Thursday, October 23, 2008

Mag Citrate #4: PAS, HCC, Thoractomies, More

It continues.  Actually this is, I hope, the end of the Mag Citrates for now.

1)

BMJ has a paper looking at depression and anxiety symptoms  in patients requesting physicians' aid in dying (ie - physician assisted suicide)  in Oregon.  The study involved diagnostic interviews with 40 Oregonians who were at least seriously considering obtaining a lethal prescription via the Oregon Death With Dignity Act process.  It's a small number of patients in one sense, however given the number of actual DWDA deaths in Oregon it's an OK N.  That said, the recruitment for the study involved referrals from a DWDA patient advocacy organization as well as referrals from practitioners who met patients expressing interest in a lethal prescription, so it's really impossible to know how representative these 40 subjects were of those actually considering lethal prescriptions in Oregon.  They compared patients who actually went through with obtaining a lethal prescription with those who didn't and found, interestingly, that those who obtained that prescription differed little from those who didn't except that they reportedless desire to die and less hopelessness.  Given the likely selection bias here I wouldn't make too much that this.  

They also found that only 3/15 patients who actually obtained a lethal prescription met criteria for depression.  I say 'only' there but the authors point out that the DWDA states that physicians 'must ensure' that patients are seen by a psychiatrist if they are concerned they have a mental illness including depression that may impair their decision making. It looks as if only one of those patients received psychiatric help and the authors conclude that the safe-guards in the DWDA protecting those with mental illnesses aren't necessarily followed.  

Accompanying editorial about the feasibility of screening for depression in all patients investigating assisted death is here.  

2)
Cancer has a paper presenting a prognostic scoring system for hepatocellular carcinoma not amenable to locoregional therapy (e.g. including resection, transplant, or chemoembolization).  The score predicts likelihood of death within 3 months.  The data come from a single institution's (Hong Kong) prospective database of all HCC referrals (about 1400 patients - they used 1100 for the derivation set and 300 for the validation set) - these subjects had a median survival of 2.3 months overall.  The prognostic index they developed uses relatively easily obtainable data (mostly routine lab tests including AFP, LFTs; data most patients would have based on routine imaging - tumor size, presence of ascites), but is only moderately predictive, and I'm not sure if this is going to add much to presently available tools and clinical acumen.  The authors, reasonably, propose using it as a way to identify better-prognosis patients for clilnical trials.

3)  
Clinical Journal of Pain has some general epidemiologic data about chronic post-thoracotomy pain (something not uncommon in many lung cancer patients).  The data come from a trial of ~120 patients who received epidural analgesia at the time of major thoracotomy; this analysis looks at the 48 week follow-up.  At 48 weeks 20% of patients continued to report any thoracotomy pain (mean ~3.3/10).  They don't present data about what number of these patients had moderate to severe pain, although 44% of them were using opioids at week 48.  A couple other observations:  1)  20% is lower than in other trials suggesting (at least compared to historical controls for what that's worth) epidural analgesia perhaps does help prevent long term pain, and 2) there was a clear division around week 12 between patients whose pain were dropping off and those whose pain persisted suggesting that's a reasonable cut-off to identify patients at high-risk for long-term pain post-thoracotomy.  

4)
Supportive Care in Cancer has a review on decision-making in cancer which focuses extensively on how decision-making changes over time and changes with quality of life, prognosis perception, and prior response to treatment.  It's pretty theoretical but a great literature review and a good one for the teaching file particularly for more advanced learners (e.g. fellows).  

5)
Mayo Clinc Proceedings  has a couple: 

One is a review of peripherally acting opioid antagonists which discusses both methylnaltrexone and alvimopam at length, at focuses heavily on physiology as well as emerging/yet-to-be-properly-investigated uses of those agents (opioid induced urinary retention, nausea, pruritis, etc.).  

The other is a survey of physicians at a single institution (all within the Department of Medicine)  looking at beliefs about and attitudes towards discontinuing implantable cardioverter-defibrillators in patients nearing the end of life.  Sobering stuff: despite there only being a 43% response rate, nearly 50% of respondents thought it was illegal (or at least were concerned it was illegal).  That could still translate to nearly 25% of physicians.  Yikes.  Cardiologists, as opposed to other internists, all knew it was legal.  

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