Sunday, June 22, 2008

Antipsychotics & death; Hope transitions; Nerve blocks

1)
Continuing the implosion of antipsychotic use for 'behaviors' in patients with dementia, Archives of Internal Medicine published a retrospective cohort analysis about 30 day mortality or hospitalization in patients prescribed antipsychotics (they were higher). All patients were living in nursing homes or at home (none were hospitalized). This is not the greatest study on this topic: increased mortality has been demonstrated in randomized controlled trials of atypicals (i.e. we don't necessarily need retrospective cohort studies). What this one adds is that it looks at both typicals and atypicals and finds that adverse outcomes were higher for both (and a little higher for typicals than atypicals). That is - this supports the idea that this is a class effect of all antipsychotics and not just newer ones (in which the problem was first identified).

2)
Cancer has a discussion addressing hope in the face of a terminal illness. Its focus is that period of time between a patient\family member hearing life-altering news (the cancer is incurable, there are no more treatments that will slow the cancer down, etc.) and them 'accommodating' (that's my language) that news. They describe this time as one in which hope undergoes a transformation (from hope to a cure, etc. to a painless death, or a few good months with the kids before things get bad again, or whatever it is) and which can take quite some time. None of this will likely be news to most readers of the blog, but this was one of the only articles I've read in a long time which focuses on and analyzes specifically that transition - what that transformation actually entails. A good one for the teaching file. I liked this quote about bedside manner:

Here, we focus on the cognitive aspects of hope management, but we also want to emphasize the profound importance of the behavioral and affective components - of the physician recognizing and responding to the patient's emotional condition. When the physician forms an empathic emotional connection with the patient, it conveys an unspoken but important message of caring; the physician's steady presence is an almost physical shelter in the emotional storm that often accompanies impending death.


3)
British Journal of Anesthesia has a review of nerve blocks in advanced cancer patients. It's a casual review of the topic written from an anesthesiologist's perspective and is somewhat interesting for its discussion of the different approach taken in dying patients than, for 'non-dying' patients. Teaching file.

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