Wednesday, August 5, 2009

Pall-Pourri: Vertebroplasty & the QTc

European Journal of Cancer
has a small case series about vertebroplasty for vertebral metastases from solid malignancies. The study involves all consecutive vertebroplasties (n=19, mostly breast and prostate cancer, mean age 70 years, 47% received multiple level interventions at the same time) performed at a single UK center. In a relatively loose fashion, pain relief was assessed afterwards and at at least 3 month followup. They report that 84% (16) patients reported 'immediate benefit' in pain and ability to ambulate, and that all 16 of those continued to report some benefit (although unclear how much) at 3 months. 15 reported decreased use of analgesics although how much etc. is not described. We talked recently about the large, randomized, unblinded trial of a similar procedure (balloon kyphoplasty) which included a handful of cancer patients. This study confirms the general clinical impression that these procedures are helpful for most patients but doesn't unfortunately add much to that (how helpful, how long, how much more than medical management, etc.).

Late entry 8/5- I'm adding this after I originally posted this earlier today so it will at least be up to date for those who read this on email: two people have already emailed me about tomorrow's NEJM which presents two randomized, sham-procedure controlled trials of vertebroplasty for osteoporotic fractures and found no benefit over a sham procedure (here & here). I've only read these in abstract at this point; but will blog in-depth soon. Exciting stuff. Thanks to Drs. David Weissman & Bob Arnold who let me know.

Annals of Internal Medicine has published a series of highly critical letters about the recently published consensus guidelines on QTc prolongation and methadone (our original blog post here; letters here, here, here, here; authors' reply here; original article here). The major themes of the letters are that QT monitoring as suggested in the guidelines is impractical, actual rates of harmful events from QT prolongation in methadone are very low, for patients on methadone maintenance therapy there is often no effective alternative to help maintain abstinence, and the evidence one way or the other is crap. This latter point is the real one; there can be such widely-divergent, well-informed opinion about this because there is really very little practical data to guide us.