Thursday, October 25, 2007

Many Items, Part 1

This is the first of a couple posts of 'many items in brief' as my inbox is overflowing with articles and I'm resigning myself to covering none of them in depth.

There have been a couple recently published articles about treating 'behaviors' in patients with advanced dementia. First was a randomized, blinded comparison of citalopram with risperidone in the American Journal of Geriatric Psychiatry. It involved ~100 patients who were started on therapy during a hospitalization and followed for 12 weeks. Basically no differences were found between groups. The problem here of course is that antipsychotics aren't particularly efficacious for behaviors in dementia in the first place so the real question is not whether citalopram is 'as good as' risperidone but if it's any better than no drug treatment at all. The other was one in the NEJM looking at donepezil vs. placebo for 'agitation' in dementia. This too was a 12 week randomized trial involving ~270 patients and found no benefit. We've occasionally tracked silly or Orwellian drug/trial-group names on Pallimed and the NEJM study provided a fresh example: the trial-group is called "CALM-AD."

Diabetes Care had a fascinating study about perceived burdens of diabetes care vs. its complications. It is based on interviews with ~700 adults with diabetes and involved questions about the perceived benefits/burdens of various scenarios (intensive glucose monitoring/control, diabetic complications such as retinopathy, etc.). To be clear - this involved asking real diabetics to speculate on the effects on their lives of hypothetical treatment/health status scenarios - it was not measuring the actual effects of these scenarios on patients' quality of life. They found that the subjects rated intensive medical therapy as bad as (having as much of an impact on quality of life as) all but the worst medical complications of diabetes. That's certainly interesting, but it's hard to make a big deal about it given all the hypothetical modeling going on. More interesting to me is just the fact that this research is going on - people are asking these questions - & I hope more to see more of this in the future.

Journal of Clinical Oncology has a metaanalysis (pooled analysis) about the use of ultra-short screening tools for psychological problems in cancer patients (such as a single-item 0-10 'distress' thermometer). Basically the pooled analysis showed that these tools are, in fact, good screening tools: sensitivity 78% and negative predictive value 93% for depression. However they are poor diagnostic tools and the accompanying editorial stresses that they should be used for screening only.

Another issue looks at psychological distress/burden of spouses of cancer patients in Israel: there is a lot of distress.

Pain is publishing revised evidence-based guidelines on the pharmacologic treatment of neuropathic pain. It's a reasonable and rather practical look at the evidence and divides agents into first line (e.g. TCA's, SNRI's, gabapentin/pregabalin), second-line, and third-line classes. Great one for the teaching file.

There's an accompanying editorial by Nathan Cherny, subtitled 'From Hubris to Humility' which is worth a read. It addresses the guidelines demotion of opioids from 1st to 2nd line agents as well as the reality that neuropathic pain isn't too easy to treat (well). A quote:

"The second change relates to the tone of the document. A new humility has been introduced into these guidelines. The 2007 guidelines are much more circumspect about what can be expected from the outcomes of pharmacotherapy for neuropathic pain. The new document describes the potential efficacy of the recommended agents whilst maintaining a realistic outlook on the actual likelihood of achieving a good outcome for the individual patient. In their conclusion, the authors remind us that despite the best of care and sequential trials of therapy, pain will remain unrelieved or inadequately relieved for 40–60% of patients suffering from neuropathic pain. The hubris is gone and the limits of what can be routinely expected from the best of care are candidly discussed. This somber assessment challenges us on many levels. How can we help the patient with persistent inadequate relief despite sequential trials of individual and combination therapies? How do we, as caring physicians, deal with the limits of our current therapeutic repertoire and with the sub-optimal outcomes our patients must endure? This question has particular poignancy in the context of the asserted right to relief of pain that we ourselves have espoused."

There's a new Cochrane review about methadone for cancer pain. Conclusions are as-expected: it's efficacious, no evidence it's better than morphine, be careful with using it. This is certainly one topic for which there are more reviews than there are actual trials....

A couple media items:

PBS's Frontline is showing a documentary about Thomas Lynch on October 30. He is the undertaker who writes/speaks very eloquently (and idiosyncratically) about death and dead bodies (see my prior post on him here).

The NY Times health blog The Well posted a provocative piece about 'When Doctors Steal Hope' about doctors giving inaccurate and pessimistic prognostic information. Read the comments which are just as interesting as the piece itself. Missing from this context of course is the well-researched reality that most of the time doctors give overly optimistic information (we both tend to overestimate outcomes to ourselves and then deliberately overestimate prognosis - at least longevity - to our patients - see Lamont & Christakis' work on this).

(Thanks to Christian who alerted me to this but was too lazy himself to post about it - c'mon man you've only posted 3 times in the last week!)

The FDA is putting out new warnings about modafinil - Stevens-Johnson Syndrome & other hypersensitivity reactions are being reported.

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