Abstract
Warmenhoeven F, van Rijswijk E, van Hoogstraten E, et al.: How family physicians address diagnosis and management of depression in palliative care patients. Ann Fam Med 2012;10:330–336.
Depression is highly prevalent in palliative care patients. In clinical practice, there is concern about both inadequate diagnosis and treatment of depression as well as excessive diagnosis and treatment. In the Netherlands, family physicians have a central role in delivering palliative care. In this focus group study, the authors explored variation in family physicians' opinions regarding the recognition, diagnosis, and management of depression in palliative care patients. The authors selected family physicians with varied practice locations and varying expertise in palliative care. Transcripts of interviews were analyzed independently by two researchers using constant comparative analysis in ATLAS. In 4 focus group discussions with 22 family physicians, the physicians described the diagnostic and therapeutic process for depression in palliative care patients as a continuous and overlapping process. Differentiating between normal and abnormal sadness was viewed as challenging. The physicians did not strictly apply criteria of depressive disorder but rather relied on their clinical judgment and strongly considered patients' context and background factors. They indicated that managing depression in palliative care patients is mainly supportive and nonspecific. Antidepressant drugs were seldom prescribed. The physicians described difficulties in diagnosing and treating depression in palliative care, and gave suggestions to improve management of depression in palliative care patients in primary care. The authors conclude that family physicians perceive the diagnosis and management of depression in palliative care patients as challenging. They rely on open communication and a long-standing physician-patient relationship in which the patient's context is of great importance. This approach fits with the patient-centered care that is promoted in primary care.
Horton MR, Santopietro V, Matthew L, et al.: Thalidomide for the treatment of cough in idiopathic pulmonary fibrosis: A randomized trial. Ann Intern Med 2012;157:398–406.
Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal disorder of unknown cause with no effective treatment. Cough affects up to 80% of patients with IPF, is frequently disabling, and lacks effective therapy. In this single university 24-week, double-blind, 2-treatment, 2-period crossover trial the authors attempted to determine the efficacy of thalidomide in suppressing cough in patients with IPF. Ninety-eight participants were screened; 24 were randomly assigned; 23 received treatment (78.3% men, mean age 67.6 years, mean FVC 70.4% predicted); and 20 completed both treatment periods. The primary endpoint was cough-specific quality of life measured by the Cough Quality of Life Questionnaire (CQLQ). Secondary endpoints were visual analogue scale of cough and the St. George's Respiratory Questionnaire (SGRQ). For all measures, lower scores equaled improved cough or respiratory quality of life. Results demonstrated that CQLQ scores significantly improved with thalidomide, with mean difference versus placebo −11.4 (95% CI, −15.7 to −7.0), P<0.001. Thalidomide also significantly improved scores on the visual analogue scale of cough, with mean difference versus placebo −31.2 (CI, −45.2 to −17.2), P<0.001). In participants receiving thalidomide, scores from the total SGRQ, SGRQ symptom domain and SGRQ impact domain improved compared with those of participants receiving placebo. Adverse events were reported in 74% of patients receiving thalidomide and 22% receiving placebo; constipation, dizziness, and malaise were more frequent with thalidomide. The authors conclude that thalidomide improved cough and respiratory quality of life in patients with IPF, and that a larger trial is warranted to assess these promising results.
Cameron P, Ellis PM, Pond GR, Goffin JR: Do beta-blockers alter dyspnea and fatigue in advanced lung cancer? A retrospective analysis. Palliat Med 2012;26:797–803.
Dyspnea is common in lung cancer and may be partially attributable to increased ventilatory drive due to muscle weakness. The authors wondered whether the sympathetic component of this pathway might be mitigated by beta-blockers. In this retrospective review of new patients with stage III–IV non-small lung cancer or any small cell lung cancer, the authors attempted to assess the impact of beta-blocker use on dyspnea and fatigue. Data were abstracted for clinical characteristics, beta-blocker use, and pretreatment Edmonton Symptom Assessment System dyspnea and fatigue scores. Results demonstrated that of 348 patients assessed, 202 met eligibility criteria. The median age was 67, 55.4% were female, 18.8% had chronic obstructive pulmonary disease (COPD), and 5.9% had active coronary artery disease. Over 60% of patients scored 4/10 or higher on their dyspnea and fatigue scores. While dyspnea and fatigue were moderately associated, no association was found between beta-blocker use and either symptom. Recorded dosages of beta-blockers were low. COPD was associated with dyspnea and fatigue, while anemia was associated with fatigue. The authors conclude that dyspnea and fatigue are prevalent and increased in the presence of COPD and anemia, and that there is no association between beta-blocker use and dyspnea or fatigue scores. This may be attributable to inadequate dosing or to retrospective bias.
Mustafa T, McAlister FA, Coglianese EE, et al.: Testosterone supplementation in heart failure: A meta-analysis. Circ Heart Fail 2012;5:315–321.
Low testosterone is an independent predictor of reduced exercise capacity and poor clinical outcomes in patients with heart failure (HF). The authors sought to determine whether testosterone therapy improved exercise capacity in patients with stable chronic HF. The authors searched Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (1980–2010). Eligible studies included randomized controlled trials (RCTs) reporting the effects of testosterone on exercise capacity in patients with HF. Reviewers determined the methodological quality of studies and collected descriptive, quality, and outcome data. Four trials (n=198; men, 84%; mean age, 67 years) were identified that reported the six-minute walk test (two RCTs), incremental shuttle walk test (two RCTs), or peak oxygen consumption (two RCTs) to assess exercise capacity after up to 52 weeks of treatment. Testosterone therapy was associated with a significant improvement in exercise capacity compared with placebo. The mean increase in the six-minute walk test, incremental shuttle walk test, and peak oxygen consumption between the testosterone and placebo groups was 54.0 m (95% CI, 43.0m–65.0 m); 46.7 m (95% CI, 12.6m–80.9 m); and 2.70 mL/kg per min (95% CI, 2.68 mL/kg–2.72 mL/kg per min), respectively. Testosterone therapy was associated with a significant increase in exercise capacity as measured by units of pooled SDs (net effect, 0.52 SD; 95% CI, 0.10–0.94 SD). No significant adverse cardiovascular events were noted. The authors conclude that given the unmet clinical needs, testosterone appears to be a promising therapy to improve functional capacity in patients with HF. Adequately powered RCTs are required to assess the benefits of testosterone in this high-risk population with regard to quality of life, clinical events, and safety.
Reeves BM, Dakhil SR, Sloan JA, et al.: Further data supporting that paclitaxel-associated acute pain syndrome is associated with development of peripheral neuropathy. Cancer 2012;118:5171–5178.
Paclitaxel causes an acute pain syndrome (P-APS), occurring within days after each dose and usually abating within days. Paclitaxel also causes a more classic peripheral neuropathy, which steadily increases in severity with increasing paclitaxel total doses. Little detail is available regarding the natural history of these two syndromes, or any relationship between them, although a recent publication does provide natural history data about weekly paclitaxel, supporting an association between the severity of P-APS and eventual peripheral neuropathy symptoms. In this study, participating patients were about to receive paclitaxel and carboplatin every three weeks. Daily questionnaires were completed for the first week after every chemotherapy dose, and European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire, Chemotherapy-Induced Peripheral Neuropathy 20-item instruments were completed weekly. Results demonstrated that the P-APS severity peaked on day 4 after the initial chemotherapy dose, with 12%, 29%, 23%, and 36% of patients having maximal pain scores of 0, 1 to 4, 5 or 6, or 7 to 10 during the first week after the first dose of therapy, respectively. Patients with P-APS scores of 0 to 4 with the first dose of chemotherapy had less eventual sensory neuropathy than did patients with P-APS scores of 5 to 10 (P=0.001). With regard to the more peripheral neuropathy, sensory neuropathy was more problematic than was either motor or autonomic neuropathy. Numbness and tingling were more common components of the sensory neuropathy than was pain. The authors conclude that patients with worse P-APS severities appear to have more eventual chemotherapy-induced peripheral neuropathy, providing support for the concept that P-APS is a form of nerve pathology.
Brush DR, Rasinski KA, Hall JB, Alexander GC: Recommendations to limit life support: A national survey of critical care physicians. Am J Respir Crit Care Med 2012;186:633–639.
There is debate about whether physicians should routinely provide patient surrogates with recommendations about limiting life support. To further explore physicians' self-reported practices and attitudes, a cross-sectional, stratified survey of 1000 randomly selected U.S. critical care physicians was mailed. The authors included a vignette to experimentally examine how surrogate desire for a recommendation and physician agreement with the surrogate modified whether physicians would provide a recommendation. Measurements and results were the proportion of respondents reporting they routinely provide surrogates with a recommendation and how responses varied based on vignette characteristics. A total of 608 (66%) of 922 eligible physicians participated. Approximately 1 (22%) in 5 reported always providing surrogates with a recommendation, whereas 1 (11%) in 10 reported rarely or never doing so. Almost all respondents reported comfort making recommendations (92%) and viewed them as appropriate (93%). Most also viewed recommendations as a critical care physician's duty (87%) and did not view them as unduly influential (80%). Approximately two-fifths (41%) believed recommendations were only appropriate if sought by surrogates. In response to the vignettes, nearly all respondents (91%) provided a recommendation when the surrogate requested a recommendation and the physician agreed with the surrogate's likely decision. Physicians were less likely to provide an unwanted recommendation both when physicians agreed (29%) and when they disagreed with the surrogate's likely decision (44%). The authors conclude that there is substantial variation among physicians' self-reported use of recommendations to surrogates of critically ill adults. Surrogates' desires for recommendations and physicians' agreement with surrogates' likely decisions may have important influence on whether recommendations are provided.