Sunday, November 11, 2007

Methylphenidate; Dialysis; Burn-out; This American Life

Supportive Care in Cancer presents another, negative, randomized controlled trial of methylphenidate in cancer patients. This study looked at ~60 (mean age 50) women with early & resected breast cancer who were starting adjuvant chemotherapy and randomized half to methylphenidate or placebo; this was a trial of prophylactic methylphenidate with the hope it would alleviate the fatigue and other symptoms associated with adjuvant chemotherapy. They took 10mg bid of methylphenidate throughout their chemo (average ~80 days), after a week's lead-in on 5mg bid (it should be noted that they used d-methylphenidate so these are hefty doses). Fatigue scales and a bunch of neuropsychiatric tests were run (looking at memory, attention, etc.).

There were no significant differences found between the groups regarding fatigue, cognitive changes, or quality of life. However, the study was severely under-powered - the researchers' goal was an N of 170 and they only achieved 60 (they noted that many of the subjects were reluctant to take another medication, particularly methylphenidate). So, unfortunately there is no good way of knowing if methylphenidate was doing something beneficial - if it was the magnitude of its effect is probably small. This seems like one of several recent, well-designed, supportive cancer studies I've come across lately which have suffered from poor accrual (although I can't off the top of my head remember what the others are) which is disappointing and underlies the difficulty of doing this research (particularly, perhaps, with scary-sounding drugs like 'Ritalin').

Unlike the last RCT looking at methylphenidate, this time the patients were not called daily by a research nurse, so no comment can be made about the hypothesis generated by that trial. One wonders, though, if this trial was born to fail - it has yet to be shown that methylphenidate is helpful for people actually experiencing fatigue, let alone for an undifferentiated group of people, many of whom will never significantly suffer from fatigue anyway.

Advances in Chronic Kidney Disease's latest issue is on mental health/symptoms/palliative care in patients with chronic kidney disease. There are two articles of particular relevance to palliative care.

First is one on, well, palliative care in CKD - focusing on illness trajectories, communication, and hospice use. It's a general review aimed at nephrologists.

The second looks at dialysis discontinuation. It reviews the research literature on the topic and discusses the practice at length. Apparently 25% of deaths of dialysis patients in the US are preceded by a decision to stop dialysis (assuming that most of the remaining 75% didn't die suddenly/unexpectedly I find this figure stunningly low). The study dramatically presents the wide variations in practice/experience around dialysis abatement in different regions/countries confirming practice around this is highly dependent on local culture and practice. While a thorough, in depth review of the topic, what I found most interesting was the author's suggestions for moving the research away from 'medical' priorities to patient/family centered priorities - information needs, communication needs, family needs.

A couple briefly:

Postgraduate Medicine recently had a review of delirium in advanced disease. It's pretty basic.

Internal Medicine Journal has a study showing that palliative medicine docs aren't any more burned out that other specialists (read another way - they're just as burned out as other specialists). These are docs in Western Australia, where my parents are from and where I lived most of my first 7 years, so maybe I'll head back home when I hit my midlife slump. Seriously, though, this is going to be an important issue as our profession matures. (How much grief and conflict can one take? How do we, as a professional community, prevent burn-out?)

Last week's This American Life (a public radio program) was called 'How to Rest in Peace' and included 3 pieces: two about coming to terms with a parent's death (murder) and which involved an interview with a man whose mother openly planned her own suicide for 20 years before actually doing it (she was so afraid of a horrible death 'with tubes' etc. that she had meticulously planned a suicide to be carried out before she got really ill). The first two, although about murders, were also about grieving, 'closure' (or not), and meaning making (or not) after a traumatic death - and a lot of it will resonate with anyone who witnesses grief in their work. The last segment is one of the few personal narrations I've encountered about what is essentially an 'assisted suicide' (no physicians were involved) and is interesting listening. It brings up issues of meaning in decline (or not), what a good death is, 'controlling death,' and the effects of such a death on a family (in this case it wasn't necessarily bad).

TAL broadcasts are available for free streaming or download/podcast.

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