Abstract
Molassiotis A, Brearley SG, Stamataki Z: Use of antiemetics in the management of chemotherapy-related nausea and vomiting in current UK practice. Support Care Cancer 2011;19:949–956.
Chemotherapy-induced nausea and vomiting is a major quality-of-life issue with cancer patients, and treatments remain far from optimal. In this study, the authors attempted to assess antiemetic prescriptions used during chemotherapy in the UK and identify if their use is in agreement with internationally agreed upon consensus guidelines (MASCC/ASCO). A web-based survey in the UK was carried out collecting data through a 32-item questionnaire using a snowball sampling technique and the e-mail lists of two large oncology societies in the country. Participants were 154 oncologists and oncology nurse prescribers. Results demonstrated a great variability in antiemetic prescriptions, with most not in accordance with MASCC/ASCO consensus guidelines. The variability was also reflected in the doses of antiemetics used. Overall, clinicians undertreated patients receiving highly emetogenic chemotherapy and overtreated patients receiving low and minimally emetogenic chemotherapy. Eight of ten clinicians, however, prescribed antiemetics in accordance with consensus guidelines in moderately emetogenic chemotherapy. There was more agreement between clinicians and guidelines for acute nausea/vomiting and less for delayed symptoms. The authors conclude that the low level of agreement between actual clinical practice and evidence-based consensus guidelines may be one of the reasons for the considerable incidence of chemotherapy-related nausea and vomiting, and that there is a need to utilize consensus guidelines more widely and to educate clinicians on this aspect of supportive care.
Marcantonio ER: Delirium: Screening and prevention. Ann Intern Med 2011;154:ITC61.
Delirium is a common problem among hospitalized patients, elderly patients, and patients at the end of life. In fact, delirium is reported in up to 75% of patients of any age admitted to an intensive care unit, with cumulative incidence of delirium at the end of life reported to be as high as 85%. As noted by the author at the beginning of this excellent piece from the “In The Clinic” section of the Annals of Internal Medicine: A recently published meta-analysis that included almost 3000 patients followed for a mean 22.7 months showed that delirium was independently associated with an increased risk for death (odds ratio [OR], 2.0 [95% CI, 1.5 to 2.5]), institutionalization (OR, 2.4, [CI, 1.8 to 3.3]), and dementia (OR, 12.5, [CI, 11.9 to 84.2]). Further, another recent systematic review found that the persistence of delirium may play an important role in its association with poor long-term outcomes. In this review, delirium persistence rates at discharge, 1, 3, and 6 months were 44.7%, 32.8%, 25.6%, and 21%, respectively, and outcomes (mortality, nursing home placement, function, cognition) of patients with persistent delirium were consistently worse than those of patients who recovered. Delirium is a debilitating and common malady with poor clinical outcomes, and as such, this article is a “must read” for anyone involved in medical care, irrespective of medical specialty. It is comprehensive and includes sections on Screening and Prevention, Diagnosis, Treatment, Practice Improvement, Tool Kit, and Patient Information. As proffered by Bob Arnold on Twitter, and as bears mentioning again, this is a valuable article that should be read by all clinicians (did I mention this should be read by all clinicians?).
Henry G, Williamson D, Tampi RR: Efficacy and tolerability of antidepressants in the treatment of behavioral and psychological symptoms of dementia, a literature review of evidence. Am J Alzheimer's Dis Other Demen 2011;26:169–183.
Antidepressants are frequently used in the treatment of the behavioral and psychological symptoms of dementia (BPSD). The objective of this review was to summarize the current data on the use of antidepressants in the treatment of BPSD and to determine whether these medications can be recommended for routine clinical use. A literature search of 6 major databases (PubMed, Medline, PsychINFO, Scopus, Web of Science, and Cochrane collaboration) and analysis of the randomized controlled double-blinded clinical trials found therein was done. At least 11 trials, 8 using a selective serotonin reuptake inhibitor (SSRI) compound and 3 using trazodone, showed benefit in the treatment of BPSD. The antidepressant drug was well tolerated in at least 14 of the 19 trials with information about tolerability in one trial not provided in the study (paroxetine or placebo for frontotemporal dementia). This review suggests that antidepressants can be effective in the treatment of BPSD and are generally well tolerated in elderly demented patients.
Cohen-Cymberknoh M, Shoseyov D, Kerem E: Managing cystic fibrosis. Strategies that increase life expectancy and improve quality of life. Am J Respir Crit Care 2011;1463—1471.
The survival of patients with cystic fibrosis (CF) continues to improve, and the management of CF will become increasingly important for palliative care clinicians. The discovery and cloning of the CFTR gene more than 21 years ago led to the identification of the structure and function of the CFTR chloride channel. New therapies based on the understanding of the function of CFTR are currently under development. The better clinical status and improved survival of patients with CF is a result not only of understanding of the molecular mechanisms of CF, but also of the development of therapeutic strategies that are based on insights into the natural course of the disease. Current CF treatments that target respiratory infections, inflammation, mucociliary clearance, and nutritional status are associated with improved pulmonary function and reduced exacerbations. Patients benefit from treatment at a specialized CF center by a multidisciplinary dedicated team with emphasis being placed on frequent visits, periodic testing, and monitoring adherence to therapy. The purpose of this review was to survey recent developments in CF care that are responsible for the improved survival and quality of life of patients with CF, patients who will increasingly be seen by palliative care clinicians.
Davidson PM, Johnson MJ: Update on the role of palliative oxygen. Curr Opin Support Palliat Care 2011;5:87–91.
Oxygen is used frequently in hospice and palliative care with little thought to its efficacy. The purpose of this review was to review the efficacy and appropriateness of palliative oxygen therapy. Despite the widespread use of oxygen therapy in clinical and community settings, data supporting this approach are sparse. The benefits of long-term oxygen therapy for severely hypoxemic people with chronic obstructive pulmonary disease are proven; however, mounting evidence suggests that oxygen does not confer additional benefit over medical air for the relief of refractory breathlessness in people with mild or absent hypoxemia. The authors conclude that on the basis of the findings of this review, the routine use of palliative oxygen therapy without detailed assessment of pathogenesis and reversibility of symptoms cannot be recommended. Promoting self-management strategies, such as cool airflow across the face, exercise, and psychological support for patients and caregivers should be considered before defaulting to oxygen therapy. If palliative oxygen therapy is considered for individuals with transient or mild hypoxemia, a therapeutic trial should be conducted with clinical review after 3 days to assess the net clinical benefit and patient preference.