Wednesday, April 30, 2008

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

Many items....

1)
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.


2)
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.

3)
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....

4)
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....

5)
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?

Wednesday, April 30, 2008 by Drew Rosielle MD ·

Monday, April 28, 2008

How to Submit A Presentation for a Medical Conference

Submitting a presentation to a medical conference can be a daunting task. It can be so intimidating many qualified people feel they should not even bother, because who are they to 'act' as experts in the field. Or one may have been rejected in the past and figured the odds are against you, so don't bother making an effort again. Others just enjoy going to the conference and not having to 'work.'

Well, I want to encourage you to submit a talk. If more people submit talks, an increased variety of talks can be selected. If more people submit talks, new viewpoints can be heard. If more people submit talks, new leaders can emerge. If more people submit talks, more professionals gain the confidence of speaking on international, national and regional stages.

So what is the best way to submit a presentation? Here are some tips I have gathered from submitting many talks to national and regional conferences, speaking and attending those conferences, and being on the committees to select from all the submissions. None of these tips are guaranteed to get your submission selected, but they may increase your chances.


What Topic to Choose?

Start Early
The time to start contemplating the talk you plan to submit, is actually at the conference you are attending. If you are planning on going next year, look at all the titles and see what areas are not covered well in breadth or depth, and see what areas have way too many offerings. This will help you gauge what area/topic may receive increased consideration from next year's committee. Be creative and think outside the box. What topics are important but often overlooked? That is how I have come to love prognostication; rarely taught, often misunderstood, used daily in medicine.

Start with Something Familiar
It is always easiest to start with something you know well, so you can at least decrease the amount of background work you must do. And if you have a lot of experience in that area, you can likely perform/improv better at your presentation as you can pull from a vast knowledge base. The corollary is...

Start with Something You Want to Understand More
Giving a presentation should not just be regurgitating facts and stories you know too well. Stretch your horizons and use this opportunity of an external deadline to learn more about some new area. That area should pique your curiosity, so you will be engaged with the material, otherwise the talk risks coming off very flat. And hopefully you have some experience with the topic, even if tangential. I can read all about llama farming in the hills of Peru, but since I am at least 3 degrees of separation from that topic, I probably would not give a sincere presentation (at least not without a lot more work).

Pick an Under-served Category
Many times conferences will post categories for desired talks. Look for the category you don't think will be popular. Chances are the committee will not have a lot of selections to choose from and your talk may be picked.

Don't Be Afraid of Bread and Butter
Being unique can get your talk selected, but often times at medical conferences there is a need for some of the basics. If you notice a topic has not been covered in the last two years of the conference, throw it out there. You can email the conference coordinators to get the last few years of programs, and then sort through what has been presented. If you are trying hard to get your talk selected, stay away from the topic that has been given yearly by the same person. Not likely to change, but sometimes change is good.

How Many Talks to Submit?
Honestly, it depends on your goal for presenting at the conference. If you really want to speak about the one thing you are passionate about, just submit one talk. If you want to get more national/regional/local exposure, submit three and hope two will get chosen. If you ever have three or more talks at a conference, you will not enjoy the conference. You will miss out on many opportunities because you will be planning your talk. So if you get all your talks selected, do not be afraid to tell the committee you would like to decrease the number of talks you will present. They may be sad, but I doubt they will seek retribution.


Submitting Your Talk

The Title
The title shouldn't be that important. It is just a few words. My talk is 60 minutes, but my title can be said in 6 seconds. Big deal. But the title is very important! This is your calling card to the selection committee and to the attendees. Think of it like a newspaper headline. In 8 words or less do you want to know more about something. And do try to use less than 8-10 words, because a title that is too long tells your audience you may not have good editing skills and your talk is bound to go too long, and have too many slides that you don't have time to get to.

Choose your words wisely and your title can shine. Pick bland but descriptive; your chances are so-so. Pick flashy but confusing; good luck. Pick creative and informative; bingo. Stay away from cliches and puns. Sinclair's Maxim: There will always be at least one presentation using 'the good, the bad and the ugly.' Alliteration is good but don't go overboard. The colon (punctuation, not the anatomy) seems to be very popular these days. It allows for something punchy and catchy on on side of the colon and something serious on the other side. Kind of like a grammatical mullet: business in the front, party in the back.

A good title gives some information, but is slightly provocative poking the learner to want to know what you are up to. That way they come to your talk. 'Evidence-based' is a buzz word, but it may start to be overused for when the speaker wants you to know, "Hey, I looked some of this stuff up." (Yes, I am guilty of using EB in my titles.)

The Speakers
Should you present alone or with others? Speaking with other people sounds like a great idea in the planning stages. 'Sara will take this part, and Dave will finish the talk, and I will cover the medicines. ' But in reality the coordination makes collaboration on presentations should cause hesitation. For a multi-presenter talk to go well, you should plan on a lot more time for ensuring the multiple presenters actually enhance one another and not turn into the Keystone Cops. Having speakers from different disciplines or different regions can help in raising the level of credibility for a talk, but that should not be the only reason to collaborate.

The Abstract
Follow the rules.

The Abstract (part two)
Did you read the section above? I mean it. Word count rules, figure rules, title format rules. Look them over again and again. And hand check the spelling after your computer does it for you. Eye now these form personnel experience. Please hand check your spelling!

Understand if the abstract is what is going to be printed in the brochures and other printed materials for the conference. Are you writing for the selection committee or for the selection committee and the learners? If #1, you can add in some commentary, if #2, it is more marketing than explanation. Don't waste your word count on what other people know about the subject by endlessly quoting others or adding references. If you can't fill up more than 80% of the word count with your original thoughts, why should they give you 60 minutes to talk?

The Deadline
Finish it early. This way you can have others look it over before the real deadline and give you critical feedback.

If there are any other lessons I missed or parts you disagree with, please feel free to leave them in the comments section.

Monday, April 28, 2008 by Christian Sinclair ·

Friday, April 25, 2008

"I Wanna Be A DNR" and other Goodness from the Web

Since it is Friday, let's have a little fun. Here are some palliative care related links and highlights from the web.

A ICU Nurse and some colleagues rewrote the lyrics to the popular Nickelback song "Rockstar" to emphasize how some patients may feel in the ICU. The video itself is just the lyrics. Here is hoping she puts together more song parodies and maybe a video or two. (Hat Tip: KPW)


If you cannot see the You Tube video, then click on the post title to hear the song on the original post.



If you go to the original You Tube page, make sure to read the comments for insight on how some medical professionals feel about this song and subject.

BMJ has selected palliative care as a focus for "Making a Difference" project. This project will focus on higlighting palliative care in BMJ Journals for the next year. Hooray, more to blog about! Thanks to all that voted. (HT: JP Pinzon)

Dr. Wes comments on the general unhelpful nature of point and click electronic medical records systems for nursing notes. I don't think this is limited to just nurses, as I have seen some doctor's notes look the same regardless of the patient. Why must EMR's have so much data that is worthless? Many of the EMR's I have seen are good for data in, but not for data out. Anybody have a solution? (Thx: Kevin MD)

Psychology Today rails against the 'stages of grief' model being misconstrued again and again as a road map for how you are supposed to grieve. The article has some good points, but without some structure for beginning to tease apart such a complex phenomena and without a basic roadmap, it is that much more difficult to identify complicated grief, and figure out how best to support those experiencing it. A real Catch-22. (Thx: HFA Blog)

Also check out HFA's blog for locally oriented coverage of the Dartmouth Atlas Study. Great post!

Hospice Guy is starting to post more...Hooray! And this time he bares his soul about the Hospice Cap. Don't know about the hospice cap. Well Pallimed has not really commented on it yet, but may soon.

The anonymous Angry Pharmacist has a few choice (not safe for work (NSFW) or sensitive ears) words about the DEA and controlled substance regulation between his pharmacy and his wholesaler. Some interesting points I did not know about pharmacies hidden in the ranting.

Dan Savage, the outspoken sex-advice columnist, eulogized his mother in his column. A profound look at emotions and grief and how one single curse word can convey so much.

At the Hospice and Nursing Homes Blog, Frances Shani Parker has a great poem about the "loss" of our senses and abilities Here is a tiny excerpt:
Handfuls of August clouds
whisk you to a picnic,
hint at mashed potatoes.

Have a good weekend all! I will be off-blog for two weeks in Australia (to give a talk on the clinician's estimate of survival and meet with my CPC mentor).

I have dutifully prepared a few posts ahead of time for Drew to post for me so I don't appear to be a slacker. I am excited to leave, but also excited to come back because Pallimed has some big surprises coming up in mid-May! Any guesses?
Photo courtesy of flick.com user Vermin Inc

Friday, April 25, 2008 by Christian Sinclair ·

Wednesday, April 23, 2008

Crying Doctors?
How to Be A Good Palliative Care Doctor

This is part one in a planned ongoing series of how to be a palliative care doctor. Why doctor and not nurse or social worker? Because I am a doctor, so I can only speak of what I know, but some of the same ideas probably apply regardless of discipline. If someone wanted to submit this from a SW or RN or other perspective, I would be willing to guest post it here.

The New York Times published an essay by a frequent NYT contributor, physician Barron Lerner about the role of emotions in caring for patients. As one may imagine the piece had much to do with working with patients diagnosed with cancer, and those who were dying, familiar arenas to an experienced palliative care doctor. The question in the essay is rhetorical: Should doctors display emotion? The answer to be found in the essay is a good one: If it fits for you and for the situation it can be powerful and potentially strengthen existing bonds. If crying in public is not your thing, don't go there.

In palliative medicine we encounter many sad, difficult and trying situations which test our emotional stamina daily. In fact for some of us, it may be that visceral connection from human to human attracting us to this specialty. I was surprised in residency when I first discovered 'breaking bad news' and 'compassionate honesty' actually led to praise and gratitude from patients and families who would cry, be angry, and eventually come to a certain peaceful but sad acceptance of dying. Using my medical knowledge to guide patients and families through this was personally rewarding and occasionally emotionally difficult, but I never cried in these meetings. In residency I would have these talks once a month or maybe once a week, but once you start doing palliative medicine full time you do this three to four times a day, sometimes 6 or 7 times.

Withdrawal of a ventilator in the ICU on an inpatient palliative consult service. The prolonged waiting of a slow decline in an inpatient hospice unit. Helping a family understand symptom control on home hospice visits. Three to five times a day you are experiencing the sadness, grief, anger, and stress of others as they approach death. Each time is not an intense 90 minute family meeting, but even if you briefly unleash those raw emotions from a patient or family, and the rest of the visit is upbeat and friendly, you as a palliative care doctor are still using some of your emotional stamina.

For some doctors crying at the bedside of a patient is acknowledgment of grief, impending loss, and the connection that has been built. If crying can restore some emotional stamina by releasing pent up negative feelings then this can be worthwhile. If crying at the bedside starts to become something you do more often than not, or start to feel as though you must or should cry, then you might need to look at other ways to replenish yourself and see if your team notices any signs of compassion fatigue/burn-out.

What a good palliative care doctor should not do is allow the crying to change the focus from the family or patient to the physician. This is a good built-in boundary check: If the family is more concerned about you then themselves, you might have gone too far. Some palliative care providers have also used their emotions to make a quick connection to the patient or family. In the guise of 'I lost my (insert relationship here) too,' the palliative care provider avoids the natural trust building and jumps right for the emotional connection. This also turns the focus away from the patient and family and to the provider. Building trust quickly is important in palliative care when you sometimes go from "Zero-to-Death and Dying in 5 minutes", but not at the expense of changing the focus away the patient/family unit.

Do I cry at the bedside? No, I don't, but have I felt a surge of sadness come to me? Sure I have and I later addressed those feelings away from the bedside. How I maintain my emotional stamina in this field is by becoming a professional chameleon, or some may say actor. By professionally adapting to the situation in front of you, your emotions can be sincere, but protected from your core by what I term a 'professional mask.' It is much like a two way mirror. Things come through the mask in both directions; I am able to outwardly display genuine compassion and concern to the level needed without compromising my emotional integrity. But when someone turns the lights on the other side of the two-way mirror, the emotions of the meeting can come through that 'mask' as well to affect me. I am sincere in my concern and compassion I display for my patients, I know because at the end of some days, I can tell my wife I don't feel much like talking and she understands. I am drained. A check of my emotional stamina is thinking about how opaque the mask is.

Is this just a guy thing? Maybe. I would like to hear what some of the female palliative care docs think of crying at the bedside. IS there a different social norm? I don't think the issue can be simplified to a male who is not allowed to show emotions or not in touch with his emotions. I am very familiar with my emotions because of palliative care, more so then I would expect without being in this field. The article also mentions the role of hugging. For me as a male physician, I don't go around giving out hugs to everyone I see, but I have pretty good Hug-dar when a family member is coming in for a hug, so I would not deny that. I am actually a big fan of free hugs from family members. So much so that if I know a family to be particularly generous with their hugs, I will make sure to take the stethoscope off my shoulders so they don't get a face full of ear pieces.

Emotions, crying, boundaries, and self-care are important to avoid burnout and depression. Newsweek recently published an article about physicians, depression and suicide risk, cheerfully titled, "When Doctors Kill Themselves." The article highlights an upcoming PBS special, "Doctors with Depression*", that features a palliative care fellow. I am hoping it highlights self-care training in his fellowship. As a fellowship director, I 'stress' self-care activities for fellows, and letting me know if they are pushing themselves too far. In a fellowship, I think it is actually a good sign if you can recognize when this happens, so don't be afraid to identify that in yourself. The work of a palliative care physician is emotionally taxing, which is why we must look out for ourselves and each other.

How do other palliative care doctors (or other disciplines) deal with emotions, depression, burnout? What is the ideal approach to outward display of emotions for our field and disciplines?

Other bloggers have posted about crying physicians here and here and here.

*Sponsored in part by Wyeth, makers of Effexor

Wednesday, April 23, 2008 by Christian Sinclair ·

Tuesday, April 22, 2008

Morphine vs fentanyl vs methadone; More

Editor's note, evening of 4/23/08: my original post from yesterday went out garbled (a couple paragraphs were missing). I've fixed it as best I can (see the comments on this post). --Drew.

1)
The European Journal of Pain has a randomized trial comparing long acting morphine with transdermal fentanyl or methadone as the initial long-acting drug in cancer patients. This was a prospective, unblinded study of ~100 Italian cancer patients (mean age ~60 years) who had ongoing moderate to severe pain (mean baseline pain scores were 7/10) on weak opioids. (It's unclear what the baseline opioid use was in these subjects - without the paper explicitly saying so one has the impression that the group doing the study used a standard 'WHO Pain Ladder' protocol and these patients were ones who were having ongoing pain despite 'weak,' 'step 2,' opioids. Doses of at least 300mg of tramadol and 180mg a day of codeine were mentioned in the methods section.) They were randomized to 60 mg daily of morphine ER, 25 mcg/hr of TD fentanyl, or 5 mg q8hours of methadone (i.e. a methadone:morphine ratio of 1:4). Doses were then adjusted without any specific protocol (the group's own usual practice was used): for better or worse this study measures one center's 'real-life' experience after the randomization. Break through medication was morphine at about 1/6th of the 24 hour morphine equivalent dose of the long-acting med. Data were collected for a month. An 'intention to protocol' analysis was used: if you know what that means exactly please leave a comment - as far as I can tell it means an intention to treat analysis and they analyzed patients based on initial randomization even if their opioids were switched mid-study for clinical reasons. The study was powered to find a 30% difference in pain intensity.

Findings are easy to summarize:
All groups looked very similar throughout the four weeks (took 2-3 days for doses to stabilize; pain had reduced to the less than 4/10 level at week one and stayed there; side effects were similar). Fentanyl, which has found to be less constipating compared to long acting morphine in previous trials, was not found to be so in this one (although it wasn't necessarily powered to do this).

Two other findings to comment on. First the opioid escalation index was lowest for methadone (not surprising) but was highest for fentanyl (essentially those randomized to fentanyl needed a larger dose increase over the 4 weeks of the study compared to the others). The most obvious suggestion for this is that their chosen equivalent dose of fentanyl (25mcg/hr = 0.6mg fentanyl a day = 60 mg of morphine a day) was too low.

The other one is that these findings seemingly contradict another randomized trial comparing morphine ER with methadone as the initial long-acting opioid (which found that methadone was poorly tolerated compared with morphine and not a better analesic). That study used a methadone:morphine ratio of 1:2 to start off with, and was also starting patients on long-acting drugs relatively earlier - using 30 mg daily of oral morphine instead of 'waiting' until they needed 60 mg. It also used methadone as the break through drug in the methadone arm. These are sufficient differences to make comparison of the studies difficult. I have used the earlier article as a(nother)** reason not to use methadone as a first-line agent but the current study suggests that using this lower, initial ratio may improved methadone's tolerability as a first-line 'strong' opioid. I'm curious as to what others think of this.

**Other reasons for not using it as a first line drug: complex drug-drug interactions, QTc prolongation which is a particular concern in my patients with prolonged prognoses, complexities of transitioning someone off methadone onto another opioid if needed, ongoing lack of head-to-head evidence that it provides any clinical benefit over other opioids, and a general impression that the psychiatric side effects of methadone are worse than with other opioids (sleep disturbances, bad dreams, hallucinations). (That last point is completely a personal impression and not based in anything else.)

ResearchBlogging.orgMERCADANTE, S., PORZIO, G., FERRERA, P., FULFARO, F., AIELLI, F., VERNA, L., VILLARI, P., FICORELLA, C., GEBBIA, V., RIINA, S. (2008). Sustained-release oral morphine versus transdermal fentanyl and oral methadone in cancer pain management. European Journal of Pain DOI: 10.1016/j.ejpain.2008.01.013

2)
Briefies:

a) The American Thoracic Society has released a policy statement on palliative and end-of-life care for patients with respiratory illnesses and in ICUs. Compared to a lot of society statements this one is somewhat of a tour-de-force in its scope and length - a good one for the teaching file. I loved these sentences:

'Families should be informed in advance of agonal breathing so they can view it is as a part of the dying process rather than a sign of patient discomfort. If one uses the term "agonal breathing," one should help the family to understand that it does not imply that the patient is in agony.'

They perhaps should have just recommended not to use the word 'agonal' in front of families altogether.

b) The latest issue of Journal of Clinical Ethics has a case discussion on Jewish law/ethics and artificial nutrition at the end of life (there are a handful of associated commentaries also - links to them are available from the PubMed citation linked-to above). This is the best commentary (from a medical perspective) on this that I've seen since I've been looking and is a good discussion of the issues involved, their history, and conflict resolution surrounding them.

c) Pain Medicine has a review about methadone's drug interactions. It's lengthy and the most comprehensive overview of the topic I've run across.

d) Pain has an editorial about efforts to get transmucosal fentanyl approved for 'breakthrough' pain for chronic non-malignant pain which is really an editorial about what is actually meant by breakthrough pain, and cautions against extrapolating from cancer pain research to CNMP.

e) BMJ has an article describing what the authors describe as the 'co-development' of palliative care and the right to euthanasia in Belgium, which is directed directly at those who worry that the growth of euthanasia would limit the development of palliative care. Their conclusion is that both 'movements' occurred together in Belgium and have shared some synergy (and common 'workers'):
Within Belgium we found few professional stances contending that palliative care and legalisation of euthanasia are antagonistic, no slippery slope effects, and no evidence for the concern of the European Association for Palliative Care that the drive to legalise euthanasia would interfere with the development of palliative care. Rather, there were many indications of reciprocity and synergistic evolution.
My assumption is that this is in BMJ as a debate-sparker as the UK considers 'assisted death' legalization.

Tuesday, April 22, 2008 by Drew Rosielle MD ·

Wednesday, April 16, 2008

Hastening death vs palliative care; Preventing aspiration; more

I am writing this on my front porch as it gets dark - it appears spring is finally arriving to the upper Midwest! I will likely be posting a little less frequently than usual the next couple of months - among other things the 4th baby to be born to a Pallimed contributor since the inception of the blog is heading my way next month and my quiet evenings blogging are fading away for a while.

Today is National Health Care Decisions Day, which I'm sure is a good thing, but as Christian pointed out to me why did it have to come the day after Tax Day? Do 'death & taxes' need to be so closely aligned on our national calendar as well?

1)
Critical Care Medicine has an article about hastening death vs. alleviating suffering in European ICUs. The data come from a large, multinational, prospective study in European ICUs in which aspects of end of life care were measured including, apparently, circumstances in which the treating physicians themselves reported that they made specific treatment decisions to actively hasten death for dying ICU patients. These accounted for ~2% of all deaths in the study. This paper presents the meds which were used (varying doses of opioids, benzodiazepines, and barbiturates mostly) and makes the point that the doses used in the intentionally hastened death patients were similar to doses used in about a third of the patients who died receiving comfort-only care but without intentionally hastened death. That is - if one only looked at drug doses one wouldn't be able to tell the difference between 'palliative care' and 'attempted euthanasia' in many of these dying ICU patients.

Well - true - but so what? First, the absolute magnitude of opioid & benzodiazepine doses doesn't mean much, particularly in opioid tolerant patients (someone giving me 50mg of IV hydromorphone would likely kill me; I've had a few patients who take that much before breakfast), and the fact that there is overlap is not surprising at all. In addition, it's likely that a certain number of these physicians were incompetent both at estimating a lethal/death hastening dose in these patients, as well as appropriate doses for alleviating symptoms (I'm sure the latter is true) and the overlap is, again, not surprising. The real issue here is one of intentionality, and intentions matter, pretty much always, but especially here. If I sneak into an ICU and stop someone's vent in order to kill them - that's murder. If I'm that person's physician, and stop the vent after an informed decision is made by the patient/proxy because the vent is no longer meeting a care goal etc. - that's good medical care, even if the outcome is the same in both cases (the patient dies earlier than they would have if they remained on the vent).

Anyway, that's sufficiently didactic for one post. The paper has a good discussion about intentions and perceptions and talks through the reality that 'palliative care' and deliberately hastening death can look very similar on the surface, which is certainly worth discussing, and is certainly a perception that many lay-people have of what we do (and I'm sure, some of our colleagues). We've commented before on having conversations with well-educated, savvy friends and family members who don't realize that (at least in our world) there is a difference between 'assisted death' and not flogging the dying.

2)
Annals of Internal Medicine has an article looking at interventions to prevent aspiration pneumonia in patients with dementia or Parkinson's disease. Patients (over 500, median age 81 years) were from hospitals or subacute rehab centers and demonstrated aspiration of thin liquids on a video swallow evaluation and were randomized to thin liquids taken in a chin-down position vs. honey thick vs. nectar thick liquids. Primary outcome was pneumonia at 3 months and there weren't major differences between the groups, and a few more adverse events (dehydration) in the thickened liquid group. The authors' discussion addresses this as a quality of life issue: thickened liquids aren't as palatable and don't seem to help (in the specific population they studied) so why not stick with thin liquids?

The question I have after reading this is is there any intervention that has been shown to reduce pneumonia in patients who aspirate? These interventions all seemed equal in this randomized study - and it's possible that none of these interventions was actually offering any protection (that is - if there was a 4th 'control' arm of no intervention - would they have done just as well?). Please comment if you know of any controlled study showing a protective effect of any intervention for aspiration.

3)
Gerontologist has a couple pieces about hospice care....

First is an overview of characteristics of hospice agencies in the US which has some consonance with the last post. The data are from an unfortunately old survey (2000 - these may be the most recent comprehensive data to be sure but things can change pretty fast - in the few years I've been in Wisconsin many local hospice agencies have altered their palette of services) of US agencies providing 'formal' or 'informal' hospice services. The study suggests there are a lot of gaps in the services provided by these agencies (particularly in psychosocial-spiritual realms) - but it looks like most of the gaps are in agencies which aren't (or don't include) a Medicare certified hospice service. My initial question from seeing this was so what?, but in reflecting on the last post maybe it's these agencies which are providing the 'informal' hospice care in regions without hospice coverage. Anyone have experience with this?

The second looks at race and hospice use place of death in nursing home patients, using Florida Medicare & Medicaid data. Consistent with prior research it showed that African American patients were less likely than whites to be receiving hospice care when they die and more likely to die in a hospital. Interestingly, these differences were really among patients who didn't have cancer (such as dementia).

4)
BMJ has a piece about teaching self-reflection in medical trainees. It's a brief, chatty piece about on-the-fly feedback and teaching of this skill. One for the teaching file.

Wednesday, April 16, 2008 by Drew Rosielle MD ·

Monday, April 14, 2008

Some Highlights from the Web

Nothing too hard hitting in this one, those last two posts wore me out. And I like many other fellowship program directors around the country are busy getting our fellowship applications ready for the first round of accreditations due in the next several weeks.

The Happy Hospitalist found a picture on Flickr took a picture from his service reflecting what he sees regularly. His blog post was then picked up by the WSJ Health Blog. The title of his post was "87 years old" and the caption read: A photo worth a thousand words. Now…. multiply by five. One hospital. One service. One day. Mine. This is American health care. It inspired very different takes on his own blog and on the WSJ Health Blog. Read the comments for a pulse of American view points on aggressive ICU care for the elderly.

The WSJ Health Blog also rediscovered a 2006 National Geographic image about the likely causes of death. The image is called the 'death spiral' although it is really more like a Venn Diagram and each circle within representing the likelihood of occurrence based on the size. The line on the outside...that represents the risk of dying if you are living. Mortality risk 1 in 1. Kind of like the satirical paper The Onion reminded us in 1997.

House calls may be making a comeback as featured in the Boston Globe op-ed, but as many hospice physicians know, there are already a lot of us making these home visits. It is always a delight to see people's expressions when they hear you make house calls. Many really don't believe you until you show up at their home.

On the heels of the Medicare Hospice cuts post, comes this study alerted to us by an anonymous poster that demonstrates wide regional variations in hospice density. Unfortunately it was only a paper presentation and not yet published so all we have to go on is the press release text and a small image map, without a clear legend. I am still having trouble with this paragraph in the press release:

On average, the study found, counties have 2.1 hospices located within their borders, but the number ranges from none to 125. When the researchers looked at 60-mile-radius service areas — the range recommended by the National Hospice and Palliative Care Organization — the average number of hospices serving a county was just over 52. But it ranged widely – from none to 280.
Maybe Dr. Silveira could let us in on what the colors mean, if anyone knows her tell her to drop by and fill us in. (She is the winner of the 2006 AAHPM Award for Young Investigators BTW) Dr. Silveira emailed me the key below.

The colors 'categories' on the map mean the following:
> red - highest hospice availability (taking into account 60mi service area around each office)
> orange -medium
> cream - average
> light blue - low availability
> dark blue - lowest availability
(added April 4/22)

The AAHPM opened the first call for the Annual Assembly 2009 in Austin, TX. I will have an upcoming post on how to submit a proposal to a conference, and will welcome any tips from long time presenters to help anyone relatively new to the process. Also, I will make a plea for someone to submit a Philosophy talk about death and dying so I can go to it next year. We need some contemplative/insightful talks at AAHPM next year. If you do propose it and it gets accepted, I promise to plug your talk here before the next conference and get hundreds of people to show up. Well...at least I promise I will show up.

The Hospice Foundation of America has a good hospice news blog that covers focuses on slightly different topics than we do here. I wanted to alert our readers to a two great links HFA Blog highlighted (1, 2). The Concord Monitor received a Pulitzer Prize for Photography for a series on a dying woman's wish to leave a final gift to her children. There is a wonderful narrated slideshow of the prize winning photographs accompanying the article. The second item is a Guardian (UK) photo exhibit of people photographed alive and on the day they died. Wonderful, touching images that are currently on display at the Wellcome Collection.

And you may have heard about bloggers writing until they die. Well, Drew, Tom and I are doing OK, so don't worry about us!

NOTE: Correction made 4/15/08 in second paragraph. Added hospice color key 4/22/08

Monday, April 14, 2008 by Christian Sinclair ·

Friday, April 11, 2008

Medicare Hospice Cuts:
Is Hospice Worth Protecting?

Since more than 83% of hospice care in the United States is funded by the Medicare Hospice Benefit, any cuts to the Medicare budget draws the attention of the hospice & palliative care community. Hospice Guy over at Hospice Blog has done a good job of keeping this issue in the news. Here is how Hospice Guy sums up information from NHPCO:

The detail I missed in the president's budget proposal is that he is proposing the end of the Hospice Wage Index. Instead of having a wage index just for hospices, we would start using the hospital wage index. Now, I'm no rocket scientist, but I'm figuring that a wage index is a wage index. In the long run, that is probably true, but in the short run, it is nowhere near true. The problem here is that there are differences between the two indexes. In my world, we get paid about 5% more using the hospice wage index than we would with the hospital wage index. That means, that if they make this change effective next year, we will not only not get a pay raise (see prior budget post) we will take around a 5% pay cut. That could really hurt.
Basically the Medicare Hospice Benefit payment structure will be frozen for FY 2009-11 and then for the next 3 years be reduced by 0.65%/year. This will provide an estimated $5.1B in savings over 5 years (roughly $1B/year). In addition to the freeze and cut, the hospice wage index will also be phased out over 3 years (what 3 years, I am not sure). This will amount to $2.3B in savings over 5 years.

So the total proposed cuts amount to $7.4B in savings over 5 years or nearly $1.5B/year less total payments to hospice programs. The estimated cost of the Medicare Hospice Benefit is around $10B/year as of 2006 growing about $1B/year (est. 9-10% growth). (Source: NAHC 2007 report)

This $1.5B/year is why you will hear about a 15% cut. Here is a rough side by side comparison of how I understand the numbers. 'Current' being the Medicare Hospice Benefit payments/expenditures and 'With Cuts' demonstrating the total payments with the $1.5B/year cuts proposed. (If anyone knows these numbers more accurately, please email me.)

Hospice agencies have increased in number of providers, and some have broken the Cap that Medicare put in place to prevent taking patients 'too early' in a terminal course. This is quite another issue for another post, but the increase in hospice agencies passing the Cap, and the growth of providers have made CMS suspicious enough to warrant closer inspection. And with Bush trying to find places to make cuts in the Medicare Budget, it may be some gloomy days ahead for hospice organizations.

Unless some action is taken by hospice organizations and grass roots efforts to push back the cuts, I imagine many hospice agencies who are not making a 15% profit are going to find it hard to stay in business. Some of the bigger hospices may be able to weather the cuts, but regardless of for-profit/not-for profit status, these cuts will change our medical landscape.
(Note: many hospices have to subsidize services with community donations and therefore are not making a profit)

And all this on the heels of the study that showed hospice care saves an average of $2,309 for every Medicare recipient receiving hospice services. With 1.3M people receiving hospice in 2006, and 83% of those people under the Medicare Hospice Benefit, hospice care saved Medicare almost $2.5B last year. That's right $2.5B. And they are suggesting 15% cuts in funding annually over the next 5 years. Looks like Medicare actually might be paying more in the end.

So what can you do? Write your elected representatives via NHPCO's handy CapWiz system and tell them what you think about the proposed cuts to hospice. Or contact your local media since this has not been there much. Or get a letter writing campaign started at your hospital or hospice. Our field touches many people so getting the word out should not be hard. If anyone wants to write a sample letter to your elected representatives, please add it in the comments. And if you do write your representatives, put a comment here so the other 700+ readers see they are not alone.

PS This post was unusually and surprisingly difficult to research. And not because I generally lack excitement over policy/budgetary issues. Most of the information on this important PUBLIC policy issue was locked behind membership walls at NHPCO, nor the NHPCO's sister lobbying organization, AFCEOL, which had some outdated links to membership blocked parts of the NHPCO website. Nothing was located on the front page of the AAHPM. Absent too was any information from the HFA. Nowhere to be found on Pallimed until now (I can point fingers at myself too.) The NAHC website had the most open access information. And looking up the OMB or White House sites was absolutely fruitless in finding any information about CMS payment. And I do not consider myself a search engine Luddite. So kudos to Hospice Guy at Hospice Blog and NAHC for being accessible on this issue. And to the rest of us, let's step this up a bit.

4/12/08 23:27 NOTE: Some items clarified from original post after an alert reader emailed me. ($ added to monetary figures, note about many hospice agencies not making profits, minor grammar changes for clarification)

Friday, April 11, 2008 by Christian Sinclair ·

Thursday, April 10, 2008

Specialized Palliative Care is Not Effective...or Is It?

(Begin sarcasm)
Stop the palliative medicine fellowship accreditation! Stop the first official accredited subspecialty palliative medicine boards this year! Tell JACHO not to include palliative care in their next round of hospital reviews! Find a job in a procedure based specialty! Quick! Hurry before it is too late. In case you have not heard, palliative care doesn't do anything beneficial.
(End sarcasm)


Don't PanicNow take a deep breath. Do some self-care. Don't over-react.

ResearchBlogging.orgLet's look at the study JAMA published this week on a detailed systematic review on the "Effectiveness of Specialized Palliative Care." Dr. Camilla Zimmermann and colleagues from Toronto and Sao Paulo did an exhaustive review of the available literature on randomized control trials looking at organized palliative care interventions. Shall we start with the Conclusion as that is what most people will look at first before deciding whether to delve in deeper.
"The evidence for benefit from specialized palliative care is sparse and limited by
 methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population are needed."
Do you think many people in or out of the field of palliative care would read this and have the feeling palliative care may not be effective and therefore is not worth the investment?
Well if I were trying to figure out whether to include palliative care in my health care facility/company budget, a study like this does not give administration warm fuzzies, which is why I would like to explain the real lesson from this study.

Read the conclusion again, slowly, and without my catastrophic thoughts from the beginning of this post. This is not a descriptive study about the failure to show a benefit from palliative care interventions. This is a prescriptive study. The article is designed to warn against further efforts of research bound to fail despite many work hours. The article is designed to teach palliative care researchers how to design better studies and to start making more uniform study designs. The key part of the conclusion is the "limitation of methodological shortcomings."

Many of us see that palliative care works. We see it every day in our work. We just have not done the best job studying and marketing our successes, especially in a objective, scientific paradigm. As I was walking out of the hospital today, a respiratory therapist from the ICU, stopped to tell me how much he appreciated the palliative care team, and the difference he has seen it make for patients, families and staff. I am sure many readers of this blog can share similar stories. But this demonstrates an anecdotal, subjective, and narrative method of effectiveness, one that does not resonate as well as statistical objective numbers would to the administrative/business/policy people.
Zimmerman and colleagues teach us some important things in the article for our field to design better studies to show our talents. Here are some of the key highlights:

Hire a statistician:
Sample size calculations for statistical power were rarely done. This is shooting your study down before it leaves the gate.
Define the population:
Just taking people referred to palliative care and then randomizing causes all sorts of biases to be introduced. That could be a greatly heterogeneous population which can never be replicated, reducing the possibility of pooled meta-analysis. Rather pick objective assessment criteria like all oncology patients with a Palliative Performance Status of 60 percent or less and then randomize to usual care or concurrent palliative care.

Pick a hypothesis: Many studies measured everything under the sun, and then reported the positive findings. Choose a primary outcome measure (single, one, uno, ein) and leave the rest in the secondary outcomes part of the article.

Pick your survey tools carefully:
Do not use the one you made up last week, because you wanted to ask 'interesting questions.' There are many survey tools with many pro/con arguments, and different applicability to palliative care populations. Choose wisely.

Cost-effectiveness analysis is tricky:
We need to take a global approach to cost-effective analysis as the hospital/insurance/Medicare may save money, but the palliative care team loses money. That is going to be hard to sustain, unless larger support exists from the system for palliative care team (inpatient and outpatient).

Overall this is a great study, which serves as a wonderful resource to palliative care/health systems researchers on how to do future studies. It does not condemn the field to irrelevance as a brief glance at the summary may suggest, and I commend the authors and JAMA for not making the lack of evidence part of the title which could have been grossly misinterpreted. I encourage you to scan the Results section to see how much variability existed in these studies. So to conclude...keep your job, sign up for the boards, get your CHPN, and make sure your administration understands this article is not a swan song for our field, and they better get ready cuz JACHO wants to see more palliative care.
Zimmermann, C., Riechelmann, R., Krzyzanowska, M., Rodin, G., Tannock, I. (2008). Effectiveness of Specialized Palliative Care: A Systematic Review. JAMA: The Journal of the American Medical Association, 299(14), 1698-1709. DOI: 10.1001/jama.299.14.1698



(For those who missed the LOLcat phenomenon of 2007, this is a riff on "I CAN HAS CHEEZBURGER?" I find them pointless and hilarious, my wife just laughs at me for laughing at the pictures.)

Thursday, April 10, 2008 by Christian Sinclair ·

Sunday, April 6, 2008

Lectures about Death at Yale and Carnegie Mellon

In perusing some of the great (and not-so-great) general education resources from colleges and universities, I stumbled across a philosophy course by Professor Shelly Kagan on Death. Dr. Kagan has written a book called Normative Ethics, which is the study of what is ultimately right and wrong rather than what we believe to be right or wrong. If that doesn't confuse you then this free course might be right up your alley. (There is another session from Yale on Intro to Psychology for those who need a little brushing up.)

The course was originally recorded in the Spring of 2007 and the 26 hour-long sessions are available in mp3, QT, flash or transcript formats. I originally started watching the videos, but since Dr. Kagan does not write on the board much and mostly sits on his desk and talks, I switched to the mp3 formats and have been listening in my car/Ipod. The talks themselves are informative and provide a helpful background into centuries of thought in regards to our current existence and approach towards dying and thoughts of the afterlife. This lecture series is not for everyone, as it can sometimes get pretty abstract, and I occasionally found myself wondering, "Is this a good use of my time? Will this change my practice?" The answers I came to were: Yes and probably not.

I am unlikely to engage many families or patients deeply on issues of spirituality or afterlife as these conversations are usually brief and affirmative of whatever core belief of the patient and family. Rarely are these bedside discussions of spirituality drilled down to the nature of 'what is the soul?' and 'Did Plato's view on forms really support the argument on recollection as a valid theory of existence?' Nor am I likely to have these sort of deep philosophical discussions with staff as we are trying to solve the latest clinical or social challenge in our daily routine. "Yes, let's see if the nausea is better with phenergan...now Heather tell me do you think you are the same person right now as you are in the future?" So to find any value in these lectures I had to realize they help me internally process/understand the suffering/death/joy/relief seen in palliative care on a daily basis. So for those that have the time, enjoy some free Yale teaching! Although I would like to see more philosophical lectures in palliative care education or at national meetings for anyone who would be qualified to give these talks.

"MY LAST LECTURE"

No, not my last lecture but Randy Pausch, the professor from Carengie Mellon University who became an internet sensation when his 'last lecture' was posted to You Tube and seen by hundreds of thousands of people. He recently highlighted some of that talk in an article he wrote for PARADE magazine. (I know, I know...we always cite the New York Times, Washington Post or Newsweek, but hey PARADE is in my Sunday Kansas City Star and he was on the cover...oh never mind.) He was diagnosed with metastatic pancreatic cancer in September 2006 and is still alive today testifying before congress and raising funds for pancreatic cancer research. The video is about 75 minutes, and demonstrates a very constructive approach to such a life-changing event. (He is also a very good presenter, so take notes on his style, use of slides, speech and engagement with the audience.)





MENTORING

The AAHPM and the College of Palliative Care are continuing the Year-Long Mentoring Program and the deadline is May 19, 2008. I have been fortunate enough to benefit from this program in being mentored by Paul Glare with a focus on Prognostication. Because of the collaboration this mentor program facilitated, I have been able to co-author a textbook chapter, and write a few journal articles on prognostication, and will soon traveling to meet with Paul and discuss prognostic research and some editorial articles I am working on. As you can see this is a great opportunity, so if you are just a few years out of training, consider applying.

If anyone is interested in working on prognosis, Pallimed/medical blogs, or other topics, I'll throw my hat in to be available to work with someone as a mentor. The AAHPM could also help in identifying a mentor. Don't be afraid to aim for the stars, as I had initially asked Nicholas Christakis (author of a seminal palliative care book, Death Foretold), but he said he was no longer doing prognosis research and referred me to Paul Glare as the go-to guy in the field on prognosis. They both have been great and supportive.

FELLOWSHIP PROGRAMS

Last week was the Fellowship Program Director annual meeting in Chicago, where we discussed the future accreditation of Palliative Medicine Fellowship Programs for July 2008. There is a lot of work to be done and forms to be filled out, and most importantly a lot of collaborating between hospice and hospitals to make sure that fellowships are well balanced. So what does it take to be a palliative medicine doctor and how do you know this is the field for you? If you are a palliative medicine fellow, recently finished fellow or faculty and want to write a guest post on what it takes, please email me at:

Sunday, April 6, 2008 by Christian Sinclair ·

Wednesday, April 2, 2008

Leukemia & ICU prognosis; More

1)
Cancer has a retrospective study looking at prognosis of patients with acute leukemia admitted to the ICU. It looks at all patients with acute leukemia (in any stage of their illness as long as it was pre-transplant) admitted to the ICU at a single institution over a 4 year period - 90 patients in all, mean age ~54 years, almost all had AML. Mortality up to 12 months was measured.

Major findings: ICU mortality was ~57% with another 11% dying that hospitalization prior to any treatment for leukemia (out of the ICU). A few percent recovered, were treated, then died. Only 27% survived to hospital discharge; 6 and 12 month survival was 18% and 16%. Having received a BMT preparative regimen and having a higher APACHE-II score were predictive of particularly bad outcomes. Of note, 2 month mortality was >90% for patients with AML, who needed inotropes and mechanical ventilation and stayed in the ICU at least 7 days.

The authors conclude, more or less, that everyone is wrong (wrong!) who ever suggested that ICU-level care is inappropriate for patients with acute leukemia because the outcomes aren't that bad. That seems like a bit of a straw-man argument to me - who are these people blocking admission to the nation's ICUs for leukemic patients? One could make an equally compelling argument that survival is so poor for these patients that a 'concurrent care model' (offering both curative and palliative-oriented care simultaneously) should be the standard of care, as well as having serious informed consent discussions with these incredibly ill patients & their families about treatment options (including limitations) given the likelihood of a poor outcome.

ResearchBlogging.orgThakkar, S.G., Fu, A.Z., Sweetenham, J.W., Mciver, Z.A., Mohan, S.R., Ramsingh, G., Advani, A.S., Sobecks, R., Rybicki, L., Kalaycio, M., Sekeres, M.A. (2008). Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit. Cancer DOI: 10.1002/cncr.23394

2)
Pain Practice has a critical, narrative review of sympathetic blocks for pain relief. Reviews the evidence (which is spotty, to be generous) and then endorses blocks heartily. That aside, it's a pretty good one for the teaching file, especially as an introduction to sympathetic ganglion blocks: it discusses the different blocks' techniques and indications, gives one a sense of their history, and has a good reference list

3)
JCO's Art of Oncology section has a personal narrative about being confronted with a dying patient and struggling with what to say, being paralyzed by fear and heartache (written by a colleague of mine from my institution who is also a blogger). There's also an accompanying editorial about educating oncologists/oncology fellows about difficult communication.

4)
The Journal of Health Psychology has published the best-titled paper I have seen in a while: Love Medicine for the Dying & Their Caregivers - The Body of Evidence.

5)
Finally, and building on a conversation Tom & I had in the comments section of his last post, Palliative Medicine has published an editorial about the term 'palliative care' - in particularly lamenting language such as 'a palliative patient.'

Wednesday, April 2, 2008 by Drew Rosielle MD ·