosphamide as well


Infusion

1-5 hours

Protocol for infusion

Premedications

Verification Procedures

Inform about side effects to expect

Cough NV intestinal cramps abnormal

taste SOB

Actual infusion protocols are pages long for what amounts to a fairly rapid infusion in less than a nursing shift Interestingly a common preservative has a profound odor so itrsquos suggested to have an open vial of peppermint oil in the room have patients suck hard candies have an emesis basin handy

20

Slide 12

Herersquos a helpful cartoon hellip actually the NCI site has good patient information but I mostly included this here because of the smiling patient Not usually the type of patient we see when we walk into a room for a consult up on the HemeOnc floors hellip





Goal





Engraftment

2-4 weeks before cells reach marrow begin

producing RBCWBCplatelets

Months before autologous transplants recover

full BM function

1-2 years for allogeneicsyngeneic

Methods to speed immunoreconstitution

T cell depletion

Genetically modified lymphocytes infused

These patients are often hospitalized for a very long time Obviously there is great effort being placed into speeding up this process T cell depletion is aimed to eliminate the presence of mature functional T cells in the graft but genetically modified lymphocytes can actually be infused which aid the recovery of bone marrow hellip way beyond the scope of this talk or my knowledge of hematologyimmunology

21





Goal





Slide 16 GRAFT-VERSUS-HOST DISEASE

New donated cells identify native cells as foreign mount immune response

Acute and Chronic forms

Most common sites Skin

Liver

Intestine

Prevention T-Cell Depletion of donated cells

One of the entities I alluded to initially then in the great balance that the hemeonc folks are trying to achieve 35-77 incidence

Slide 17 GRAFT-VERSUS-TUMOR

Graft versus Leukemia

Mature T cells from donor attack stray cancer cells

Enhanced prognosis in certain types of leukemia

T-cell depletion to avoid GVHD hindersthis

Also alluded to the Graft vs Leukemia which is an entity which occurs due to the lack of complete eradication of leukemic cells with chemotherapy (otherwise these folks would just be treated with chemo and not need a stem cell transplant right) This graft vs tumor battle actually is something that is a necessary part of the cure of these illnesses So again itrsquos a balancing act here to deplete T cells to minimize some significantly morbid complication but not quite fully so as to allow graft vs tumor The problem is again the balance

22

T-cell depletion is done prior to stem cell infusion to avoid GVHD (and decrease risk of graft failure and relapse) but again you donrsquot want to deplete completely hellip

Slide 18 GVHD TREATMENT

Steroids

Tacrolimus

Mycophenolate Mofetil

Methotrexate

Anti-thymocyte globulin

Often means months of immunosupression

Acute GVHD more monoclonal Abs sirolimus mycophenolate mofetil Chronic GVHD steroids more also mycophenolate mofetil

Slide 19 COMMON TIMES FOR PSYCHIATRIC

CONSULTATION Immunosuppressant use

Delirium

Mania

Bone marrow suppression associated with SSRIs

Complications Mucositis medication adjustments

Infections delirium

Anemia Anxiety

o Delay in engraftmentbull DepressionDemoralization

bull Anxiety

bull Bone marrow suppression associated with SSRIs

Relapse DepressionDemoralization

Anxiety

DeathDying

So months of immunosuppression mean months of vulnerability to infections but also psychiatric sequelae where we come into the picture

23

Slide 20 REFERENCES

Peccatori J and Ciceri F Allogeneic stem cell transplantation

for acute myeloid leukemia Haematologica Vol 95 Issue 6

857-859 doi103324haematol2010023184

Chang G et al Mental Status Changes After Hematopoietic

Stem Cell Transplantation Cancer 2009 Oct 1115(19)4625-

35

Websites

httpwwwcancergovcancertopicsfactsheetThera

pybone-marrow-transplant

httpwwwcancergovcancertopicsunderstandingca

ncerStemCellspage1

Mayo clinic - video

Didactic 1 Poster Picture

24

Appendix 2

Didactic 2 Slides

Slide 1

Assessment of Depression in Patients with Cancer


Slide 2 Is She Depressed

You are asked to consult for diagnostic clarification on a 57-year-old woman sp stem cell transplant for high risk ALL who is recovering from a recent episode of EBV encephalitis Her primary team concerned about tearfulness and minimal participation in her care started an SSRI and a stimulant 10 days ago At the time of psychotropic initiation the team did not note disorientation or a waxingwaning element to her presentation She and her husband were unaware of the new medications until today and do not think she was ever depressed They hypothesize that she just feels better physically this week

25

Slide 3 Depression and Cancer Diagnostic Challenges

bull Diagnosis is confounded in cancer patients

ndash Patient family and provider factors

bull We are lacking a standard way to define depression in the setting of cancer

bull Use depressed mood and loss of interest as ldquogatewayrdquo symptoms to screen cancer patients

Weinberger et al 2011 Spoletini et al 2008 Fisch 2004

Solicit ideas about the factors Patients family and providers may all have beliefs that being down or hopeless is natural providers may have biases that depression is inevitable Patients and families often have strong beliefs that a ldquofighting spiritrdquo is essential to a good outcome making perceived risks for the patient if they disclose depressive symptoms Patients have physical symptoms that can cause sleep disturbance psychomotor retardation appetite disturbance poor concentration low energy A wide variety of scales (Hamilton CES-D-Center for Epidemiologic Studies ESAS-Edmonton Symptom Assessment System) are used in the US other studied regions may favor one scale or the other (HADS in Europe) Should we exclude neurovegetative symptoms for cancer or other chronically ill patients 3 Weinberger and colleagues advocate for use of depressed mood and loss of interest as ldquogatewayrdquo symptoms meaning further symptom assessment is predicated on the presence of these symptoms

26

Slide 4 What do I Say

As you stand outside the patientrsquos door you feel the butterflies in your stomach begin catastrophizing about your knowledge deficits about cancer treatment and anticipate the derision which will surely be cast upon you after asking someone this sick how theyrsquore eating and sleeping and enjoying themselves this week What might you ask both to help your assessment and to build rapport with the patient

Solicit ideas prior to heading to next slide

Slide 5 What do we talk about

bull Worries are common in cancer patientsndash Death dependency disfigurement disability sexual

dysfunction disruption of relationships pain

bull Methods to elicit mood in the context of illness

bull What vocabulary and strategies to we use to disscuss suicide in CL patients compared to 7N patients

bull Areas to assess to aid in depression diagnosisndash Assess the particulars of pain and symptoms

ndash Assess hopelessness Assess sleep

Roth and Modi 2003 Weinberger et al 2011

Worries about death dependency disfigurement disability sexual dysfunction disrupted relationships pain May not be items yoursquod run off like a checklist but may ask about how cancer has affected some of these areas or ask if they have these worries or listen for these themes validate and normalize their concerns Questions you could ask How well are you coping with your cancer How are your spirits since diagnosis During treatment How does the future look to you (gets at suicide risk) Do you feel that you can influence your care or is it totally under othersrsquo control Do you worry about being a burden to your familyfriends during treatment (gets at suicide risk) Do you feel others might be better off without you (gets at suicide risk) Do you have pain that is not well controlled How much time do you

27

spend in bed Are you weak Do you fatigue easily Do you feel rested after sleep Is there any relationship to change in treatment and how you feel physically How is your interest in sex Do you have concerns about sexual function 3 Methods to differentiate cancer symptoms from depression from Weinberger (specific to the elderly depressed patients more likely to report) General malaise often reported rather than sadnesslost interest General achespains rather than tumor specific pain Diffuse somatic complaints rather than treatment related effects Hopelessness Late insomnia waking in the middle of the night with worries Mood variation throughout the day Loss of sexual interest

Slide 6 Educating Your Patient

After an hour of careful assessment you find that you agree with the patient and her husband that she does not meet criteria for depression and you recommend stopping the medications for now However talking with you left them with questions How likely is it that she or other patients with cancer become depressed

28

Slide 7 Epidemiology

bull Depression is 2-3 times more prevalent in hospitalized or chronically ill patients

bull Prevalence similar across cultures

bull Depression is not inevitable

Fisch 2004 Spoletini et al 2008 Krishnan et al 2002

Than in outpatient primary care where prevalence of depression is 6-14 and the lifetime incidence is 15 Prevalence is lower in studies where depression is more narrowly defined

Slide 8 What Treatments are Helpful

Four weeks later in the midst of discussing another consult the primary team updates you about your past consult indicating that over the past three weeks the patient has become depressed with increasing neurovegetative signs despite recovering physically from her treatment They returned her to a medication treatment but wonder what other modalities might be helpful for treating depression in patients with cancer

Slide 9 Psychosocial Treatments in Cancer Patients

bull Cochrane reviews find psychotherapy effective for depressive states in incurable cancer

bull Level 1 evidence for these psychosocial treatmentsndash Depression can be managed with medications plus supportive or

cognitive behavioral psychotherapyndash Psychological support plus information about upcoming procedures

relieves psychological distress

bull Overall data for efficacy of psychological interventions in reducing depressive symptoms remains equivocal

bull No data on whether combination treatment is superior in cancer patients but patients often prefer psychotherapy alone

bull Psychotherapy may improve treatment adherence or regulate the HPA axis thus modifying physical health outcomes but the evidence for this effect is equivocal or conflicting

Fisch 2004 Spoletini et al 2008 Jacobsen and Jim 2008 Akechi et al 2008

Psychotherapy was CBT supportive or problem solving therapy 6 total studies No studies used clinically diagnosed depression 3 The two largest systematic reviews have different results though no meta-analysesreviews focus on psychological interventions specifically for the endpoint of depression One reports a significant moderate effect size for reduced depressive symptoms from psychoeducation Another systematic review of psychotherapy finds only 24114

29

studies showed an advantage for the intervention on the endpoint of depression

Slide 10 Want to Learn More

Akechi T Okuyama T Onishi J Morita T Furukawa TA Psychotherapy for depression among incurable cancer patients Cochrane Database of Systematic Reviews 2008 Issue 2 Art No CD005537

Fisch M Treatment of Depression in Cancer Journal of the National Cancer Institute Monographs 32 (2004) 105-111

Jacobsen PB Jim HS Psychosocial Interventions for Anxiety and Depression in Adult Cancer Patients Achievements and Challenges CA A Cancer Journal for Clinicians 58 (2008) 214-230

Krishnan KRR et al Comorbidity of depression with other medical diseases in the elderly Society of Biological Psychiatry 52 (2002) 559-588

Roth AJ Modi R Psychiatric issues in older cancer patients Critical Reviews in OncologyHematology 48 (2003) 185-197

Spoletini I et al Depression and cancer An unexplored and unresolved emergent issue in elderly patients Critical Reviews in OncologyHematology 65 (2008) 143-155

Weinberger MI Bruce ML Roth AJ Breitbart W Nelson CJ Depression and barriers to mental health care in older patients Geriatric Psychiatry 26 (2011) 21-26

30

Appendix 3

Didactic 3 Slides

Slide 1

Resilience and Coping Resilience and Coping

with Demoralizationwith Demoralization

PsychoPsycho--oncology Curriculumoncology Curriculum

Slide 2 GoalsGoals

bullbull Identify selfIdentify self--reaction to cancerreaction to cancer

bullbull Understand concept of resilienceUnderstand concept of resilience

bullbull Identify factors in resilience in Identify factors in resilience in

cancercancer

31

Slide 3 Distress in CancerDistress in Cancer

bullbull ldquoldquoAn unpleasant emotional experience An unpleasant emotional experience

of a psychological social andor of a psychological social andor

spiritual nature which extends on a spiritual nature which extends on a

continuum from normal experiences continuum from normal experiences

of vulnerability sadness and fears to of vulnerability sadness and fears to

disabling problems such as disabling problems such as

depression anxiety panic social depression anxiety panic social

isolation and spiritual crisisisolation and spiritual crisisrdquordquo

Adopted NCCNAdopted NCCN

Slide 4 ResilienceResilience

bull ldquoResilience is the ability to maintain normal functioning despite adversity It can be viewed as the successful operation of ldquobasic human adaptational systemsrdquo

Charney Southwick 2007

Slide 5 ldquostress inoculationrdquo

bull Those who successfully managed stressful

situations in childhood including death

illness of a parent or sibling family

relocation and loss of friendshipmdashare more

resistant to adulthood stressors

Khoshaba DM Maddi SR Early experiences in hardiness development Consulting Psychology Journal Practice and Research 199951(2)106-16 Ptrsquos with abuse and

32

trauma and their confidence from the past-- DF

Slide 6 Resilience Factors in CancerResilience Factors in Cancer

bullbull Social SupportSocial Support

bullbull Spirituality and faith Spirituality and faith

bullbull SelfSelf--EfficacyInternal Locus of EfficacyInternal Locus of

ControlControl

bullbull Cognitive appraisalCognitive appraisal

bullbull Benefit findingBenefit finding

Stewart and Yuen lsquoA Systematic Review of Resilience in the Physically Illrsquo Psychosomatics 2011 52199 ndash209

Slide 7 Also Also Sense of CoherenceSense of Coherence

bull Integrates essential parts of

the stresscoping model

(comprehensibility

manageability) and of

spirituality (meaning)

Antonovsky A Health Stress and Coping San Francisco Jossey-Bass Publishers 1979

33

Slide 8 Support-- Patientrsquos words

bull ldquoI had that image of my

parentshellipstanding behind mehellipand

telling me everything would be

alrighthellipthat really gave my comfortrdquo

bull ldquo[Itrsquos important] for people to try to

understand what people are going

through I think itrsquos just as important

as the medical treatmentrdquo

Coolbrandt and Grypdonk ldquoKeeping courage during stem cell tranplantation a qualitative researchrdquo European Journal of Oncology Nursing 2010 Lipsman et al ldquoThe attitudes of brain cancer patients and their caregivers towards death and dying a qualitative study ldquo BMC Palliative Care 2007

Slide 9 Benefits of Faith

bull ldquoIrsquom not sure where Irsquom going or what Irsquom

here for But my belief is strong that I

belong here for a reason that I have

something to do and I will find it There is a

reason that Irsquom hererdquo

bull ldquoWe believe wersquore all connected and that

therersquos a reason for thisrdquo

bull ldquoThe soul never dies The body is just like

the jacket you are putting onrdquo

Parry C ldquoEmbracing uncertainty the experiences of childhood cancer survivorsrdquo Qualitative Health Research 2003 Lipsman et al ldquoThe attitudes of brain cancer patients and their caregivers towards death and dying a qualitative study ldquo BMC Palliative Care 2007

Slide 10

Internal Locus of Control and Self-Efficacy

34

Slide 11

ldquoWhen you think about it what other choice is there but to hope We have two options medically and emotionally give up or Fight Like Hellrdquo

Slide 12 Self-efficacy active coping

bull ldquoproblem-focusedrdquo (working to

solve the problem)

bull ldquoemotion-focusedrdquo (accepting

and dealing with emotions)


Slide 13 Viktor Frankl

bull We who lived in concentration camps can remember the men who walked through the huts comforting others giving away their last piece of bread They may have been few in number but they offer sufficient proof that everything can be taken from a man but one thing the last of the human freedoms - to choose ones attitude in any given set of circumstances to choose ones own way

Invented Existential Pyschotherapy

35

Slide 14 Cognitive Reappraisal

bull ldquoIt is just bronchitis as long as it isnrsquot

pneumonia you donrsquot have to worry but it is still

annoying because if it is a weaknesshellipbut at

least itrsquos curablerdquo

bull You know I donrsquot think about [relapse or another

cancer] If it happens I know it could always

happen buthellipI try not to think about ithellipI try to

keep a positive attitude about it and go for

today and worry about tomorrow when it

comesrdquo

Coolbrandt and Grypdonk ldquoKeeping courage during stem cell tranplantation a qualitative researchrdquo European Journal of Oncology Nursing 2010 Parry C ldquoEmbracing uncertainty the experiences of childhood cancer survivorsrdquo Qualitative Health Research 2003

Slide 15 Finding Benefits

bull ldquoI donrsquot think that I would have the attitude that I

have hellipI think that totally came from that

experiencehellipIrsquom so optimistic so positive and

willing to live for nowrdquo

bull ldquoTaught me how to face adversity and not feel

sorry for myself and just fight and be strong

and it just gave me a good examplerdquo

bull ldquoI can cope with this I can deal with this and in

a way thatrsquos been empowering for mehellipIrsquove

had to rise to the challengerdquo


Slide 16 Can you improve resilience and Can you improve resilience and

ldquoldquofighting spiritfighting spiritrdquordquo

ndashndash3 Studies Say Yes3 Studies Say Yes

36

Slide 17 1) 1) AntoniAntoni and Carverand Carver

Enhancing AdaptationEnhancing Adaptation

bullbull Cognitive Behavioral Stress Management Cognitive Behavioral Stress Management in Breast Cancerin Breast Cancer

ndashndash Decreased distressDecreased distress

ndashndash Decreased serum Decreased serum cortisolcortisol

ndashndash Decreased inflammatory cytokine Decreased inflammatory cytokine activityactivity

Antoni MH Lechner S Diaz A Vargas S Holley H Phillips K McGregor B Carver CS Blomberg B Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer Brain Behav Immun 23580-91 2009

Slide 18 2) 2) NezuNezu ldquoldquoProject GenesisProject Genesisrdquordquo

bullbull Benefits of problemBenefits of problem--solving focused solving focused

therapytherapy

ndashndash Improvement in wellImprovement in well--beingbeing

ndashndash Decreased distress and improved life Decreased distress and improved life

qualityquality

Nezu AM Nezu CM Felgoise SH McClure KS Houts PS Project Genesis assessing the efficacy of problem-solving therapy for distressed adult cancer patients J Consult Clin Psychol 2003 Dec71(6)1036-48

37

Slide 19 3) Cimprich Taking CHARGE

Positive feedback from participants of 6 week

Program after breast cancer -- steps

Choose a concern

Have the information

Assess the situation

Record the plan

Gain confidence

and insight

Evaluate progress

Cimprich B Janz NK Northouse L Wren PA Given B Given CW Taking CHARGE A self-management program for women following breast cancer treatment Psychooncology 2005 Sep14(9)704-17

Slide 20 Further Reading

bull Stewart and Yuen lsquoA Systematic Review of

Resilience in the Physically Illrsquo Psychosomatics

2011 52199 ndash209

bull Antoni MH Lechner S Diaz A Vargas S

Holley H Phillips K McGregor B Carver CS

Blomberg B Cognitive behavioral stress

management effects on psychosocial and

physiological adaptation in women undergoing

treatment for breast cancer Brain Behav

Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1

Countering Demoralization in Cancer

Slide 2 Definition

bull ldquoVarious degrees of helplessness confusion and subjective incompetencerdquo to adversity

bull Normal human response to overwhelming circumstances

39

Slide 3 Depression vs Demoralization

Sleep

Appetite

Energy

Suicidal Thoughts

DepressionGuiltAnhedonia

Demoralization

Slide 4 Demoralization vs Depression

bull Shorter duration

bull Reactive to family and supports

bull Specific to stressors

ndashldquoHow would you be coping if this went awayrdquo

Slide 5 Responding to

Support

40

Slide 6 Existential Challenges

Slide 7 Treatment

1) Assess the existential dilemma

2) Provide Compassion

Slide 8 Dealing with demoralizationExistential Postures of Vulnerability and

Resiliencebull Vulnerability

bull Confusion

bull Isolation

bull Despair

bull Helplessness

bull Meaninglessness

bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude

I lost my flight planndash issue of control as control for one patient From Psychosomatics 46109-116 April 2005 copy 2005 The Academy of Psychosomatic Medicine Brief Psychotherapy at the Bedside Countering Demoralization From Medical Illness James L Griffith MD and Lynne Gaby MD

41

Slide 9 DO

1) Ameliorate physical or emotional stress

2) Strengthen patients resilience to stress

Slide 10 Promoting resilience

bull Assess for prior strengths and life challenges

ndashWhat have you overcome previously like this

ndashWhat has helped in the past

ndashHow do you cope with adversity

bull Engage the family and members of the treatment team

Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12

Treatment NOT Antidepressants

Slide 13 Case 1 Depression

bull 32yo woman with recurrent lymphoma with failed bone marrow transplant She is upset that her oncologist has inadequately treated her pain and that he disagreed with her wish to stop chemotherapy She felt alone and uncared for adding ldquowhy canrsquot everyone leave me alone so I can dierdquo She was visibly confused and overwhelmed

Slide 14 Coherence vs Confusion

bull How do you make sense of what you are going through

bull How do you deal with being confused

bull To who do you turn when you feel confused

43

Slide 15 Your intervention

bull You restate patient concerns and help her make a list of priorities to discuss with her team including a consultation for a second opinion pain feeling depressed and whether to continue treatment

bull Help your patient stay focused in her meeting with her oncologist and team

bull ldquoI can think more clearly Now I have a planrdquo

Slide 16 Case 2

bull Ms E a 60-year-old woman had had neurosurgery for a brain glioma 3 days earlier Psychiatric consultation was requested for her depressed mood Her initial symptoms had begun a week earlier with incoordination and weakness in her left arm

Slide 17 Agency vs Helplessness

bull What is your list of concerns Which is firstnext

bull What helps you stand against the challenges of your illness

bull What should I know about you as a person that lies beyond your illness

44

Slide 18 Your interventions

bull Review patientrsquos coping with her own motherrsquos chronic illness ldquoWhat would she say to yourdquo (ldquoGet on with itrdquo)

bull Connect her with physical therapy and rehabilitation

Slide 19 Case 3

bull Ms F was a 35-year-old non-English-speaking Asian woman with recurrent metastatic breast cancer who had a poor prognosis for long-term survival With her husband interpreting she told about her fears that she could not bear more bad news that she could not bear the pain and that she could not face going home from the hospital

Slide 20 Courage vs Cowardice

bull Were you tempted to give up but didnrsquot

bull How did you make a decision to persevere

bull If you saw someone else make such a step despite their fear would you consider it courageous

bull Might others who witness how you cope describe you as courageous

45


bull Amplify husbandrsquos statement ldquoldquoI think she is a very courageous woman She has already been through this twice and now she may be facing it again Most people couldnrsquot do what she has donerdquo

bull Look for other opportunities to view courage or her familyrsquos witnessing of this

Slide 22 Case 4

bull Mr C was a 48-year-old man who had been admitted to the hospital 72 hours earlier because of weakness in his arm and leg After a chest X-ray and MRI of his brain however he was told ldquoYou have stage-four cancer and it has metastasized to your brainrdquo He responded that ldquoitrsquos the end of the racerdquo and he told a nurse that he was going home to shoot himself with his gun

Slide 23 Hope vs Despair

bull From what sources do you draw hope

bull On difficult days what keeps you from giving up

bull Who in your life would not be surprised to see you stay hopeful amid adversity

46


bull Assess for safety

bull Review his previous strengths as statistician in industry to bear on dealing with his prognosis ldquoWhen in your life did you learn to do this or who did you learn it fromrdquo

Slide 25 Resources

bull Griffith James L Gaby Lynne Brief Psychotherapy at the Bedside Countering Demoralization From Medical Illness Focus2010 8 143-150

bull Slavney PR Diagnosing demoralization in consultation psychiatry Psychosomatics 1999 40325ndash329

bull Clarke DM Kissane DW Demoralization its phenomenology and importance Aust N Z J Psychiatry 2002 36733ndash742

47

Appendix 5

Didactic 5 Slides

Slide 1

PsychooncPsychoonc Curriculum Curriculum

Pharmacology VignettesPharmacology Vignettes

Slide 2 Case 1Case 1

A 40yo woman with a history of estrogenA 40yo woman with a history of estrogen--receptor receptor positive breast cancer currently on positive breast cancer currently on tamoxifentamoxifen is is hospitalized for pneumonia Psych CL is hospitalized for pneumonia Psych CL is consulted for her report of two months of consulted for her report of two months of symptoms meeting criteria for major depression symptoms meeting criteria for major depression She reports her sister had good benefit and She reports her sister had good benefit and minimal side effects from minimal side effects from sertralinesertraline The The consulting psychiatrist discusses other consulting psychiatrist discusses other medication options but agrees that medication options but agrees that sertralinesertraline is is reasonable Two years later she has a reasonable Two years later she has a recurrence of her breast cancer and dies of recurrence of her breast cancer and dies of metastatic diseasemetastatic disease

The first case involves the unusual circumstance of regarding data suggesting that several common antipsychotics inhibit the metabolism of tamoxifen thereby making breast cancer recurrence more likely While there is not an absolute consensus there is enough evidence for specific recommendations

48

Slide 3 Did the psychiatrist increase her Did the psychiatrist increase her

chances of deathchances of deathTo varying degrees the To varying degrees the SSRIsSSRIs and and buproprionbuproprioninhibit 2D6 inhibit 2D6 TamoxifenTamoxifen requires 2D6 for requires 2D6 for transformation into an transformation into an activeactive metabolite metabolite

A study of 2430 patients found a significant A study of 2430 patients found a significant increase in death from breast cancer in patients increase in death from breast cancer in patients who concurrently used who concurrently used tamoxifentamoxifen and and paroxetineparoxetine(Kelly BMJ 2010 Feb 8340) The findings (Kelly BMJ 2010 Feb 8340) The findings have not been universal howeverhave not been universal however

A good review of the topic is CroninA good review of the topic is Cronin--Fenton Fenton Future Future OncolOncol 2010 6(6) 2010 6(6)

Slide 4 The Clinical Bottom LineThe Clinical Bottom Line

ParoxetineParoxetine sertralinesertraline fluoxetinefluoxetine and and bupropionbupropion are strong 2D6 inhibitors and are strong 2D6 inhibitors and for now you should avoid them in patients for now you should avoid them in patients on on tamoxifentamoxifen

CitalopramCitalopram escitalopramescitalopram venlafaxinevenlafaxine and and fluvoxaminefluvoxamine are weak 2D6 inhibitors and are weak 2D6 inhibitors and there is no current evidence that these are there is no current evidence that these are contraindicated contraindicated


A 50yo man with a history of depression A 50yo man with a history of depression spspstem cell transplant has ongoing mild stem cell transplant has ongoing mild neutropenianeutropenia and is experiencing low mood and is experiencing low mood intractable nausea poor appetite and poor intractable nausea poor appetite and poor sleep An Oncologist calls the Psych CL noting sleep An Oncologist calls the Psych CL noting he has heard that he has heard that mirtazapinemirtazapine might help this might help this patientpatientrsquorsquos sleep appetite and nausea However s sleep appetite and nausea However he is worried about the propensity of psych he is worried about the propensity of psych meds to cause marrow suppression meds to cause marrow suppression

The second case addresses our use of mirtazapine for depressionnauseaappetite stimulationsleep In truth there are better hypnotics and better anti-emetics than mirtazapine The unusual bone marrow suppression associated with mirtazapine (perhaps in the range of Clozaril) should be a bit alarming One could still justify mirtazapinersquos use if for example the intractable nausea outweighed the marrow suppression risk

49

Slide 6 Can we allay the concerns about Can we allay the concerns about

mirtazapinemirtazapine

Though so rare that a true incidence is not Though so rare that a true incidence is not known blood known blood dyscrasiasdyscrasias have been have been reported in reported in tricyclicstricyclics phenelzinephenelzine trazodonetrazodone venlafaxinevenlafaxine and and mirtazapinemirtazapine

MirtazapineMirtazapine works centrally to increase works centrally to increase gastric motility and has been used gastric motility and has been used successfully for refractory nausea during successfully for refractory nausea during cancer treatment The literature suggests a cancer treatment The literature suggests a 002002--19 incidence of bone marrow 19 incidence of bone marrow toxicity with this toxicity with this mirtazapinemirtazapine

Slide 7 Are antipsychotics toxic to bone Are antipsychotics toxic to bone

marrowmarrow

Blood Blood dyscrasiasdyscrasias have been reported with have been reported with every typical and atypical antipsychotic every typical and atypical antipsychotic though though clozarilclozaril is by far the most notorious is by far the most notorious (risk of (risk of neutropenianeutropenia and and agranulocytosisagranulocytosis is is 3 and 08 respectively) with 3 and 08 respectively) with phenothiazinesphenothiazines coming in a distant second coming in a distant second (risk of (risk of agranulocytosisagranulocytosis 013) 013)

Flanagan Flanagan Hum Hum PsychopharmPsychopharm ClinClin ExpExp 2008 has more info 2008 has more info

Slide 8 Clinical Bottom LineClinical Bottom Line

Oncology inpatients are so physically ill in Oncology inpatients are so physically ill in general that we tend to show even more general that we tend to show even more restraint than normal about using restraint than normal about using psychotropicspsychotropics We try hard to employ nonWe try hard to employ non--pharmacologic pharmacologic interventions reserving meds for patients whose interventions reserving meds for patients whose symptoms are causing clear harm symptoms are causing clear harm

For more reading on hematologic toxicity from For more reading on hematologic toxicity from psychotropicspsychotropics see Flanagan Human see Flanagan Human Psychopharmacology 2008 23 27Psychopharmacology 2008 23 27--4141

50


A 60yo woman with 2 months of mild depression A 60yo woman with 2 months of mild depression

currently on currently on citalopramcitalopram is now 15 days is now 15 days spsp stem stem

cell transplant She is experiencing significant cell transplant She is experiencing significant

fatigue beyond what is expected by the fatigue beyond what is expected by the

Oncologist and is not able to muster the effort to Oncologist and is not able to muster the effort to

work with PT and OT Oncology calls Psych CL work with PT and OT Oncology calls Psych CL

worried that her low energy is going to lead to worried that her low energy is going to lead to

prolonged hospitalization and medical prolonged hospitalization and medical

complications They would like to put her on complications They would like to put her on

methylphenidate for her depression and energymethylphenidate for her depression and energy

The third case addresses the use of methylphenidate for depression and cancer-related fatigue This comes up during consults on Rehab Medicine as well You might convey how the quick results and short half-life of methylphenidate make it an easy trial in appropriate cases Residents have often heard that it is an appetite suppressant though our clinical experience is that lethargic patients may be too tired to eat and that methylphenidate can actually improve caloric intake Provigil has also been used in many types of medical fatigue and information on this can be found in Jean-Pierre Cancer 2010

Slide 10 What is the evidence for methylphenidate in What is the evidence for methylphenidate in

depression and fatiguedepression and fatigue

For depression in otherwise healthy adults there For depression in otherwise healthy adults there is some evidence that at least in the short term is some evidence that at least in the short term psychostimulantspsychostimulants have a statistical benefit though have a statistical benefit though not a clear clinical benefit (Candy Cochrane not a clear clinical benefit (Candy Cochrane Database 2008) Database 2008)

In cancerIn cancer--related fatigue methylphenidate showed related fatigue methylphenidate showed a small but statistically significant benefit (Minton a small but statistically significant benefit (Minton Cochrane Database 2008) Cochrane Database 2008)

In terminally ill patients there is no clear data to In terminally ill patients there is no clear data to suggest benefit but in a palliative care model suggest benefit but in a palliative care model sometimes we try anyway (Hardy Am J sometimes we try anyway (Hardy Am J GeriatrGeriatrPharmacotherPharmacother 2009 Feb7(1)) 2009 Feb7(1))

51


A 25yo man currently on A 25yo man currently on citalopramcitalopram for for depression is undergoing induction depression is undergoing induction chemotherapy for a stemchemotherapy for a stem--cell transplant cell transplant He develops oral He develops oral mucositismucositis to the point to the point that while he can still take sips of water that while he can still take sips of water he cannot swallow tablets or capsules he cannot swallow tablets or capsules Oncology calls Psych CL noting that Oncology calls Psych CL noting that while all of his other meds have been while all of his other meds have been switched to IV there do not appear to be switched to IV there do not appear to be any IV antidepressants any IV antidepressants

The mucositis during chemo induction is something that residents may only see at UWMC but using Prozac for SSRI withdrawal is a good trick for other situations too

Slide 12 How do we manage antidepressant How do we manage antidepressant

drug delivery during oral drug delivery during oral mucositismucositis MucositisMucositis usually lasts less than a week though usually lasts less than a week though the absence of antidepressants could have a the absence of antidepressants could have a clinical impact or result in SSRI withdrawalclinical impact or result in SSRI withdrawal

See if the patient can tolerate a liquid form of See if the patient can tolerate a liquid form of their antidepressant (their antidepressant (egcitalopramegcitalopram 10mg5mL) 10mg5mL) Unfortunately there is no data on how GI Unfortunately there is no data on how GI mucositismucositis impacts liquid SSRI absorptionimpacts liquid SSRI absorption

If SSRI delivery seems unpredictable and the If SSRI delivery seems unpredictable and the patient has significant SSRI withdrawal you patient has significant SSRI withdrawal you could consider switching to liquid could consider switching to liquid fluoxetinefluoxetine BenazziBenazzi IntInt J J NeuropsychopharmacologyNeuropsychopharmacology 2008 Aug11(5)725 2008 Aug11(5)725--66

52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology

Neuropsychiatric symptoms

caused by cancers and their

treatments

Slide 2

What about the Brain

53

Slide 3 CASE 1

A 73 year old male with no psychiatric history

has metastatic prostate cancer He received

a pulse of high dose prednisone (up to 80mg

a day) as an outpatient Over the last week

he has not been himself He is sleeping less

than 2 hours a night and has been doing

multiple projects around the house including

re-roofing his home

Slide 4

Wife tried to get him to come into the clinic but he got very angry and refused He became verbally aggressive and frightened his wife She called the police and he was brought to the ED

In the ED he had pressured speech grandiosity and was intensely angry refusing care He required restraints and was admitted to the Heme-onc service

Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54

Slide 6 Steroid Induced Symptoms

Incidence 2-71

5-10 incidence of major sx on high doses

Psychiatric history isnrsquot a predictor

Past steroid induced symptoms donrsquot predict

subsequent reactions (Kershner amp Wang-Cheng)

Past LACK of steroid induced symptoms are

not predicative of future symptoms (Stiefel

Breitbart Holland)

Incidental findings ndash psych sx not specifically monitored ndash those that do ndash higher incidence

Slide 7 Risk Factors

High doses higher incidence of severe AE

Dose does not predict onset duration or type

of symptoms

Hypoalbuminemia

Slide 8 What can steroids cause

Anxiety

Depression (more likely in chronic use)

Hypomania (most common)

Mania (more likely with high dose pulse)

Psychosis

Delirium (more likely in CA patients)

Cognitive Impairment

Cognitive ndash even at low doses with low co-morbidities folks show poor declarative verbal memory Profound dementia found as well Usually reversible

55

Slide 9 Management of Steroid Induced

Sx

Benzodiazepines (anxiety mania)

Antipsychotics (mania psychosis delirium)

Mood stabilizers (mania)

Avoid TCArsquos

Reduce and DC steroids when

possible

TCArsquos have been shown to worsen sx if needed use ssri but data isnrsquot good about antidepressants so avoid (Brown J Clin Psych) Severe psychiatric sx are rare in doses lt 40mg a d (13) at doses gt80mgd it is 184 (Boston Collaborative Drug Surveillance Prg Clin Pharmacol Ther 1972 13694-698 looked at 667 pay put on steroids with not prior psych hx

Slide 10 Steroid References

1 Kenna HA Poon AW de los Angeles CP Koran LM Psychiatric complications of treatment with corticosteroids review with case report Psychiatry Clin Neurosci 2011 Oct65(6)549-60

2 Warrington TP Bostwick JM Psychiatric adverse effects of corticosteroids Mayo Clin Proc 2006 Oct81(10)1361-7

3 Wada K Yamada N Sato T Suzuki H Miki M Lee y Akiyama K Kuroda S Corticosteroid-induced psychotic and mood disorders diagnosis defined by DSM-IV and clinical pictures Psychosomatics 2001 Nov-Dec42(6)461-6

4 Stiefel FC Breitbart WS Holland JC Corticosteroids in cancer neuropsychiatric complications Cancer Invest 19897479-491

Slide 11 CASE 2

48 year old woman is sp

BMT for recurrent AML

and is on

immunomodulation

therapy She begins

having headaches and

then becomes more

confused with visual

loss

Tacrolimus

56

Slide 12 Posterior reversible encephalopathy

syndrome (PRES)

CT and MR lesions involving the occipital and parietal regions VASOGENIC EDEMA Less often fronto-parietalinferior temporo-occipital junction MR low SI on T1-weighted images FLAIR most sensitive sequence for cortical and subcortical lesions

Slide 13 PRES

Rare complication of immunosuppressive therapy (tacrolimus and cyclosporine)

Also seen in eclampsia TTP AIPorphyria

Possibly related to vascular dysregulation

Findings on MRI

Relatively dire prognosis

Also seen with hypertensive encephalaptathy - eclampsia

Slide 14 Presenting symptoms

Seizures-- 87

Encephalopathy-- 92

Headache-- 53

Visual Symptoms-- 39

Lee et al 2009

TX treat hypertension seizures (phenytoin- Mag and delirvery in eclampsia) lower agent or switch Higher risk of developing PRES with chemo fluid overload BP gt 25 of base line Cr gt18

57

Slide 15 PRES References

1 Hinchey J Chaves C Appignani B Breen J Pao L Wang A Pressin MS Lamy C Mas JL Caplan LR A reversible posterior leukoencophalopathy syndrome N Engl J Med 1996 334494-500

2 Aranas RM Prabhakaran S Lee VH Posterior reversible encophalopathy syndrome associated with hemorrhage Neurocrit Care 2009 10(3)306-12

3 Ni J Zhou LX Hao HL Liu Q Yao M Li ML Peng B Cui LY The clinical and radiological spectrum of posterior reversible encephalopathy syndrome a retrospective series of 24 patients J Neuroimaging 2011 Jul21(3)219-24

Slide 16 Neurotoxicity of Chemotherapy

(just to name a fewhellip)

Encephalopathyseizure

Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-

fluorouracillevamisole

Methotrexate IT (can be

delayed years)

Purine analogs

Dropcho Neurological Complications of Cancer Seminars in Neurology 244 2004

Slide 17

Now we know tx is no cake walk--- what can Cancer itself dohellip

58

Slide 18 CASE 3

23 year-old woman presents to the ER initially for severe headache and malaise felt to be related to a viral illness Over the next several days she developed odd behaviors including laughing inappropriately talking to herself and having hallucinations

She re-presents to the ER for a psychiatric evaluation and has a seizure and severe autonomic instability She is intubated and admitted to the ICU

Slide 19

Slide 20 Paraneoplastic Syndrome

What are the symptoms

What cancers are associated

How do we differentiate from psychiatric conditions

How do we treat

59

Slide 21 Symptoms of Paraneoplastic

Syndrome

Limbic Encephalitis is one of the most

common manifestiations of PNS

Mimics delirium

Behavioralmood disturbance

Irritability depression

Hallucinations

Personality disturbacnes

Cognitive changesKayser et al Am J Psychiatry 2010 1671039-1050

Foster et al Psychosomatics 502 March-April 2009

PLE usually considered when Delirium is atypical (not responding to neuroleptics sx of sze eye motility dysfunction hypventilation) or with no clear other cause (metabolic infectious intracranial process)

Slide 22 Associated Cancers

Thymomas (20)

Small Cell Lung Cancer (3-5)

Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010

Prevelance of Paraneoplastic syndroms are in ( ) Kayser 2010

Slide 23 Treatment

Treat underlying cancer

Immunotherapy

Methylprednisolone

Plasmapheresis andor

IVIGhellipif poor response consider

Cyclophosphamide or Rituximab

Psychiatric medications

ECTKayser et al Am J Psychiatry 2010 1671039-1050


60

Slide 24 Paraneoplastic References

1 Kayser MS Kohler CG Dalmau J

Psychiatric manifestations of paraneoplastic

disorders Am J Psychiatry 20101671039-

1050

2 Foster AR Caplan JP Paraneoplastic

limbic encephalitis Psychosomatics

200950108-113

Slide 25 Objectives

1 Identify neuropsychiatric effects associated

with chemotherapy agents

2 Identify neuropsychiatric sequelae of PRES

as well as list causes of PRES

3 List symptoms of paraneoplastic syndrome

cancers associated with paraneoplastic

syndromes and differentiate these

symptoms from a primary psychiatric illness

61

Appendix 7

Needs Assessment Survey Questions

Question 1 Question 1 What is your current year of training

R1

R2

R3

R4

Fellow

Question 2 Question 2

Outside of on-the-fly discussions have you gotten any psycho-oncology training

during residency

Yes

No


If you answered yes to Question 2 could you briefly describe your previous

training to us

Question 4 Question 4 How would you rate your understanding of the expected medical course and side

effects of stem cell transplantation

poor

decent

great

Question 5 Question 5 How would you rate your understanding of the psychological challenges of stem

cell transplant (or cancer and its treatment)

poor

decent

great

Question 6

62

Question 6 How would you rate your understanding of psychopharmacology issues (psych side

effects of cancer meds drug interactions drug delivery variability) during cancer

treatment

poor

decent

great

Question 7 Question 7 How would you rate your comfort and skill in treating demoralization with at-the-

bedside psychotherapy

poor

decent

great

Question 8 Question 8 Beyond the previous four ideas are there other psycho-oncology topics that you

would like us to address Where do you perceive the deficiencies (skills knowledge

attitudes etc) in your current psycho-oncology CL training

Question 9 Question 9 Given how full your lecture schedule already is our best idea so far is to develop a

short series of mini-didactics (20 minutes) that we would deliver during rounds

on the R2 CL rotation What do you think

Thats great

Im skeptical


If you answered Im skeptical above

Skeptical Hey man who do you think you are We put a lot of thought into this

Why all the hatin

Seriously thoughwould you prefer something different Different teaching style Different setting

63

Appendix 8

Needs Assessment Results for Quantitative Questions

Calculated using numeric values

Total submissions 36

Multiple choice - one answer (menu) Question What is your current year of training

Total responses (N) 36 Did not respond 0 Numeric value Answer Frequency Percentage

1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111

Multiple choice - one answer (button) Question Outside of on-the-fly discussions have you gotten any psycho-oncology training

during residency Total responses (N) 36 Did not respond 0

Numeric value Answer Frequency Percentage

1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038

Multiple choice - one answer (button) Question How would you rate your understanding of the expected medical course and side

effects of stem cell transplantation Total responses (N) 36 Did not respond 0


1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049

Multiple choice - one answer (button) Question How would you rate your understanding of the psychological challenges of stem cell

transplant (or cancer and its treatment) Total responses (N) 36 Did not respond 0


1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65

Multiple choice - one answer (button) Question How would you rate your understanding of psychopharmacology issues (psych side


treatment Total responses (N) 36 Did not respond 0


1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035

Multiple choice - one answer (button) Question How would you rate your comfort and skill in treating demoralization with at-the-

bedside psychotherapy Total responses (N) 36 Did not respond 0


1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052

Multiple choice - one answer (button) Question Given how full your lecture schedule already is our best idea so far is to develop a

short series of mini-didactics (20 minutes) that we would deliver during rounds on

the R2 CL rotation What do you think

66


1 Thats great 34 9444

2 Im skeptical 2 556

Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

2

Table of Contents

Introduction and Problem Identificationhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 3

Needs Assessment Methods and Results Summary 3

Goals and Objectiveshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4

Educational Strategies and Objective Measurementhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 4


Didactic 1 Medical Overview of Stem Cell Transplantationhelliphellip 6

Didactic 2 Cancer and Depressionhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 8

Didactic 3 Resiliencehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 10

Didactic 4 At-The-Bedside Supportive Psychotherapy of Demoalizationhellip 11

Didactic 5 Common Psychopharmacology Dilemmashelliphelliphelliphelliphelliphelliphelliphellip 12

Didactic 6 Neuropsychiatric Sequelae of Cancer Medicationshelliphelliphelliphelliphellip 14

Appendix

1 Didactic 1 Powerpoint Slides and Poster Imagehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 16






7 Needs Assessment Survey Questionshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip 63

8 Needs Assessment Survey Results for Quantitative Questionshelliphelliphelliphelliphellip 65

3
























Needs Assessment






manageable












4


didactics






















psychopharmacology




oncology inpatients










5













6







Objectives





Overview





more detail below






Myeloablation



Stem Cell Infusion



Engraftment















7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

3
























Needs Assessment






manageable












4


didactics






















psychopharmacology




oncology inpatients










5













6







Objectives





Overview





more detail below






Myeloablation



Stem Cell Infusion



Engraftment















7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

4


didactics






















psychopharmacology




oncology inpatients










5













6







Objectives





Overview





more detail below






Myeloablation



Stem Cell Infusion



Engraftment















7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

5













6







Objectives





Overview





more detail below






Myeloablation



Stem Cell Infusion



Engraftment















7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

6







Objectives





Overview





more detail below






Myeloablation



Stem Cell Infusion



Engraftment















7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

7

References


Cancer 2009 Oct 1115(19)4625-35



Websites


transplant


1


8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

8







to learn more

Objectives






suicidality



symptoms



Case


















9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

9




References



16(2)CD005537


11



Aug58(4)214-30






2004 Nov48(2)185-97






10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

10









Objectives


cancer diagnoses









rotations


Appendix 3

References



















11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

11






















Objectives


demoralization









Appendix 4

References





12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

12








Objectives










of mirtazapine

Case 1





Case 2







Case 3









13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

13

Case 4



References

Case 1






2010 Jun6(6)877-80

Case 2



Case 3








Case 4



14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

14











clinical vignettes




Objectives






Case 1







Case 2







neurotoxicity

Case 3




15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

15





References

Case 1



Oct65(6)549-60


Proc 2006 Oct81(10)1361-7






Case 2



1996 334494-500






Case 3




113

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

16

Appendix 1

Didactic 1 Slides

Slide 1

STEM CELL

TRANSPLANTATION



Amyloidosis




Hodgkins Disease

Acute Leukemias




Multiple Myeloma

Osteopetrosis


Solid Tumors


17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

17





Goal




effect






Autologous self






VERY different

hESC



cultured


years



18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

18







Goal





Myeloablation





RadiationTotal Body

Tomotherapy


19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

19





Goal









Apheresis

4-6 hours



Central line



Infusion

1-5 hours


Premedications




taste SOB


20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

20

Slide 12






Goal





Engraftment




full BM function



T cell depletion



21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

21





Goal









Liver

Intestine









22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

22



Steroids

Tacrolimus


Methotrexate






Delirium

Mania



Infections delirium

Anemia Anxiety


bull Anxiety



Anxiety

DeathDying


23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

23

Slide 20 REFERENCES



857-859 doi103324haematol2010023184



35

Websites




ncerStemCellspage1

Mayo clinic - video


24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

24

Appendix 2

Didactic 2 Slides

Slide 1





25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

25








26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

26













27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

27




28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

28



















29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

29










30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

30

Appendix 3

Didactic 3 Slides

Slide 1




Slide 2 GoalsGoals




cancercancer

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

31





















32






ControlControl







(comprehensibility




33






















Slide 10


34

Slide 11




solve the problem)







35











comesrdquo

















36










therapytherapy



qualityquality


37




Choose a concern



Record the plan

Gain confidence

and insight

Evaluate progress





2011 52199 ndash209







Immun 23580-91 2009

38

Appendix 4

Didactic 4 Slides

Slide 1


Slide 2 Definition



39


Sleep

Appetite

Energy

Suicidal Thoughts


Demoralization







Support

40


Slide 7 Treatment





bull Confusion

bull Isolation

bull Despair

bull Helplessness


bull Cowardice

bull Resentment

bull Resilience

bull Coherence

bull Communion

bull Hope

bull Agency

bull Purpose

bull Courage

bull Gratitude


41

Slide 9 DO









Slide 11 Provide

Witnessing

Validating

Normalizing

42

Slide 12








43





Slide 16 Case 2






44




Slide 19 Case 3







45




Slide 22 Case 4






46




Slide 25 Resources




47

Appendix 5

Didactic 5 Slides

Slide 1






48











49






marrowmarrow






50


















51








52

Appendix 6

Didactic 6 Slides

Slide 1

Psychooncology



treatments

Slide 2


53

Slide 3 CASE 1








re-roofing his home

Slide 4



Slide 5 Steroids

What can steroids

cause

Does dose matter

How do we manage

symptoms

54


Incidence 2-71







Breitbart Holland)





of symptoms

Hypoalbuminemia


Anxiety




Psychosis




55


Sx




Avoid TCArsquos


possible







Slide 11 CASE 2



and is on

immunomodulation

therapy She begins


then becomes more


loss

Tacrolimus

56


syndrome (PRES)


Slide 13 PRES




Findings on MRI




Seizures-- 87

Encephalopathy-- 92

Headache-- 53


Lee et al 2009


57








Cisplatin IV

Cytarabine (araC)

Eoposide

Interleukin-2

Paclitaxel

ThioTEPA

Leukoencephalopathy

Carmustine (BCNU)

5-



delayed years)

Purine analogs


Slide 17


58

Slide 18 CASE 3



Slide 19





How do we treat

59


Syndrome



Mimics delirium



Hallucinations






Thymomas (20)


Ovarian (1)

Breast (1)

Testicular Cancer

Prostate

Neuroblastoma

Rhabdosarcoma

And more

Kayser 2010


Slide 23 Treatment


Immunotherapy

Methylprednisolone







60





1050



200950108-113

Slide 25 Objectives









61

Appendix 7



R1

R2

R3

R4

Fellow



during residency

Yes

No



training to us



poor

decent

great



poor

decent

great

Question 6

62



treatment

poor

decent

great



poor

decent

great







Thats great

Im skeptical




Why all the hatin


63

Appendix 8






1 R1 8 2222

2 R2 12 3333

3 R3 7 1944

4 R4 9 2500

5 Fellow 0 000

Response statistics

Mean 247

Median 200

Mode 2

MinMax 14

Standard deviation

111




1 Yes 6 1667

2 No 30 8333

Response statistics

Mean 183

Median 200

Mode 2

MinMax 12

64

Standard deviation

038




1 poor 23 6389

2 decent 13 3611

3 great 0 000

Response statistics

Mean 136

Median 100

Mode 1

MinMax 12

Standard deviation

049




1 poor 19 5278

2 decent 17 4722

3 great 0 000

Response statistics

Mean 147

Median 100

Mode 1

MinMax 12

Standard deviation

051

65





1 poor 31 8611

2 decent 5 1389

3 great 0 000

Response statistics

Mean 114

Median 100

Mode 1

MinMax 12

Standard deviation

035




1 poor 12 3333

2 decent 23 6389

3 great 1 278

Response statistics

Mean 169

Median 200

Mode 2

MinMax 13

Standard deviation

052




66




Response statistics

Mean 106

Median 100

Mode 1

MinMax 12

Standard deviation

023

Documents

A Curriculum for Psychiatry R2s - Psychiatry Residency - University