Friday, August 3, 2007

Bowel obstructions; Buccal fentanyl; Frailty; Deep brain stimulation; More

It's August, it's hot, I'm jealous of Tom Quinn who has seemed to be on an endless vacation (please give us the details when you get back), my little boy is about to take his first steps, I know all the secrets of the Harry Potter series, and my wee brain isn't working well, so I'm just going to touch on the interesting items cluttering my inbox this week.

1)
The latest issue of the Journal of Supportive Oncology has several notable articles (table of contents here; JSO is always available free online). There's a review on endoscopic procedures for malignant bowel obstructions (both small and large), particularly focusing on the use of self-expanding metal stents. It contains, among other things, a narrative review of the research surrounding SEMS use, and makes a good place to start for those who aren't familiar with their use. Two associated editorials are here & here.

The other article I wanted to mention was another trial looking at fentanyl buccal tablets for breakthrough cancer pain. It was an industry funded placebo controlled trial of opioid tolerant patients (median daily oral morphine equivalent dose of 180mg) which found, shockingly, that FBT provided more pain relief than placebo! What was interesting was that this trial provided further evidence that, at least with buccal fentanyl, baseline opioid dose does not correlate well with effective FBT breakthrough dose (i.e. the more opioids one is on at baseline does not mean one will need a higher breakthrough dose) and all patients need to go through a dose titration phase to find the right dose. Previous posts looking at the same question are here.

Oh and there's also a letter/case series on inhaled lidocaine for intractable cough; not a ringing endorsement of the practice.

2)
The American Journal of Health System Pharmacy has a review on long term trends in long-acting opioid prescribing in hospitalized cancer patients. It's from MD Anderson and, among other things, examines trends before & after their palliative care team was established in 1999. Basically what they found was that after the palliative care team was established, patients were prescribed more long acting opioids, but most of this increase was due to increased methadone prescribing, and overall costs went down because methadone is dirt cheap.

3)
JAGS has a study looking at the natural history of 'frailty' in older men. It is data from a large, multicenter, prospective study which followed ~6000 elderly community dwelling men (mostly in their 70's and 80's). Frailty was defined as: "A man was considered frail if three or more of the following five criteria were present: shrinking/sarcopenia, low activity, weakness, slowness, or low energy...." These criteria were each defined more objectively. 4% of the subjects were frail at baseline and these individuals had a strikingly different course than the 'robust' men: got sicker and died more. By the end of the study (mean follow up 4.7 years) 42% of the frail men had died compared to only 7% of the robust men and frailty was a very strong predictor of mortality (hazard ratio 2.05). Sounds like a perfect target population for early, palliative-care oriented, interventions.

4)

Nature and many news outlets have been reporting about the man in a minimally conscious state who has shown dramatic improvements after implantation of a thalamic stimulator (Nature article - actually it's a letter, Nature news story 1, Nature news story 2, NY Times story). The patient was 38 year old man who had been in a MCS for over 6 years after a traumatic head injury; he occasionally showed some awareness and attempts to communicate but was mostly stuporous. He is now alert much of the time, can verbalize appropriately at times, and can eat orally. He appears to have anterograde amnesia. There's a lot of neuro/MRI chatter in the case report that is too technical for me but it seems he showed imaging evidence of functioning cortex but his arousal system (including the thalamus) was not functioning - thus the apparent success of electrically stimulating his thalamus.

This is just one patient and the wider applicability of this technology may be be small, not to mention how unclear the long term outcomes are at this point. However it seems reasonable to assume we're moving into an era in which long term cognitive impairment (e.g. post strokes and anoxic and traumatic brain injuries) may be treatable (i.e. at least partially reversible with medical interventions other than supportive care & waiting to see if people get better with time which has been pretty much the only available options until now). This may make prognostic uncertainty even more difficult for these patients which will be a challenge and one for which we should be prepared as a profession. Talking through options, weighing uncertainties, identifying values and goals and hopes and helping people make decisions in light of them - these are our strengths in palliative care and as 'disease-modifying' options proliferate for even the sickest of patients these skills will become even more valuable. I hope.

(Image from the Cleveland Clinic's deep brain stimulation patient page.)

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