Monday, October 31, 2005

Anemia articles in Archives

Archives of Internal Medicine has several articles on anemia in its current issue, including another study tying anemia to mortality in the elderly, and one questioning whether anemia is a risk factor for mortality in CHF independent of comorbidities.  
The most interesting, though, is a paper on the association of anemia with energy and physical functioning in HIV/AIDS.  It is a prospective cohort study which looked at anemia in adults with HIV (the data was taken from ~1400 HIV patients who were being followed in a study on ocular complications of AIDS).  Essentially the patients were followed, data was gathered, and the authors looked at both the presence & absence of anemia as well as the absolute hemoglobin level and correlated that with energy level & physical functioning.  CD4#, viral load, age, sex, race, education, and HIV risk factors were controlled for.  What was interesting was not that they found that the presence of anemia was associated with worse energy/functioning but that there was a linear relationship between hemoglobin level & well-being.  That is, even for those who weren't anemic (Hgb >13g/dL for men; 12 for women)--the higher the Hgb the higher the energy level.  This, currently, probably means very little for practice (who is going to pay for Epo for people with 'crits of 40?), but it does suggest leaving 'relative anemia' on the differential for fatigue in HIV patients with low-normal hemoglobins.
Happy Halloween!

Monday, October 31, 2005 by Drew Rosielle MD ·

Sunday, October 30, 2005

Too many articles

I'm back from my vacation & there are many, many articles to blog & I'll hopefully be slogging through them in the next couple of weeks.  Some brief follow-up:  last week I promised an expanded "recent posts" sidebar but will have to renege on that--it's impossible to do in Blogger without manually entering every post into html & unless someone wants to pay me to do that I don't have the time.  You can use the Blogger "search this blog" toolbar up above to look for topics or old posts etc. 

One quickie::  J of Urology has a review article on palliative care for urologic malignancies.  It's quite comprehensive and an interesting view of palliative care from urologists' perspectives.  These sorts of articles are also always so useful as reference sources (looking for a reference on the use of alum bladder irrigation to control bleeding from bladder cancer?--it's in this article). 

Sunday, October 30, 2005 by Drew Rosielle MD ·

Yes, duloxetine is effective for painful diabetic neuropathy

The current Pain presents another randomized, placebo-controlled trial looking at duloxetine in painful diabetic neuropathy.  348 people were enrolled who were not depressed and on no analgesics (traditional or adjuvant) other than acetaminophen & were randomized to 60mg qday, bid, or placebo.  Both the 60mg qday & bid were more effective than placebo (starting at about 1 week and lasting for the 12 weeks of the trial).  The effect, typical for neuropathic pain trials with adjuvants, was quite modest, about -2.5 on the 11 point pain scale (placebo was about -1.2), but statistically significant.  Importantly, 60mg daily provided equivalent relief to 60mg bid but with markedly fewer side effects.  For those of you who haven't used duloxetine (Cymbalta), it's a relatively new antidepressant that is both a serotonin and norepinephrine reuptake inhibitor and so has more promise as an analgesic than the traditional SSRI's.  It actually has an indication for treating painful diabetic neuropathy already but it seems the editors of Pain thought the world needed one more article about this.  I suspect there will be more RCTs involving it in other neuropathic pain states.

by Drew Rosielle MD ·

Friday, October 21, 2005

Web layout problems--fixed.

I fussed with the layout last night in Firefox but today am realizing that in Internet Explorer Pallimed's layout is screwy. Sorry & am trying to fix asap.

Addendum: as of 2pm CST it looks like the layout problems are resolved, at least in IE.

Friday, October 21, 2005 by Drew Rosielle MD ·

Thursday, October 20, 2005

Risk of death with atypical antipsychotics in dementia

This week's JAMA has a meta-analysis examining the increased risk of death with atypical antipsychotics in demented patients.  The authors looked at only randomized placebo-controlled trials (although a couple of trials had haloperidol arms) for a total of ~3300 patients.  Generally, all the meta-analysis i's & t's were dotted and crossed.  The OR of death with atypicals vs. placebo was 1.54 & the authors calculated a number-needed-to-harm of 100 (with 95% CI NNH ranging from 53-1000).  They point out that the NNT for atypical antipsychotics in dementia is 4-12 & that, then, for every 9-25 patients helped in these trials there was 1 excess death.   This, I think, makes the NNH of 100 seem a bit less acceptable.  None of the novel antipsychotics were particularly worse than the others.  They did briefly analyze the mortality with the haloperidol patients and compared them to placebo & found that those patients receiving haloperidol died more too.   It's important to note as well that most of these trials followed patients for less than 12 weeks, meaning that the mortality difference was noticable in this relatively short time. 
So is it time to bring out the principle of double-effect for antipsychotics in dementia?  That these are drugs that may improve people's quality of life but also may hasten death in a few?  There are probably a few geriatricians amongst this blog's readers & I'd be interested in any comments.

On a mundane note I'm travelling this coming week &, depending on how busy I am, may not post much.  I've noticed that the last week I've been getting quite a few more hits than before and am creeping up to 50 a day sometimes which is astonishing to me.  Thank you, all who read.  Please leave me comments if you'd like:  in general I'm curious as to who, besides my mother & immediate colleagues, reads this blog, as well as any general feedback, criticism, etc.  You can leave comments anonymously if you want.  I'm going to try to lengthen the "recent posts" section to make reviewing past posts easier especially for new or infrequent readers.  I've also decided that I'm really angry at the Lancet website which makes you log-on just to read a simple abstract (unless you're visiting from a proxied server) & am going to try to put those links into PubMed.  The problem is that on occasion PubMed can be days or weeks behind electronic publication so sometimes there's nothing in PubMed to link to. 

Thursday, October 20, 2005 by Drew Rosielle MD ·

Tuesday, October 18, 2005

New PC-FACS out

I probably should have blogged these before but haven't.  The AAHPM for the last couple of months has been publishing "PC-FACS"--brief, critical summaries & appraisals of palliative care related articles (based on the POEMS or CAT EBM models of summarizing evidence).  Clearly this is something after my own heart.  This month's includes a review of the Lancet early decompressive surgery for malignant cord compression trial I blogged a while back.

This is the website's description of the PC-FACS:
(F ast Article Critical Summaries for Clinicians in Palliative C are), a new electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 30 medical and scientific journals. Each month, systematic reviews and insightful commentary on 3-4 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice.  In its first year of publication, PC-FACS is being e-mailed to AAHPM members as a benefit of membership. Comments from readers are welcomed at

Tuesday, October 18, 2005 by Drew Rosielle MD ·

Sunday, October 16, 2005

Small cell lung cancer review

Reviews of the more vicious cancers keep on coming out in the general journals, this time a "seminar" on small cell lung cancer in Lancet.  Not much to say about this but I am finding these reviews quite helpful as a non-oncologist.  This one has a middle section about the history of various chemotherapy regimens for small cell which is pretty interesting.  But I have to point out that even though this article doesn't have pretenses of "medical progress" like the NEJM one, there is not even a nod here to supportive--let alone palliative--care for this routinely lethal disease.  Not a peep.

Sunday, October 16, 2005 by Drew Rosielle MD ·

Friday, October 14, 2005

Malignant mesothelioma review

The current New England J of Medicine has a review of advances in malignant mesothelioma.  It was interesting to note the different tone in this review vs. the recent cholangiocarcinoma review--much more optimistic.  I don't know whether this represents a real difference in the outlook for these diseases or the disposition of the authors.  Nevertheless things aren't great--rates of mesothelioma are rising in most of the world (although they may have peaked in the US) & median survival is 1 year.  The "big" development in chemotherapy is adding pemetrexed to cisplatin which yields an objective response of 41% & extends life by less than 3 months.  Ugh.  As usual there are glosses of multiple novel agents, biologic therapies, etc. which may or may not pan out.  This context didn't get the section on "palliation" much column space, which is fine as this is from the  NEJM "medical progress" series, but the authors did make the interesting point that the legal process surrounding asbestos compensation often heightens the anger & fear surrounding the patients' lethal diagnosis.

Friday, October 14, 2005 by Drew Rosielle MD ·

Thursday, October 13, 2005

September's JPSM

September's J of Pain & Symptom Management has a couple of letters I wanted to highlight.  The edition as a whole has, as usual, a bunch of interesting articles (including one examining a switch from reservoir to matrix fentanyl patches) but 2 letters struck me.  One is about nicotine withdrawal in the palliative care setting.  It introduced to me the small body of literature about nicotine withdrawal & delirium.  As a relucatant ex-smoker I was somewhat disappointed in reading this letter & the problems patients have smoking due to physical disability or facility restrictions--I had always planned on lighting up again the moment I checked myself into the hospice but it looks like this may not happen.  The other letter is a case report on a young woman with cancer who ended up on 10 lidocaine patches at a time for 24hrs a day for many months & had no problems with this & still had systemic lidocaine levels that were far from cardiotoxic.

Thursday, October 13, 2005 by Drew Rosielle MD ·

Wednesday, October 12, 2005

Palliative sedation in JAMA

The current JAMA has a perspectives article about palliative sedation.  I don't have much to say about it other than that it is well written, thorough, & mostly focuses on the practical aspects of the practice.  They mention controversies around palliative sedation for existential suffering but not much more.  They also, in discussing proportionality & the ethics of palliative sedation (severe symptoms vs. hastening death for example) suggest that, in their opinion, hastening death by "a few months" can be justified & proportional but say any more about this.  I think many people will feel that there's a difference between a few days and a few months (especially when talking about proportionality & not intention) & that this statement needs some follow-up. 

Wednesday, October 12, 2005 by Drew Rosielle MD ·

Tuesday, October 11, 2005

Effects of defining a patient as "terminal"

J Clinical Oncology has pre-released an article on-line about the effects of defining cancer patients as 'terminal.'  It looks at a Danish population of deceased cancer patients and compares those who were labelled 'terminal' vs. those who weren't.  Apparently, in Denmark, a physician can make a 'terminal declaration' about a patient--that they have less than 6 months to live.  With the terminal declaration a patient can get increased reimbursement for medication expenses, home care services, and informal caregivers can receive compensation (so, akin to the timing of hospice referral in the US, the timing of the terminal declaration may have as much to do with specific patient/caregiver needs as with actual recognition on the part of the patient or physician about the terminal nature of the illness).  Essentially, the authors looked at everyone in an area who died of cancer & compared those with the official terminal declaration vs. those without.  They found a few differences in the groups based on type of cancer etc. as well as a marked difference in rate of hospitalization and place of death (39% of terminal diagnosis patients died in a hospital vs. 65% of those without).  This is, unfortunately, as far as they looked.  Obviously there are major problems here--not least being that probably some significant portion of the "non-terminal-declaration" patients weren't terminally ill prior to an acute event that killed them.  However this article struck me because 1) this terminal declaration business is potentially a mother-lode of information & one hopes these Danish researchers & others keep mining it & 2) it's another drop in the bucket of information suggesting that defining the dying early, referring dying people for services early (hospice or otherwise) is beneficial to our patients.

Tuesday, October 11, 2005 by Drew Rosielle MD ·

Sunday, October 9, 2005

BMJ reviews the role of opioids in cancer pain

BMJ has published a review of opioids for cancer pain which is really an introduction to the use of opioids for cancer pain.  It's pretty simple & simplistic, and actually it's somewhat disheartening--but probably not unrealistic--that the editors of BMJ felt that their readers needed something like this.  It may be useful as a teaching aide. 

Sunday, October 9, 2005 by Drew Rosielle MD ·

Cholangiocarcinoma review

The current Lancet has a review of cholangiocarcinoma, unfortunately an over-represented disease for us in palliative care.  I personally found it very helpful.  The news isn't good:  intrahepatic cholangiocarcinoma is becoming more common & mortality hasn't improved in the last 30 years.  The last few sections of the review cover palliative therapies** including the role of biliary stenting & photodynamic therapy which I've been reading about for a bit but have yet to see used although, per this reviewer, it sounds quite helpful:

In this novel treatment, the photosensitiser sodium porfimer (which localises to mitochondria) is given intravenously and localises preferentially in tumour tissue over 24–48 h. This process is followed by endoscopic direct illumination of the tumour bed with a specific wavelength of light resulting in the activation of the porfimer, generating oxygen free radicals and leading to ischaemic cancer cell death. This technique has been shown to regress carcinomas of the skin, lungs, pharynx, oesophagus, and stomach. The tumoricidal tissue penetration achieved is a depth of 4 mm and hence it is regarded as a palliative option. The estimated time to tumour progression is about 6 months, meaning that photodynamic therapy is needed twice yearly.
In a prospective study, 39 patients with Bismuth III/IV cholangiocarcinomas were randomised to treatment with either biliary stenting plus photodynamic therapy or stenting alone.
The photodynamic therapy group had higher median survival (493 days vs 98 days), less cholestasis, better quality of life scores, and better stabilisation of Karnofsky performance status than did the stenting group. The improved survival was probably secondary to relief of obstruction rather than a reduction in tumour mass.   Further studies are needed, especially of photodynamic therapy in combination with radiation or chemotherapy, or both.
**"Palliative" in this article means all non-curative interventions.  The authors unfortunately perpetuate the confusion surrounding the use of "palliative" by including both life-prolonging but non-curative interventions & interventions that are only intended to improve quality of life.  By this logic ACE-inhibitors for heart failure & insulin for diabetes are palliative therapies. 

by Drew Rosielle MD ·

Wednesday, October 5, 2005

Supreme Court & Oregon's PAS law

It is not news to report that today Oregon's physician assisted suicide law was argued in front of the Supreme Court. I will probably write about it in the coming weeks, but I thought's round-up of the hearings today & a brief history of the case was particularly informative.

Wednesday, October 5, 2005 by Drew Rosielle MD ·

Memory deficits with morphine

The current Pain has an curious article about the cognitive effects of morphine. It's a small study (n=14) of patients on chronic long acting opioids (average MEDD of 190mg) who require minimal breathrough. They are given their usual breakthrough dose (avg. 20mg) or placebo & a bunch of cognitive tests are run. The next day they get the other treatment and more tests are run. Interestingly the VAS pain scores weren't much different but those who received morphine reported substantially more pain "relief." There were no differences in sedation. Anyway, the patients experienced more anterograde and retrograde memory loss after the morphine dose than placebo; other than that other cognitive domains were intact. This study is clearly very small & limited & I don't think any clinical implications can be made; nevertheless it looks at a practice which is probably second nature to most of us (the use of breakthrough short acting opioids in patients on long acting opioids) & asks what are some of the drawbacks. The authors warn of quality of life problems based on their findings however they didn't measure quality of life & I wager there would be quality of life problems with not having as needed analgesia....

(There is also an interesting case report of a woman with congenital insensitivity to pain whose first painful experience was a tension headache after a traumatic emotional event.)

by Drew Rosielle MD ·

Monday, October 3, 2005

Current Gerontologist

The current issue of The Gerontologist has several articles about end of life care. There's a not-so-shocking article surveying bereaved family members on end of life care in nursing homes finding it globally wanting (not enough staff, physicians inaccessible, hospice referrals late, etc.), a qualitative study interviewing nursing home residents about how they make decisions about advanced directives, and a narrative review on the current research about end of life care preferences amongst different racial & ethnic groups.
Most interesting to me was a nursing home study of people with advanced dementia (average MMSE of 4!) and agitation. The article is based on data from a trial of a psychosocial intervention for agitation & so the data about levels of agitation etc. were carefully & prospectively gathered. The current paper looks at the 32 people who died during the study and compares them to 32 survivors (apparently chosen to be matched for age and level of cognitive impairment). They found that those who died were more verbally agitated, spent less time verbally interacting with nursing staff, and were restrained more; there were no differences in deterioration of cognitive status (although an MMSE of 4 doesn't leave much room), perceived pain, or analgesic use; neuroleptic use was higher in the surviving group. Clearly not a huge amount can be taken from this--I can't quite decide if the comparison group is completely or just mostly bogus. This is a difficult group to prognosticate in so anything that's helpful is of interest; however no one's going to go amending the NHPCO hospice guidelines based on this.

Monday, October 3, 2005 by Drew Rosielle MD ·

Sunday, October 2, 2005

Lancet's end of life viewpoints series ends with a whimper

Well it's over--concluding with a humanist perspective, & unfortunately it's the worst of the lot. Perhaps some of you who watched cable access television in the US growing up remember a show called "Atheism Today" (or something similar) which was a forum for atheist leaders to self-righteously pity the foolish believing public, humorlessly discuss slights against atheists, and devise a way to re-brand themselves "Brights" without seeming like they are the sort of people who, in trying to find a way to describe themselves in contradistinction to the rest of the world, chose the term "bright." Well these same people wrote the current piece & it shows--it is full of meaningless platitudes and gripes against hospital chaplains.

Some nuggets: "Fear and sensitivity are not alien to the humanist psyche." "...every humanist is an individual forging his or her own meaning in the world...."

Sunday, October 2, 2005 by Drew Rosielle MD ·