Tuesday, May 30, 2006

Exercise programs in palliative care

The currrent Journal of Pain & Symptom Management has an article about the use of an exercise program in palliative care patients.   It involved 34 patients recruited from a Norweigan cancer center/palliative care center with life expectancies between 3 and 12 months.  They were mostly older patients, with relatively high Karnofskys (~80).  The patients received 6 weeks of an exercise program:  twice weekly; 50 minutes at a time; structured group exercises involving stations (combination of stretching, balance, aerobic, strengthening exercises); exercises were tailored somewhat based on the individual patients.  There was no control group.  After 6 weeks there were globally improvement trends on quality of life and functional scales (although these were generally not significant).  Dyspnea, interestingly, did improve significantly, and there was a strong, but non-significant (that is, p= 0.06), trend favoring an improvement in fatigue. 

There has been some study of this in cancer patients, particularly those undergoing chemotherapy (for example here & here), however there's been much less study involving patients with 'more advanced' cancers.  Most studies have been with healthier patients with long life expectancies, so it is good to see this study involving a sicker population (albeit a much healthier one than the average U.S. hospice patient population for example).  For obvious reasons, the sicker/weaker the patient population, the less viable this type of study or therapy becomes (coming to the hospital twice weekly, dying during the study, etc.).  In addition this was a small study, involving a single institution and its physiatrists, with a high chance of interference from selection bias, and the placebo and Hawthorne effects.  (For these reasons, the authors label this study as a "Phase II" one, which seems a little out of place it not being a drug/device trial, but I'll take it to mean a 'proof of principle' trial--that you can do this in a 'palliative' population and that it may work). 

The whole point of me mentioning this article is that our current therapies for cancer-associated fatigue stink, and that's being polite, and so anything that's promising is welcome, even if this may not pan-out in the presumably planned "Phase III" trial. 

Tuesday, May 30, 2006 by Drew Rosielle MD ·

Thursday, May 25, 2006

Street drug names

In preparing for a talk on methadone, I came across the White House Drug Policy web site, which has a very interesting list of slang terms for street drugs and more importantly for health care professionals the slang terms for medications that have made their way to the street.

Unfortunately many of the medicines that are in the arsenal of a hospice and palliative medicine practioner can be abused. Patients who truly can benefit from these medications and not become addicted unfortunately are the ones who suffer because of the black market for these medications.

I thought some of the names were interesting and this list may be helpful to others when preparing talks on medications used in our field.

Slang terms (main page - here) for morphine, methadone, oxycodone, fentanyl, methylphenidate, lidocaine, scopolamine (who knew?), and steroids.

Obviously I am not advocating for illegal use of any of these medicines. Just pointing out that we need to be careful and fully knowledgeable about the medications we prescribe.

Thursday, May 25, 2006 by Christian Sinclair ·

Wednesday, May 24, 2006

Death doulas in the NY Times

The NY Times a few days ago had a story about death 'doulas' in the NY area.  These are trained volunteers who sit with actively dying patients, coaching and supporting the families, etc.  The article is a little 'rah rah' and uncritical, but it was for me a good introduction to a phenomenon I had only peripherally heard of, and imagine will become more widespread in the coming years.  (NY Times articles are usually available free for a week--sometimes you need a free registration.)

Thanks to Marcin Chwistek at Pitt for alerting us to this article.

While we're discussing media--To the Best of Our Knowledge--one of my favorite public radio shows--aired an hour-long show about cancer this weekend.  A couple of the interviews involve first person accounts of living with cancer and are worth listening to (you can stream TTBOOK online). 

This is Pallimed post #202.  Holy cow.  And our first year anniversary is coming up in June.  Thank you to all our readers and commenters.  Tell your colleagues about Pallimed! 

I'm still wading through my move and probably won't start posting in earnest until at least next week.

Wednesday, May 24, 2006 by Drew Rosielle MD ·

Tuesday, May 23, 2006

ABHPM Boards - All Aboard!

Last chance notice for signing up for the Palliative Medicine Boards! May 31st -$1500

By the way that last post was the 200th on Pallimed in less than a year! (0.6 posts per day chock full of information for the palliative care world! Tell-a-friend!)

Tuesday, May 23, 2006 by Christian Sinclair ·

Palliative Care in the NICU

I came across an article from Feb 2006 in Advances in Neonatal Care which covered a subject not often discussed in Palliative Care circles. (At least not the ones I am privy to, and I am interested in Pediatric Palliative Care (mostly because my wife is a pediatrician)). The article on Implementing a Palliative Care Program in a Newborn Intensive Care Unit is available online free (for how long, who knows?) in a sample issue of Advances in Neonatal Care.

This issue became of particular interest to me since my son, Gabriel and daughter, Lindsay were born 3 months ago and were immediately placed in the NICU since they were born at 32.1 weeks old. Now before you get all worried about some NICU sob story, they are doing fine and growing well with all their fingers and toes. But back to my lesson learned...being a parent and patient advocate for my children let me in on a lot of new feelings that I had never experienced as a physician.

As a palliative care practioner I always felt I was keenly aware of how difficult it could be for patients and families to cut through all the medical mumbo-jumbo. But trying to get a prognosis for GOING HOME out of a NICU doc was impossible. I wasn't even talking death here, but something to at least plan on so I could let my work know when I might not be available for two weeks. "Well, if I had a nickel for everytime I was asked when the babies are going home...." and "I have been proven wrong so many times, I never try to speculate anymore." Ugh...so frustrating.

But the thing that caught my eye as a parent in the NICU was the two babies near ours that were not doing so well. Our NICU was nice and private but you could still overhear some very sensitive conversations. The NICU docs did an adequate job but I could see lots of room for improvement in language, context, use of silence and support staff.

So with that as a background I give you a pretty good article that serves as a foundation for anybody interested in starting a NICU specific palliative care program. Nothing wrong about the article so no need for any cynical remarks. Just a good quality review.

NB: in the same sample issue there are articles on "A Parent''s Guide to Palliative Care" and a good editorial on "Death in the NICU"

by Christian Sinclair ·

Wednesday, May 17, 2006

WSJ article on days in ICU before death

There is an article in the May 16th WSJ (Wall Street Journal, as opposed to the other WSJ I know, the Winston-Salem Journal) on D1 regarding the increased cost at certain academic/tertiary care hospitals. The article is referring to a Dartmouth Study that looked at the number of days in the ICU or hospital for patients in the 6 months before their death for 12 chronic medical conditions.

The national average for days in ICU in the 6 months before death was 3.6 days, but UCLA and Thomas Jefferson Med Centers were above 11. Now there may obviously be some selection bias and I have not read the primary report to see if they adjusted for the fact that patients at academic/tertiary care centers may have more aggressive goals.

Well the study is not the most interesting point. The most interesting point is that palliative care got mentioned. At the very end (ironic?). But here is the quote from the Chief Medical Officer at NYU, Dr. Max Cohen:

"There are very distinct patient and family preferences, and major differences in the culture of different patient populations" that explain some of the above-average use of services, he says. But he adds that the hospital has established "a palliative-care service which we hope can be effective in limiting overuse of resources, where a patient has a terminal disease." (emphasis mine)

Ack! I can't tell you exactly what problem I have with this because I have submitted a letter to the WSJ for publication to better explain what palliative care is. But feel free to discuss in the comment section below.

If the WSJ does not publish my letter, I may show it here for commentary. If anyone knows Dr. Max Cohen, please send him over here. This may have been selective quoting for the article focusing on financial issues, and I am sure he explained much more about the true goals of a palliative care team.

Wednesday, May 17, 2006 by Christian Sinclair ·

Tuesday, May 16, 2006

Codeine for cough; osteonecrosis of the jaw

The Journal of Allergy and Clinical Immunology has published a trial indicating that codeine is ineffective for COPD related cough.  This was a randomized, double-blind, placebo-controlled cross over trial of 21 people with 'stable' and moderate COPD.  They took 60mg of codeine or placebo--the authors note that this dose of codeine is substantially higher than what's in most cough syrups.  Essentially they found that codeine didn't decrease time spent coughing, frequency of cough, or cough sensitivity (using a laboratory based challenge) compared to placebo.  Both placebo and codeine decreased time coughing a little bit compared to baseline, suggesting that there is a small placebo effect.  Clearly the numbers here are small, and the patients weren't studied long term at all.  Per the authors this is the first RCT of codeine in COPD which itself is depressing.  All of this is reminding me that despite my regular use of antitussives I've never read one shred of evidence to support their use--I just use them as I was trained to use them.  Of course me never having read a shred of evidence is because I've never looked for it, and so perhaps that'll change. 

Anyway, the most interesting aspect of this article is the authors' discussion at the end of how one goes about studying cough.  What is an outcome?  Number of coughs?  If so is a peal of coughs, a fit of coughing, a single coughing event, or is it a dozen individual coughs, etc?

Annals of Internal Medicine this week has a review of jaw osteonecrosis related to bisphosphonates--a rare but increasingly recognized and potentially devastating adverse effect of some of these drugs.  I won't summarize it here, other than to wonder if this is going to become more of a problem as indications for the use of these agents increase.  From the review it appears that prevalence data is not widely available, but some in some myeloma series it looks like it is up to 10% (of patients receiving high dose, long term IV bisphosphonates to prevent skeletal complications of myeloma)--which to me seems like a frighteningly high number.

I am packing up and moving across town this coming week and don't anticipate I'll be blogging much until next week sometime.  That being said, you can still leave comments!!

Tuesday, May 16, 2006 by Drew Rosielle MD ·

Sunday, May 14, 2006

Neuroimaging and chronic pain in NY Times

The NY Times Sunday Magazine today has an interesting article about using neuroimaging to modulate chronic pain.  Specifically it is about using functional MRI as a sort of 'biofeedback,' allowing chronic pain patients to see their chronic pain 'circuit' as well as their pain modulation 'circuit' as a way to modulate their pain.  That is of course interesting.  But the article is written, and written well, by someone who suffers from chronic pain and discusses her own experience with it, and with the fMRI, as well as the 'meaning' of pain for her and others.  Worth reading. 

(NY Times articles are usually available free online for about a week). 

Sunday, May 14, 2006 by Drew Rosielle MD ·

Thursday, May 11, 2006

Neoplastic meningitis review; Palliative care & liver transplantation; Communicating prognosis

Lancet Neurology has a review of neoplastic meningitis in their May issue. Good for us non-oncologists. Despite this usually being a highly lethal 'complication' of cancer, only a vague mention of 'supportive care' is given in the paper's final paragraph.

JAMA has a "Clinician's Corner" piece about palliative care for those awaiting liver transplantation. It is a cased-based discussion of palliative care and end stage liver disease/transplantation (much like JAMA's Perspectives on the Close of Life series) that is well worth the read. Among other things it has a focused discussion of prognosis in liver failure and symptom management in end stage liver disease. More importantly though, the piece is a powerful advocate of the palliative-care-early/palliative-care-alongside-curative-care paradigm, and directly addresses the emotional difficulties for patient and clinician alike of the "hoping for the best/planning for the worst" paradigm. Ugh--I just used 'paradigm' twice in a single sentence.

I also found this nugget buried in the middle of the article of note--I'm looking forward to seeing this paper: "Preliminary results of an ongoing qualitative study of 30 patients with cancer and 30 patients with oxygen-dependent chronic obstructive pulmonary disease suggests that most patients do not associate honest prognostic information with the loss of hope, provided that information is delivered in a sensitive and caring way (J.R.C., unpublished data, 2006)."

Journal of Supportive Oncology has a review of communicating prognosis to cancer patients (free full text .pdf link here; html link of the issue's table of contents here). It is crap. Ok, that is a joke, which I made because it is authored by my friend and blog collaborator Dr. Christian Sinclair, who is apparently too modest to mention this on the blog himself. It is excellent, and what I really appreciated about it is that it is very much about the art of communicating prognosis, and is clearly written by someone who does it a lot and pays attention to what he is doing. Congratuations Christian! My one question, which I'm sure he'll answer, is that he uses the language "communicating a prognosis." I usually say "communicating prognosis"--no "a." Is "a prognosis" the preferred usage?

The same issue also has a preliminary (only a few patients; completely uncontrolled) report about nitric oxide-donating aspirin which may or may not turn out to be an effective and much safer NSAID-type analgesic.

Thursday, May 11, 2006 by Drew Rosielle MD ·

Monday, May 8, 2006

Improving pain management in the hospital

Archives of Internal Medicine has just published a large trial of a project to improve pain management in the hospital from R. Sean Morrison & Diane Meier & colleagues at Mt. Sinai in New York. It was a somewhat complicated trial involving different combinations of pain interventions amongst hospitalized medical, surgical, and oncology patients at Mt. Sinai. Click on the table below to see the interventions in the two blocks (block A was one set of wards and block B was another--all patients admitted to these wards received the interventions, although data was collected only on those who consented etc.).

As you can see the 3 main interventions were 1) use of an enhanced pain scale (current severity, worst pain, pain relief, pain acceptibility vs assessing current severity only on a 0-3 scale), 2) nursing audit and feedback about pain assessment, and 3) a computerized clinical decision support tool (the exact details of which remain murky--it appears to be something developed just for this trial and integrated into the Mt. Sinai computer system--it offered suggestions and prompts about appropriate analgesic prescribing but was a passive/ignorable system).

Assessment-wise, the use of the enhanced scale increased the amount of nursing pain assessments, and the use of audit-feedback or the computer system increased nursing assessment even more. To give you a sense of the magnitude--rates of pain assessment went from ~20-30% to ~60-70% with the interventions. The interventions also increased the percent of patients with moderate to severe pain who received a WHO Step 2-3 analgesic (i.e., an opioid), although pain severity was not affected by any of the interventions. The mean pain level of the patients on days 1-3 was however 1/3 (=mild) indicating that this may not be the best group of people to test pain interventions on.

Studies like this are also nice opportunities to look at the natural history of pain in the hospitalized patient--in this case 30% of patients had moderate to severe pain at enrollment--which I would bet makes it one of the most common symptoms experienced in the hospitalized population.

Anyway, what to make of this? I'm confused by the exact nature of the computerized clinical decision support tool--how that improved nursing assessment of pain on par with auditing their performance--but that may just be due to the way it is described in this article. Regardless it, along with auditing, quite dramatically improved nursing assessment of pain--that is good news and a challenge to any institution to do the same. The big disappointment of the trial is I guess the not-too-surprising lesson that physician behavior is tough to change. Maybe that is too harsh--this intervention did change physician behavior--it increased prescription rates of analgesics. Perhaps they just didn't do a good job of analgesic titration? One hopes the Mt. Sinai group continues this line of investigation and develops an intervention that demonstrably improves pain control and physician pain management in the hospital. (And one then also hopes it would be easily portable to other hospitals). An obvious solution would be using audit-feedback on the physicians, but one can imagine a certain amount of 'resistance' to that if you know what I mean.

Monday, May 8, 2006 by Drew Rosielle MD ·

Friday, May 5, 2006

Galactorrhea and snoring strips and other quasi-palliative-care-related topics

A few things in brief for the weekend:

A recent New England Journal of Medicine had a "Medical Progress" series article on hematopoietic stem cell transplantation. From time to time at Pallimed we take note of cancer reviews in non-palliative journals and if there is a nod given in them towards supportive or even palliative care. This one had zip.

BMJ has a brief letter reminding us that hyperprolactimemia and galactorrhea can be complciations of long-term methadone use.

The same issue continues BMJ's very basic and thus aptly named "ABC of Palliative Care" series with an article about "difficult pain." The whole series seems to be geared towards people** who know nothing about pain control and has a "hey, there are some treatments out there you know" tone to it. **One must unfortunately assume that these people are practicing physicians.

April's PC-FACS are out--excellent as usual--but it seems they aren't yet posted on the AAHPM web-site...?

There's also a list of palliative care related PDA resources on the AAHPM site now. This may be old, but I've just noticed it, and it's being promoted in the AAHPM's current news e-letter.

April's Supportive Care in Cancer has an article about an interesting, but completely non-controlled and probably bogus trial of external nasal dilator strips to relieve dyspnea in cancer patients. Yes, these are the strips people use for snoring. I'm not sure how you'd actually do even a single-blinded study with these....

Friday, May 5, 2006 by Drew Rosielle MD ·

Thursday, May 4, 2006

Mayday Fellowship Opportunity in "Pain & Society"

What does it mean to be a fellow in "Pain & Society?" Well...apply for the six Mayday Fund Fellowships and you could spend some time working with the media to spread the word about improving pain control. The deadline is June 1, 2006. Training starts in late October of 2006 and requires a 6 month commitment.

I am applying, so you should too. Think about how much fun it would be to hang out with me! (Joking!) If you are applying please feel free to email me or post a comment. The more people complete the better the selection will be!

Thursday, May 4, 2006 by Christian Sinclair ·

Pharmaceutical Knowledge of Physician Prescribing Practices and a speech by Giuliani

As from previous posts you may have noticed that I have a small suspicion when it comes to dealing with pharmaceutical companies. A very interesting article in the NY Times about the AMA and Big Pharma coming together to take action (before states do) to limit the physician outrage of data mining companies selling prescribing patterns of individual physicians to pharmaceutical companies. The article states

77% of physicians are opposed to the release of this information
so the AMA is making an opt-out option. While this does not relate to a specific palliative med issue, it does raise concern about monitoring of prescribing patterns. And for the palliative medicine/hospice physician, there is always this concern/fear that when someone starts monitoring your prescribing patterns that they would see almost exclusive prescriptions of opioids and benzodiazepines along with a small selection of other medications.

I was hoping to hear more about this subject when I recently heard Rudy Giuliani speak at the Annual Dinner for the Center for Practical Bioethics. His topic was 'Pain Control' as he is the Chairman of the Rx Action Alliance. Unfortunately his talk seemed to lack preparation and was merely a string of anecdotes, so I came away learning nothing of his leadership in the role of pain control, and prosecution of diversion, despite his experience as a prosecuting attorney and as a victim of prostate cancer. Despite the main talk being disappointing, the night was great because I got to meet so many of the movers and shakers of Ethics and Health Care in the Kansas City area. I would like to do that more often. There were a lot of great intelligent people gathered there.

One thing that was interesting to note is that the 'stakeholders' for the Rx Action Alliance include: Cephalon (makers of Actiq), Novartis and Purdue Pharma (makers of Oxycontin, OxyFast, OxyIR, MS-Contin, and Palladone).

Other blog post about the NY Times article here

by Christian Sinclair ·

Tuesday, May 2, 2006

Randomized, controlled trial of methylphenidate for cancer fatigue; Electric fish for pain

The Journal of Clincal Oncology has published a randomized, double-blinded, placebo-controlled trial of methylphenidate for cancer related fatigue from Eduardo Bruera and colleagues at MD Anderson. It was, unfortunately, a wash.

About 100 cancer patients were randomly assigned to methylphenidate (5mg tabs, taken q2hours per patients' wishes, up to 20mg a day) or identical placebo. Per the authors, this provided adequate power to detect a difference between the groups, based on the findings from a preliminary study they did several years ago. There is no mention of opioid use in the article--it wasn't an exclusion criterion--so presumably many of these patients were on opioids and had some amount of opioid-associated fatigue as well. The primary outcome was fatigue at day 8 based on the FACIT-F subscale of the FACIT quality of life scale. After 8 days patients could continue on open-label methylphenidate and data was collected for a total of 36 days. During the 8 day study period patients received daily phone-calls from a nurse. Patients took an average of ~10mg of methylphenidate a day.

The good news: methylphenidate was well-tolerated and didn't cause sleep disturbance or a higher rate of drop-out. Patients on methylphenidate had a significant improvment in fatigue at day 8 (and 36 for those who stayed on it). The magnitude of the improvement was approximately 3 on a 0-10 scale (baseline fatigue was ~7/10 in both groups...10 being bad).

The bad news: placebo was equally effective at day 8--patients had the same amount of improvement.

What does this mean?

It could mean 1) methylphenidate truly is no better than placebo for cancer associated fatigue, 2) the daily nurse calls were such a powerful intervention for fatigue that it overshadowed any effect from the methylphenidate, 3) one actually needs a longer period of follow-up to identify a difference (this counters clinical experience in which methylphenidate begins to work quite quickly), or 4) effective doses are higher than previously suspected. Another question is could the problem be one of patient selection--in this study the patients were a relatively unselected group of people at MD Anderson with cancer, fatigue, and without a few exlusion criteria (no severe anemia, anxiety disorders, etc.). Maybe responders to methylphenidate have occult depression and are responding to the anti-depressive effects of the drug. Anyway this is beginning to sound like the desperate thoughts of someone who has felt methylphenidate has helped many of his patients, which it did, but perhaps only through the gentle sugar-pill kiss of the placebo effect. The authors acknowledge many of these interpretations and one hopes they continue their research to address these. If not, on to modafinil, which I have yet to use.

Pain Medicine
has an interesting article about the history of using electrical stimulation to modulate chronic pain. It is really, really fascinating (the Romans used contact with the torpedo fish for gout pain as early as 15 C.E.) and a recommended read.

Tuesday, May 2, 2006 by Drew Rosielle MD ·