PC-FACS
2011; Elsevier BV; Volume: 41; Issue: 2 Linguagem: Inglês
10.1016/s0885-3924(11)00044-3
ISSN1873-6513
Autores ResumoPC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev 2010;(7):CD007570. Carlson LE, Groff SL, Maciejewski O, Bultz BD. Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol. 2010 Oct 12. [Epub ahead of print]. Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med 2010; 170(15):1302–1307. Macea DD, Gajos K, Daglia Calil YA, Fregni F. The efficacy of web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. J Pain 2010;11(10): 917–929. Kerba M, Wu JS, Duan Q, Hagen NA, Bennett MI. Neuropathic pain features in patients with bone metastases referred for palliative radiotherapy. J Clin Oncol 2010 Oct 4. [Epub ahead of print]. Fainsinger RL, Nekolaichuk C, Lawlor P, et al. An international multicentre validation study of a pain classification system for cancer patients. Eur J Cancer 2010;46(16):2896–2904. Jang Y, Kwag KH, Chiriboga DA. Not saying I am happy does not mean I am not: cultural influences on responses to positive affect items in the CES-D. J Gerontol B Psychol Sci Soc Sci 2010;65(6):684–690. Fleishman SB, Khan H, Homel P, et al. Testosterone levels and quality of life in diverse male patients with cancers unrelated to androgens. J Clin Oncol 2010 Oct 25. [Epub ahead of print]. Lynch-Jordan AM, Kashikar-Zuck S, Goldschneider KR. Parent perceptions of adolescent pain expression: the adolescent pain behavior questionnaire. Pain 2010;151(3):834–842. Chanques G, Viel E, Constantin JM, et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain 2010;151(3):711–721. Note to readers: Please see the December 2010 JPSM for the PC-FACS Issue 99 table of contents. Contextual errors are failures to identify elements of a patient's environment or behavior that require consideration in planning care. How effective at decreasing contextual errors is an educational intervention designed to help physicians incorporate patients' contexts into assessment and care management? This was a quasi-randomized controlled trial of an educational intervention vs. control (observation only). The intervention consisted of four weekly one-hour case-based sessions to help medical students develop knowledge and skills in contextualizing patient care. Participants were fourth-year medical students in internal medicine subinternships. Domains of patient context covered in the intervention were cognitive abilities, emotional state, cultural and spiritual beliefs, access, social support, caretaker responsibilities, attitudes to illness, relationship with clinicians, and finances. Participants applied these concepts to four validated standardized patient encounters. Main outcomes were probing for contextual issues, probing for medical issues, and developing an appropriate treatment plan. Participants (n=124) were mean age 28 years (SD 3), 48% male, and 35% white. Students receiving the educational intervention were significantly more likely to probe for contextual issues in standardized patient encounters than students who were only observed (90% vs. 62%; 95% CI, 87%-94% and 54%-69%, respectively) and to develop appropriate treatment plans for standardized patients with contextual issues (69% vs. 22%; 95% CI, 57%-81% and 12%-32%, respectively). Groups were similar in rates of probing for medical issues (80% vs. 81%; 95% CI, 75%-85% and 76%-86%, respectively) and developing appropriate treatment plans for standardized patients with medical issues (54% vs. 66%; 95% CI, 42%-67% and 53%-79%, respectively). Palliative care providers naturally incorporate the full biopsychosocial aspects of care for both patient and family into clinical decision making. However, studies of clinical decision making of residents and attending physicians demonstrate that physicians are more likely to make contextual errors than biomedical errors.1,2 This study demonstrates that a brief training improves student awareness and exploration of contextual issues. Putting any decision into proper context is essential for patient-centered care; however, several important issues are not resolved by this study. The evaluation occurred just 3-10 days after the intervention. Whether contextual awareness persists over time is unclear. It is also uncertain whether such an intervention would work with practicing clinicians or residents and if the intervention impacts actual clinical encounters. If so, future research evaluating the impact of contextualizing patient care in different settings would be of interest, because more vulnerable populations such as those at the end of life may experience greater benefit. Teaching contextual issues with cases improves medical student probing for and incorporating issues into care plans for standardized patients. Paul E. Tatum III, MD, MSPH, CMD, FAAHPM, University of Missouri, Columbia, MO. Schwartz A, Weiner SJ, Harris IB, Binns-Calvey A. An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients. JAMA 2010;304(11): 1191–1197.References1.Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making. Med Decis Making 2007;27(6):726–734.2.Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med 2010;153(2):69–75. Despite the recognized importance of psychological distress in cancer patients, routine screening for distress is rare.1 What is the comparative effectiveness of three levels of distress screening? This was a randomized controlled trial of three routine online screening conditions for distress: (a) minimal screening: National Comprehensive Cancer Network Distress Thermometer (DT), usual care; (b) full screening: DT, problem checklist, Psychological Screen for Cancer Part C measuring anxiety and depression, personalized summary report, report placed in medical record; (c) triage: full screening, optional personalized phone triage to psychosocial care resources/referral. All new adult patients in the breast and lung cancer outpatient clinics of a university cancer center were eligible. Primary outcome was distress at 3 months. Participants (n=1,134) were mean age 63 years (SD 13), 73% female, 19% living alone. Overall, controlling for baseline distress, there was a marginally significant main effect of screening condition (F=2.37; P=0.09); triage was associated with significantly lower distress at 3 months than minimal screening (P < 0.03). In the triage group, 36% of patients were highly distressed at 3 months vs. 46% and 49% in full and minimal screening, respectively (χ2=10.55; P < 0.005). Among lung cancer patients with baseline distress, 20% fewer in triage than in full or minimal screening continued to have high distress at follow-up. Breast cancer patients in full screening and triage had lower distress at follow-up than those in minimal screening. The best predictor of decreased anxiety and depression in full screening and triage was receiving referral to psychosocial services. In this study, Carlson and colleagues found a high prevalence of distress in patients with lung and breast cancers. Distress scores were lowered at follow-up for patients who received full screening and triage. The greatest improvements in anxiety and depression were seen in patients who received psychosocial interventions; those with the highest level of distress benefited the most. Interestingly, most patients did not accept referral to services. Most importantly, measuring distress as a sixth vital sign alerts caregivers so they can attend appropriately to patients' needs. As has been seen with pain, asking the right question facilitates improved care. To provide quality cancer care today, psychosocial aspects must be integrated into routine cancer care. Identification of patients' needs is essential to develop plans to manage those needs. The DT is a simple tool to facilitate the process. Gregory J. Miller, MD, Utah Cancer Specialists, Salt Lake City, UT. Carlson LE, Groff SL, Maciejewski O, Bultz BD. Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 2010 Oct 12. [Epub ahead of print].Reference1.Jacobsen PB. Screening for psychological distress in cancer patients: challenges and opportunities. J Clin Oncol 2007;25:4526–4527. The 10-item Center for Epidemiologic Studies-Depression (CES-D) scale is a tool widely used to screen for depression in clinical and research settings. Given that Asian cultures tend to refrain from exhibiting expression of positive emotion, is there a cultural bias in responses to positive-affect items on the CES-D, leading to elevated scores on the instrument? This secondary data analysis examined differential item functioning (DIF) using three large datasets comprised of non-Hispanic white Americans, Korean Americans, and Koreans living in Korea; each dataset included the CES-D. The Korean Americans also completed a 12-item Acculturation Inventory to examine the association between degree of acculturation and patterns of responses on the CES-D. Participants were aged≥65 years and had intact mental status. Multiple Indicator Multiple Cause models were estimated to identify DIF between groups on the CES-D's positive-affect items (i.e., hopeful, happy) while controlling for the latent trait of depressive symptoms. Positive items were reverse-coded to allow combining of item scores; higher scores indicated greater frequency of depressive symptoms. Participants were non-Hispanic white (n=450; mean age 75 years [SD 7]; 63% female; < 5% < high school education); Korean Americans (n=519; mean age 73 years [SD 6]; 53% female; 30% < high school); and Koreans (n=2,030; mean age 71 years [SD 5]; 43% female; 70% < high school). Korean Americans had the highest total scores on the total CES-D, followed by Koreans and non-Hispanic whites (mean differences, P < 0.001). For negative items only, Korean Americans had the highest score, followed by non-Hispanic whites and Koreans. For positive items only, Koreans ranked highest (indicating lower levels of endorsement in these reverse-coded items) followed by Korean Americans and non-Hispanic whites (all mean differences, P < 0.001). Positive item and negative item totals were positively correlated in whites (r=0.38; P < 0.001) and Korean Americans (r=0.22; P < 0.001) but not in Koreans (r=0.03; P > 0.05). Less acculturated Korean American older people were less likely to endorse positive-affect items compared with those who reported higher levels of acculturation to American culture. The finding that Koreans and less acculturated Korean Americans endorse CES-D positive-affect items less frequently than non-Hispanic white Americans is consistent with earlier studies. The authors attributed this difference to the cultural tendency of Asians to refrain from exhibiting positive emotion. One troubling omission is that alternative explanations for the findings were not explored. Older Koreans may actually be more depressed than their white, non-Hispanic counterparts. Although the authors argue that including the positive emotions CES-D items for Korean patients may result in overestimates of depression, ignoring the items may underestimate or miss depression in these patients. Despite this limitation, this intriguing study underscores the importance of recognizing differences in how patients from diverse groups report symptoms. Care must be taken when using symptom assessment tools with diverse populations, including tools with strong psychometric properties. Although not a major aim of the study, the finding that, on average, Korean Americans score highest on total CES-D and total CES-D negative-item scales warrants attention from clinicians working with this group of patients. Mary Ersek, PhD, RN, FPCN, University of Pennsylvania School of Nursing, Philadelphia, PA. Jang Y, Kwag KH, Chiriboga DA. Not saying I am happy does not mean I am not: cultural influences on responses to positive affect items in the CES-D. J Gerontol B Psychol Sci Soc Sci 2010;65(6):684–690. Hypogonadism is common in men with advanced cancer and malnutrition. How prevalent is hypogonadism, and is it correlated with quality of life (QOL) and sexual dysfunction in male cancer patients? This was a cross-sectional study conducted in three outpatient cancer centers. Eligibility criteria were male, age≥18 years, and documented malignancy. Exclusion criteria were prostate, testicular, or male breast cancer; known hypogonadism; and HIV. Serum was analyzed for total testosterone (TT), free testosterone (FT), bioavailable testosterone (BAT), and sex hormone-binding globulin (SHBG). Participants completed the Functional Assessment of Cancer Therapy-Prostate (FACT-P), which measures physical, social, emotional, and functional domains of QOL as well as sexual function. Participants (n=407) were mean age 62 years (SD 13), 66% white, 39% with gastrointestinal cancer, and 41% with stage IV cancer. Hypogonadism was defined as TT<300 ng/dl. Mean and median TTs were 337 and 310 ng/dl, respectively. The crude prevalence of hypogonadism was 48%; mean TT in hypogonadal patients was 176 ng/dl. The prevalences that were based on FT (hypogonadal<52 pg/dl) and BAT (hypogonadal 300 ng/dl; replacement needs to be based on biologically active testosterone levels.4,5 Mood and anxiety do not improve with replacement.6 The impact of testosterone replacement on QOL is presently under investigation. Low testosterone is associated with metabolic syndrome, opioid use, and impaired quality of life. Mellar P. Davis, MD, FCCP, The Cleveland Clinic, Cleveland, OH. Fleishman SB, Khan H, Homel P, et al. Testosterone levels and quality of life in diverse male patients with cancers unrelated to androgens. J Clin Oncol 2010 Oct 25. [Epub ahead of print].References1.Greenfield DM, Walters SJ, Coleman RE, et al. Prevalence and consequences of androgen deficiency in young male cancer survivors in a controlled cross-sectional study. J Clin Endocrinol Metab 2007;92(9):3476–3482.2.Garcia JM, Li H, Mann D, Epner D, et al. Hypogonadism in male patients with cancer. Cancer 2006;106(12):2583–2591.3.Strasser F, Palmer JL, Schover LR, et al. The impact of hypogonadism and autonomic dysfunction on fatigue, emotional function, and sexual desire in male patients with advanced cancer: a pilot study. Cancer 2006;107(12):2949–2957.4.Chiang HS, Hwang TI, Hsui YS, et al. Transdermal testosterone gel increases serum testosterone levels in hypogonadal men in Taiwan with improvements in sexual function. Int J Impot Res 2007;19(4):411–417.5.Reyes-Vallejo L, Lazarou S, Morgentaler A. Subjective sexual response to testosterone replacement therapy based on initial serum levels of total testosterone. J Sex Med 2007;4(6): 1757–1762.6.Seidman SN, Spatz E, Rizzo C, Roose SP. Testosterone replacement therapy for hypogonadal men with major depressive disorder: a randomized, placebo-controlled clinical trial. J Clin Psychiatry 2001;62(6):406–412. Because adolescents may not verbally communicate about pain, their behavioral expressions may help evaluate their pain experiences. What is the reliability and validity of the Adolescent Pain Behavior Questionnaire (APBQ), an instrument used to collect the parent report of adolescent pain expression? This was a cross-sectional psychometric study of a new pain assessment instrument conducted in a multidisciplinary pain management clinic; the APBQ was built from a pool of items drawn from published measures of pain expression. Patient/parent dyads were enrolled. Patient eligibility criteria were (a) primary presenting complaint of chronic pain (daily or almost daily pain>3 months), (b) 11-19 years old, and (c) ability to read and understand questionnaires written in English. The APBQ and other instruments were administered as part of a comprehensive multidisciplinary evaluation. Adolescents completed the Functional Disability Inventory (FDI), Pediatric Quality of Life (Peds-QL), Pain Catastrophizing Scale for Children (PCS-C), Visual Analogue Scale (VAS), and Children's Depression Inventory (CDI). Parents completed parent versions of the FDI and Peds-QL, Pain Catastrophizing Scale for Parents (PCS-P), APBQ, VAS of their adolescent's average pain intensity, and the parent information form. Participating patients (n=138) were mean age 15 years; 75% were female, and 91% were Caucasian. The final APBQ contained 23 items with high internal consistency (α=0.93). No relationship was found between parent-reported pain behaviors and adolescent-reported pain intensity. However, parent-reported pain behaviors were significantly associated with parent- and adolescent-reported functional disability, pain catastrophizing, depressive symptoms, and poor quality of life (all P < 0.002). Results of this study underscore the multidimensional nature of pain and the challenge of adequately assessing pain when limited to intensity ratings alone. Although there was no association between parent-reported adolescent pain behaviors and adolescent self-report of pain intensity, there were significant correlations between parent-reported pain behaviors and both parent and adolescent ratings of depression, functional disability, pain catastrophizing, and quality of life. Interestingly, there was also a strong correlation between parental perception of adolescent pain catastrophizing and pain behaviors and between parental pain and treatment history and parental reports of adolescent pain behaviors. Pain is more than a number. Adequate pain management requires an understanding of the complex interactions among its constitutive domains for the adolescent at hand and as potentially influenced by the parents' response to their child's pain behaviors. Donna S. Zhukovsky, MD, FACP, FAAHPM, M. D. Anderson Cancer Center, Houston, TX. Lynch-Jordan AM, Kashikar-Zuck S, Goldschneider KR. Parent perceptions of adolescent pain expression: the adolescent pain behavior questionnaire. Pain 2010;151(3):834–842. Amy P. Abernethy, MD, FAAHPM, of Duke University Medical Center, is the Editor-in-Chief of PC-FACs. Donna S. Zhukovsky, MD, FACP, FAAHPM, of UT M.D. Anderson Cancer Center, is Associate Editor-in-Chief. The editors thank Jane Wheeler, MSPH, and Robin Fowler, MDiv, for their assistance in compiling this feature. The AAHPM thanks the following for their reviews of the critical summaries and preparation of the commentaries: Robert M. Arnold, MD Stephen Bekanich, MD Janet Bull, MD, FAAHPM Ira Robert Byock, MD Ronald J. Crossno, MD, CMD, FAAHPM Mellar P. Davis, MD, FCCP Mary Ersek, PhD, RN, FAAN, FPCN Tommie W. Farrell, MD Betty Ferrell, PhD, RN, FAAN, FPCN Perry G. Fine, MD Daniel Fischberg, MD, PhD Anthony Nicholas Galanos, MA, MD Gail Gazelle, MD, FACP, FAAHPM Harry Goforth, MD Laura Hanson, MD, MPH Peter Mahler, MD, PhD John F. Manfredonia, DO Gregory J. Miller, MD J. Cameron Muir, MD Alan Nixon, MB BCh, BAO, FAAHPM David Nowels, DM John Peppin, DO, FACP Francine Rainone, DO, PhD, MS, FAAHPM Brad Stuart, MD Paul E. Tatum III, MD James A. Tulsky, MD Joanne Wolfe, MD The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 4700 West Lake Avenue Glenview, IL 60025-1485, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org
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