Wednesday, April 30, 2008

Head & neck cancer; Vitamin D; Do not 'METuscitate'; More

Many items....

From JAMA:

First is one in their ongoing series 'perspectives on care at the close of life' on palliative care for patients with head & neck cancer. Besides being a solid review of the topic, as are most of the 'perspectives' pieces, this one stood out for two reasons. It's the most 'supportive care-y' one in this piece, and really reflects a broad perspective of palliative care as not just for the dying (despite the name of the series). The other is this wonderful (and rarely seen in the medical literature) discussion of self-image and blame:

Although some patients may blame themselves and feel they caused their own illness, patients may also feel guilt about the toll that the illness takes on their family and caregivers. Eating is a major social, cultural, and religious ritual in society, and patients with head and neck cancer often cannot participate in this activity. Even going out to dinner can become an impossible task, and patients may often be concerned about the impact this has on their family. Likewise, facial disfigurement—even if only temporary—may make it emotionally difficult for patients to leave the house, which can change the dynamic between patients and their loved ones. Feelings of guilt and self-blame in patients with head and neck cancer are therefore not only related to their own role in their illness but also to the belief that they are to blame for the impact the illness has on the quality of life of their loved ones. Physicians can assist patients with these feelings by encouraging them to talk about them with their loved ones, and even facilitating these conversations. For example, if a patient is accompanied to an office visit with a caregiver, the clinician can ask both of them, "What role has the illness taken on your relationship?" or even more directly, "Are you finding it difficult to eat out in public? How are you handling the changes imposed by the cancer on your social life or religious practices?"

The same issue also has a 'coda' for a previous perspectives piece about nausea and vomiting from last year.

And on the general cancer front JAMA also recently published the results of a randomized, controlled non-blinded trial comparing chemoembolization with radiofrequency ablation
with both in patients with hepatocellular carcinoma. The study involved ~290 patients with unresectable (but not metastatic) hepatocellular carcinoma, at least one lesion greater than 3cm (as well as certain other tumor-specific entry criteria) & they were randomized to one of the 3 arms. I'm mentioning the trial for a couple reasons. First, there aren't too many therapies out there which have been shown to significantly improve survival in these patients and second, the study provides some general prognostic information for outcomes in this population: median survival was 24 months in the chemoembolization group, 22 months in the RFA group, and 37 months in the combined treatment group; 1, 3, and 5 year survivals were 75%, 32%, 13% in the chemoembolization group (very similar to the RFA group) and 83%, 55%, and 31% in the combined therapy group.

I'm curious how many other palliative clinicians are seeing these patients - my group sees a good number of them (usually referred by interventional radiology) as they near the end of their treatment course (or earlier if they're having a lot of symptoms) - and some relatively solid prognostic data are helpful.

Archives of Internal Medicine has a research letter furthering the Vitamin D For Everything consensus that seems to be gathering in the last several years (falls, frailty/muscle weakness, cancer prevention, cancer therapy, and chronic generalized pain are just a few topics off the top of my head that vitamin D has been shown/purported to impact). This is about vitamin D for neuropathic pain; the letter presents uncontrolled observational data from giving 50 patients with painful diabetic neuropathies (and low serum D levels) ~2000 IU of vitamin D for a few months. The pain got quite a bit better. This is swell, and hypothesis generating to be sure - clearly controlled research is needed.

Two from Journal of the American Geriatrics Society:

First is one looking at 6 month mortality after hospitalization for a COPD exacerbation. This was a single institution (Italian) prospective cohort study of ~240 elderly inpatients (mean age 82 years) with COPD exacerabations who were followed for 6 month mortality. For some reason patients with a previous history of 'chronic hypoxia' were excluded (???). Of note, the study cohort had 'nonacidemic' exacerbations which they defined as an arterial blood pH of greater than 7.34 (they don't clarify if they also excluded chronically hypercapneic patients who had high pCO2 but weren't actually acidemic). 2% died during the hospitalization (seems a touch low to me, given the age of the cohort) and 20% died by 6 months. They found a lot of the usual suspects were associated with a higher chance of death at 6 months (low BMI, poorer performance status, greater severity of COPD exacerbation) in univariate analysis. (None of the data were robust enough or presented in a way to affect clinical decision making, however.)

The one particularly interesting finding was that the functional status (measured via the Barthel Index) at the time of discharge (not at baseline) was predictive of 6 month mortality in the multivariate analysis - the authors comment on this too as it suggests (maybe) that the 'functional hit' one takes during the exacerbation is of particular prognostic importance. This makes sense but it's the first time I've seen it show up and I hope the authors/others look into this.

The other one is really for the prognosis completists out there: it looks at long term survival and functional outcomes for elderly patients who have already survived 1 year after 'planned or unplanned surgery or medical intensive care unit treatment.' Why one would want to study this exact population (both unplanned surgery or MICU stay? already survived one year?) remains unclear to me. Most people were doing fine, but of course they were since they'd already lived a year....

Journal of Trauma has a paper looking at outcomes in elderly patients who suffer cervical spine fractures. This is a retrospective review of a single trauma center's experience with these patients. I have encountered only a very few elderly patients with cervical spine fractures (at least high C-spine ones) who have done well so this paper caught my eye. Acute mortality was ~25%, higher for high C-spine injuries and for those presenting with neurologic deficits (40-50% range). They also looked at the role of having an advance directive (they don't specify at all what they meant by this - POA forms, living wills, treatment limitations or not, etc.) and found that overall hospital length of stay was about 6 days shorter for these patients (despite having worse injury severity scores). They speculate that it may be because these patients' care goals were more palliative focused and so didn't linger in the hospital too long (although their ICU length of stays were identical to patients without ADs). Perhaps, but having an advance directive may also be a marker of increased family/social support, or preexisting nursing home residence, or other factors which could shorten a hospital stay....

Resuscitation has a letter about the (what sounds like informal) development in one Canadian institution of "Do not MET" orders (MET being medical emergency team which sounds like what are frequently called rapid response teams in the US - essentially teams called in to rapidly assess/stabilize/transfer 'crashing' hospitalized patients prior to the patient needing a full 'code' called). It sounds like the MET team is still called even if a patient has a DNR order and so for appropriate patients people at their institution are writing, essentially, 'Do Not MET' orders as well.

If you found the 'METuscitate' in the title unbearable I'll point out that it's from the title of the the letter and I didn't make it up. It got me thinking, however, what does one actually call such a word? Is it a portmanteau? If so, how does one account for the acronym?

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