Thursday, June 30, 2005
One wonders why this was even published...
Acupuncture for the relief of cancer-related pain – a systematic review
This systematic review summarises the existing evidence on acupuncture for cancer-related pain.
Literature searches were conducted in seven databases. All clinical studies of acupuncture, electroacupuncture and ear acupuncture in cancer patients with the main outcome measure of pain were included. Data were extracted according to pre-defined criteria by two independent reviewers and methodological quality was assessed using the Jadad scale.
Of the seven studies included, one high quality randomised clinical trial of ear acupuncture showed statistically significant pain relief in comparison with placebo ear acupuncture. All the other studies were either non-blinded (n = 2) or uncontrolled clinical trials (n = 4). Most investigations suffered from methodological flaws such as inadequate study design, poor reporting of results, small sample size and overestimation of the results.
The notion that acupuncture may be an effective analgesic adjunctive method for cancer patients is not supported by the data currently available from the majority of rigorous clinical trials. Because of its widespread acceptance, appropriately powered RCTs are needed.
Thursday, June 30, 2005 by Drew Rosielle MD ·
Wednesday, June 29, 2005
The Journal of the National Cancer Institute has a randomized controlled trial of short course vs long course radiotherapy for painful bony mets . A single 8 Gy therapy is compared to 30 Gy over 10 treatment fractions. Both were found to be equally efficacious with more toxicity in the 30 Gy arm but with more need for retreatment in the 8 Gy arm (18% vs 9%). This is not the first trial to conclude that they are, by some measures, equivalent; nevertheless apparently short course is not being widely adopted. It seems, however, that if short course therapy becomes commonplace it will further its use in the hospice (& not only palliative) setting as it will be cheaper, easier, and more accessible to hospice patients.
Wednesday, June 29, 2005 by Drew Rosielle MD ·
July's Academic Medicine devotes most of its issue to palliative care education for physicians, residents, and medical students. Among the many articles are reviews of Pittsburgh's CEX palliative care training program for residents, Harvard's PCEP for training faculty in palliative care, a review of the literature regarding residents and end of life care (their attitudes, frustrations, training etc.), and some qualitative articles about med students and physicians experiences with patients' deaths. There is way to much to bother trying to summarize but I'll note that this issue presents good evidence that palliative care training does make an impact, and that, despite very much being part of the 'art of medicine,' EOL communication skills can be effectively taught.
by Drew Rosielle MD ·
Tuesday, June 28, 2005
Journal of the American Geriatrics Society has just released a supplement on insomnia in the elderly from a symposium about the same. It includes overviews of the current research, adverse effects of insomnia, as well as its diagnosis and treatment. Three promising new agents indiplon, eszopiclone, and ramelteon (formerly TAK-375) are discussed.
Tuesday, June 28, 2005 by Drew Rosielle MD ·
Monday, June 27, 2005
Sunday's Palm Beach Post has an (unfortunately) short article about providing services to Hispanic patients. Abriendo Puertas was created in 2002 with a $494,000 grant from the Robert Wood Johnson Foundation. The money was used to create a model program designed to reach out to the growing Hispanic community in Palm Beach and Broward counties. The program required local matching funds. The Quantum Foundation pledged $300,000 and the Allegany Franciscan Foundation of Palm Beach County provided $100,000.
The program provides not only care but bereavement counseling and other services a family might need, such as helping with long-distance communication or sending remains back to a home country.
"Hospices are starting to recognize it isn't enough to say we want to serve these people," said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization. "They are recognizing that care providers need to reflect the faces of the communities they want to serve."
As the three-year grant comes to an end next month, Hospice by the Sea has seen its Hispanic patient population grow from 1.5 percent to 8 percent and has become a model for the rest of the country.
Nationwide, about 4 percent of the hospice population is Hispanic, according to the national organization. In 2003, an estimated 950,000 terminally ill patients used hospice services in the United States.
Abriendo Puertas was created in 2002 with a $494,000 grant from the Robert Wood Johnson Foundation. The money was used to create a model program designed to reach out to the growing Hispanic community in Palm Beach and Broward counties. The program required local matching funds. The Quantum Foundation pledged $300,000 and the Allegany Franciscan Foundation of Palm Beach County provided $100,000.
Monday, June 27, 2005 by Drew Rosielle MD ·
Friday, June 24, 2005
This month's Lancet Oncology has a critical review of radionucleotides for bone cancer. As usual the the methodologies used in the reviewed papers are too diverse to allow for any aggregation of data, but radionucleotides appear quite effective. In my brief career I've never seen these used, and the authors note their use is now coming back into favor. This is the article's summary:
Strontium-89 and samarium-153 are radioisotopes that are approved in the USA and Europe for the palliation of pain from metastatic bone cancer, whereas rhenium-186 and rhenium-188 are investigational. Radioisotopes are effective in providing pain relief with response rates of between 40% and 95%. Pain relief starts 1–4 weeks after the initiation of treatment, continues for up to 18 months, and is associated with a reduction in analgesic use in many patients. Thrombocytopenia and neutropenia are the most common toxic effects, but they are generally mild and reversible. Repeat doses are effective in providing pain relief in many patients. The effectiveness of radioisotopes can be greater when they are combined with chemotherapeutic agents such as cisplatin. Some studies with 89Sr and 153 Sm indicate a reduction of hot spots on bone scans in up to 70% of patients, and suggest a possible tumoricidal action. Further studies are needed to address the questions of which isotope to use, what dose and schedule to use, and which patients will respond.
Friday, June 24, 2005 by Drew Rosielle MD ·
This month's Chest has a retrospective study of cryosurgery for
unresectable endobronchial lung cancer showing it improves cough,
dyspnea, hemoptysis, and Karnofsky scores. This was a "before-after"
analysis with no controls. Interestingly, there was a slight
mortality benefit for those who received more than one 'surgery,'
raising the possibility that this may also be a life-prolonging
palliative intervention. Clearly the exact role of this promising
therapy warrants more study, but this article is encouraging.
by Drew Rosielle MD ·
Wednesday, June 22, 2005
I learned a new word today: alexithymia, the inability to accurately describe one's feelings (and, by extension, one's symptoms). PubMed finds 8203 citations for it as a search term. This month's Pain Medicine (whose full-text I don't have access to) has an article probing whether alexithymia may partially explain differences in pain reporting amongst different racial and social groups. Answer (per the abstract): "maybe." Nevertheless this is a phenomena that we all encounter and struggle with in our patients, and it's nice to see it has such an important sounding name. I'll never forget the patient whose chief complaint was that she was having "total body shutting down spells." I've yet to decide whether this was full blown alexithymia or actually a precise descritption of what she was experiencing.
Wednesday, June 22, 2005 by Drew Rosielle MD ·
This week's JAMA (JAMA's website, I'll add, has had very spotty service this week) has a metaanalysis on the use of opioids for neuropathic pain. It concludes:
Short-term trials yielded mixed results with respect to the analgesic efficacy of opioids. Intermediate-term trials demonstrated consistent opioid analgesic efficacy in reducing spontaneous neuropathic pain that was statistically significant when their results were pooled.
Doses used were, not surprisingly, widely divergent, but were overall low to moderate doses of long acting opioids (appx. <80mg/day of long acting oxycode, <80mg/day of methadone, up to 300mg/day of long acting morphine). Reported side effects were as expected. When I was in medical school--not too long ago--we were still being taught that opioids were ineffective for neuropathic pain, which by now seems quite ridiculous. Clearly they are a second line choice behind TCAs/anticonvulsants and nonopioid analgesics, but hopefully this article will end any remaining controversy over whether they have a role at all.
by Drew Rosielle MD ·
Monday, June 20, 2005
Monday, June 20, 2005 by Drew Rosielle MD ·
Saturday, June 18, 2005
Annals of Oncology this month publishes Communicating prognosis in cancer care: a systematic review of the literature (Annals of Oncology 2005 16(7):1005-1053). Due to the obvious heterogeneity of the literature on communicating prognosis this is really more of a critical overview than a systematic review (let alone metaanalysis). Their conclusions are general, and perhaps can be summarized as 'every patient's preferences are different.' What is really useful about this article though are the 39 (!) pages of tables which contain concise summaries of dozens and dozens of published articles on communicating prognosis. If you're looking for an article on communicating prognosis, starting here may save you a lot of time.
Saturday, June 18, 2005 by Drew Rosielle MD ·
Happily, much of the media fallout from the Schiavo autopsy has been positive & reasonable. Two of my favorite articles from the last week are:
At Schiavo's Hospice, a Return to Routine in today's Washington Post paints a very positive picture of the hospice where she died. Mostly it is a description of what actually occurs there, on a day to day basis, with a little bit about what the hospice workers called 'The Siege.'
Slate.com has another great piece this week, this time by William Saletan, about the autopsy. Mostly it is about the infamous videos released by the Schindlers, and how they were used to deceive an ignorant public (...& Senate Majority Leader). Saletan reports there are journalists who have seen the full (unreleased) videos made by Terri Schiavo's parents and claims it confirms what all people of reason knew all along. "It's largely a wasteland," showing an unresponsive, vegetative young woman being harangued by her parents to open her eyes, smile, etc. He concludes about the Schindlers, "This is what happens when you deny reality. First you lose your senses, then your mind, then your soul."
by Drew Rosielle MD ·
Thursday, June 16, 2005
Thursday, June 16, 2005 by Drew Rosielle MD ·
drosielle (at) gmail (dot) com
Founded Pallimed in June 2005 before beginning his Palliative Care Fellowship at the Medical College of Wisconsin. I will let him fill in more here since he is a pretty modest guy.
Ok, fine.... I'm an assistant professor of medicine at the Medical College of Wisconsin, where, by some strange dispensation, I'm allowed to practice palliative care full-time. I am the clinical director of MCW's palliative care center. I'm more or less from the Midwest. I studied English and Religion at the University of Iowa as an undergraduate, did medical school at the University of Minnesota, internal medicine residency in Denver (University of Colorado), palliative fellowship at MCW. I have two young boys and a wife and they have me in return. I'm mostly interested in the translation of clinical research into clinical practice--often fancifully known as Evidence-Based Medicine--even when to use the term "evidence" is a stretch of the imagination. I edit Fast Facts, probably the world's largest & best resource of free (and sometimes even evidence-based) palliative care knowledge, wisdom, and know-how. Email me if you have ideas for Fast Facts or are interested in writing one.
ctsinclair (at) gmail (dot) com
~Medical Director, Palliative Care Team, Providence Medical Center, Kansas City, KS
I pleaded with Drew to join Pallimed as a co-editor in November of 2005 after being addicted to reading the blog daily. I thought I could take some of the load off of Drew in posting, but Drew still outposts me 4:1 at least! I did my fellowship at the Hospice & Palliative CareCenter of Winston-Salem, NC after completing a internal medicine residency at Wake Forest University Baptist Medical Center. I did my undergraduate and medical school studies at the University of California, San Diego. I have particular interests in the following topics and have given national and regional talks on some of them: Prognostication, fellowships and education, methadone & opioid rotation for pain control, ethics, subcutaneous infusions, social media. I was elected to the AAHPM Board of Directors in 2009.
lypafe (at) gmail (dot) com
tquinn152 (at) gmail (dot) com
Pallimed has a comment function (at the bottom of each post) that allows you to give us feedback on each post. Tell us your opinions and thoughts. This can be a great community for discussion but you may get bored if it is only Drew and I discussing back and forth. You can even add comments anonymously, especially if you want to say something controversial. Even something as pithy as 'great post' or 'what are you talking about?' helps us to keep working at the blog day in and day out for you.
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Also feel free to email Drew (drosielle at gmail dot com) or Christian (ctsinclair at gmail dot com) to let us know about things we may have missed but should blog about, or to give us general feedback on the site.
(Last updated December 21, 2009)
by Drew Rosielle MD ·
Wednesday, June 15, 2005
#1) This month's issue of Palliative Medicine contains an article by Julie Robinson & colleagues from Australia about an empirically derived screening algorithm for depression in the (in- & outpatient) hospice setting. They found it to be more sensitive & specific than the standard 2 question depression screen ("During the past two weeks have you often been bothered by feeling down, depressed or without hope?" & "During the past two weeks have you often been bothered by a lack of interest or pleasure in doing things?") that is used commonly in the primary care setting. It is a simple algorithm that could, for instance, be performed by a hospice nurse during an intake visit. The article's appendix has a graphic of the algorithm that could be directly printed & used as a screening tool. If anyone wants to algorithm I can email it on an individual basis. It doesn't seem to be listed in PubMed yet, here is the Ingenta link & citation:
AU: Robinson, Julie A.; Crawford, Gregory B.
JN: Palliative Medicine
PD: June 2005
Click on the URL to access the article or to link to other issues of the publication.
#2) According to the AAHPM's website, the ABIM has formally endorsed subspecialty status for Palliative Medicine & 2007 may be year zero of official recognition...
A Quote: In June 2005, the Board of Directors of the American Board of Internal Medicine (ABIM) agreed to begin the formal process of gaining permission from the American Board of Medical Specialties (ABMS) to offer a subspecialty certificate in Hospice and Palliative Medicine. Their next steps are to submit a letter of intent and then a formal application to ABMS. After consideration of the application—likely to happen at their March 2006 board of directors meeting—the application will undergo a year of review by all of the ABMS member boards. If no significant objections are raised, approval could be obtained in 2007.
(combined from two previous posts to make room for Pallimed Contributors post) - CSinclair Oct 22, 2007
Wednesday, June 15, 2005 by Drew Rosielle MD ·
Terri Schiavo's autopsy has been made public (the full .pdf report is available from the NYTimes.com site). There seems to be no medical surprises, including the conclusion that there is no evidence of abuse. Presumably there will be a few days here of hysteria and name calling based on the autopsy but it really shouldn't make any difference. Those opposed to withdrawing nutritional support from Ms. Schiavo did so on ethical/moral/religious grounds & their beliefs about Terri's wishes, and the autopsy isn't going to change that (although perhaps they'll back off from some of their more unsubstantiated claims such as she was abused). & for those of us who believe that Michael Schiavo had the right, per his understanding of his wife's wishes, to discontinue tube feeding, there is nothing new from the autopsy that wasn't already well established in her public medical record.
I was somewhat surprised, though, at how definitively the pathologists stated in the press conference that her rehab potential was nil. I'm not surprised by that conclusion, just that they felt it was important to so publicly state it. One wonders if this was their way of putting their own two cents in about the entire disgraceful episode.
by Drew Rosielle MD ·
Monday, June 13, 2005
Monday, June 13, 2005 by Drew Rosielle MD ·
Saturday, June 11, 2005
A quote: "Qualitative studies make up the majority of research support in the area of hospice and palliative care music therapy, but there is a real dearth in the literature of empirical, quantitative studies."
The April 2005 issue of Evidenced Based Complementary and Alternative Medicine has a review of the literature on music therapy in the hospice setting (free full text is available from PubMed Central). Basically there is zero quality quantitative evidence that it is effective in improving quality of life in the hospice setting. One wonders--if any payors are considering this--on what grounds they would. Pain, discomfort, & dysphoria are, by definition, subjective experiences and one hopes that with large trials music therapy can demonstrate it can alleviate these at the end of life.
Saturday, June 11, 2005 by Drew Rosielle MD ·
The current issue of the American Journal of Psychiatry as a rather staggering case report involving physician assisted suicide in Oregon . It involves a depressed and suicidal man with advanced lung cancer who is eventually deemed mentally incapacitated by a judge but whose (pre-existing) lethal prescription is not removed from his house. The piece is a rather vivid example of perhaps unforeseen problems with the OR PAS law, of which the authors are--very reasonably--critical. However the report smacks of a personal dispute, aired publicly, between the authors and an unnamed "Dr. B." This Dr. B--a proponent of PAS--is never named, however the authors give sufficient literature references on him/her that presumably anyone who bothers to dig up some old copies of the Hastings Center Report could presumably identify him or her. Although I could not imagine myself being involved with PAS, I'm not a priori against it, but this case presents one of the perils created by explicitly making PAS legal. For me, a major issue is that it creates a mechanism for physicians who have no prior relationship with patients becoming involved with their suicides & how easy it is to act, then, without adequate knowledge of the patients' histories, psychiatric problems etc.--all vital elements of medical decision making--especially in this most extreme circumstance of medical decision making.
by Drew Rosielle MD ·
Thursday, June 9, 2005
The current issue of the Oncologist has a pretty interesting article from Mass Gen about the fear of death & facing, as providers, our patients' existential suffering.
This week's NEJM has 2 articles about EOL ethics and conflicts, both clearly in response to the Terri Schiavo tragedy/debacle. The first is a brief piece about the role of the legal system in EOL decision making (the author's opinion that the law should have as minor a role as possible).
A quote: Resort to the courts by warring family members to try to narrow the acceptable range of end-of-life choices on religious grounds is more worrisome. The clinical options at issue in the Schiavo litigation — removing the feeding tube and allowing a patient with a devastating brain injury to die or continuing tube feedings and embarking on an almost certainly futile therapeutic course — were both within the range allowed by ethics and law. To their credit, the judges who heard the case declined to narrow this range. The escalation of a family dispute through fiery religious references represented an attempt to reduce the latitude allowed by law. A Florida bishop's op-ed piece invoked "the passion of Terry Schiavo," and some insisted that, to God, stopping tube feedings is murder. The attempt failed, but the incendiary language set a new standard for family divisiveness at the end of life.
The other piece is a Dutch perspective on persistent vegetative states.
Thursday, June 9, 2005 by Drew Rosielle MD ·
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by Drew Rosielle MD ·
Wednesday, June 8, 2005
Lancet has a reivew article overviewing palliative care in Sub-Saharan Africa . Of interest, the authors seem concerned that HAART programs for HIV will displace/not integrate with palliative care programs. This, to me, is heartening as my initial concern was that palliative care services would be seen by some as a band-aid for lack of HAART.
Wednesday, June 8, 2005 by Drew Rosielle MD ·
The homepage for AAHPM posts a PowerPoint presentation by Bob Arnold & colleagues about 7 important pall care articles published in 2004. This was a presentation at the SGIM meeting recently.
This is the direct link for the .ppt
by Drew Rosielle MD ·
by Drew Rosielle MD ·