For more on that subject …

March 12, 2009

UNC Health Sciences Librarian Jean Blackwell offers resources

In this debate about government funding for comparative effectiveness research, it seems like there’s a lack of understanding about what this means.

AMA News (research into best treatments)
http://www.ama-assn.org/amednews/2009/03/09/gvsb0309.htm

AHRQ – Effective Health Care (listing by diseases/conditions)
http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=all

Articles by UNC Chapel Hill faculty:

Systematic Review: Comparative Effectiveness and Harms of
Disease-Modifying Medications for Rheumatoid Arthritis
http://www.annals.org/cgi/reprint/148/2/124.pdf

J Am Acad Nurse Pract. 2006 Jan;18(1):31-9.

Effective interventions for lifestyle change after myocardial infarction or coronary artery revascularization.

Cobb SL, Brown DJ, Davis LL.

Healthlink, University of North Carolina Healthcare, Chapel Hill, NC, USA. scobb3@nc.rr.com

PURPOSE: This science clinical paper reviews medical literature and examines interventions that are currently used to assist patients in achieving lifestyle change after myocardial infarction or coronary artery revascularization. Interventions that focused on both provider- and patient-implemented strategies were included. The effectiveness of these interventions to significantly reduce coronary heart disease risk factors was explored. DATA SOURCES: Original longitudinal research studies or reviews indexed in PubMed between 1999 and 2004 were included. Eight studies were identified that met the inclusion criteria and presented successful interventions to increase participants’ adherence to recommended lifestyle changes. CONCLUSIONS: Current strategies for achieving recommended risk factor reductions include frequent follow-up, intensive diet changes, individualized and group exercise, coaching, group meetings, education on lifestyle modification and behavior change, and formal cardiac rehabilitation programs. IMPLICATIONS FOR PRACTICE: Nurse Practitioners can help close the gap between evidence-based recommendations and clinical practice by implementing education programs in their practices and in the community. Recommendations include frequent follow-up visits, negotiating personalized treatment plans, and a general emphasis on therapeutic lifestyle change as an essential component of the treatment plan.

1: J Psychiatr Pract. 2008 Mar;14 Suppl 1:9-14.
Erratum in:

• J Psychiatr Pract. 2008 May;14(3):193.

Effectiveness of antiepileptic drugs for the treatment of bipolar disorder: findings from a systematic review.

Melvin CL, Carey TS, Goodman F, Oldham JM, Williams JW Jr, Ranney LM.

The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, NC 27599-7590, USA. cathy_melvin@unc.edu

Bipolar disorder is characterized by chronic and recurrent symptoms including mania, hypomania, and depressive and mixed episodes, with approximately 5.7 million Americans over age 18, or 2.6% of the U.S. population, suffering from the illness. The prevalence of the disorder may be higher due to its chronic and recurrent nature. Individuals with bipolar disorder often first present in general medical settings with depressive symptomatology. Long-term management typically occurs in mental health settings by psychiatrists or other mental health specialists. While there have been major advances in pharmacotherapy for bipolar disorder, evidence-based information on drug effectiveness is not always easily accessible to prescribers in daily practice. Available information has sometimes led to inappropriate use of various classes of drugs, specifically antiepileptic drugs (AEDs), for bipolar disorder. Originally approved in 1993 by the U.S. Food and Drug Administration (FDA) only for adjunctive treatment of partial complex seizures, the manufacturer of gabapentin (Neurontin), an AED, promoted its off-label use for treatment of psychiatric disorders, including bipolar disorder. The efficacy of the drug for this indication had not been demonstrated, nor had the manufacturer sought FDA approval for the indication. In 2004, 50 Attorneys General settled consumer protection claims regarding alleged deceptive off-label marketing practices of Pfizer subsidiary Warner-Lambert. At about the same time, a consortium of State Medicaid agencies funded a drug class review to compare effectiveness and adverse event profiles of AEDs in the treatment of bipolar mood disorder, neuropathic pain, and fibromyalgia. This article presents a summary of the findings from the drug class review related to prescription of the AEDs in bipolar disorder.

Larry Katz on induced hypothermia therapy

Posted Jan. 16, 2009

I got interested in hypothermia in the early 80s after reading an article on the great survival of cold water drowning victims. Some of these victims were dead for over an hour yet went on to lead normal lives. I thought we could apply this “mother nature therapy” (aka hibernation) to patients with acute brain injuries such as stroke, cardiac arrest, traumatic brain injury and spinal cord injury. I worked with the father of CPR (Peter Safar) at the International Resuscitation Research Center [now the Safar Center for Resuscitation Research]to help bring this therapy from the bench to the bedside.

Hypothermia works through a number of mechanisms, but it essentially helps put out the fire in the brain that occurs with acute brain injury.

We are in the process of developing drugs that simulate hibernation so we can make this therapy available to a broader group of patients with acute brain injury. The current method for inducing hypothermia (forcing the body temperature down by mechanical methods) is very crude, slow and stressful. If we can develop a more efficient and less stressful method for cooling we will be able to optimize therapeutic hypothermia for a broader group of patients.

Jim Evans on the news-science interface

Posted Aug. 27, 2008

The 24 hour news cycle is particularly damaging to an accurate appreciation of science and the rational implementation of scientific advances. Science is fraught with blind alleys. We try something…it looks promising….and then more data show that our original observations were flawed or inappropriately interpreted. This happens all the time in science, indeed it is the way that science moves forward; two steps forward, one step back. What propels it to ultimately provide a gradually more accurate representation of the universe we live in is that it is ultimately self-correcting. We constantly test the assumptions that have gone before. Indeed, it is the “glory” achieved by showing that a cardinal feature of our prior world view is incorrect that scientists most desire (an admittedly pathetic scientific and dweebish version of real glory!).

By constantly reporting on and trumpeting every development and experimental result, we inevitably trumpet things that are wrong. And then, because of science’s self correcting but stuttering trajectory, the next news cycle trumpets seemingly contradictory results and conclusions. And so it goes. Such constant reporting of stuttering progress understandably leads some to give up on the whole enterprise and turn to drivel like astrology because they’ve never been taught how science really works. At the end of the day we do indeed make progress (we are pretty sure that the earth isn’t flat and doesn’t rest on the back of a big turtle) but if we only join in the middle and for a short period, we perceive chaos. Thus, the constant spotlight on “advances” in science, displayed to a largely scientifically illiterate public, threatens to discredit the whole field. The media drives this, seeking to fill their news slates and scientists are complicit, being too eager to see their latest incremental (and perhaps erroneous) “breakthrough” publicized.

Consumers would be well advised to take a long view and to resist the idea that each small step in science should lead to a revision in the world view we had yesterday. This is a tough task; because, of course, science does legitimately revise our world view. I would admonish the press and the public to remember that new findings could be wrong and to remember that dramatic claims demand dramatic evidence.

Finally, remember that it is one thing to think that perhaps we should look at the world differently because of a particular advance. But it’s a whole ‘nother thing to actually take action (for example with our health care) based on a new idea. The stakes are much higher when we talk about healthcare because we can – and do – cause harm by the premature embrace of what seems like a good idea. Hormone replacement therapy is only the latest in a long history of good ideas that weren’t so good once we generated quality data. So I would recommend one other thing to the public before they embrace the latest medical news: remember that good ideas and individual experiences are not good guides to what we should do in health care. Only clear data derived from well constructed studies can really guide us as to how to implement the new knowledge that we are gaining about science, medicine and health.

Talking with friends who have cancer

Transcript of recorded interview with Theresa Raphael-Grimm, Ph.D., clinical associate professor in the University of North Carolina at Chapel Hill School of Nursing and member of the psychiatric consult team in UNC’s hospitals.

The conversation was about how to talk with a friend when that friend tell you she has cancer. The interview segued into the difficult emotional strains of caring for very ill patients.

Some of the answers have been truncated for clarity and brevity.

Recorded Aug. 20, 2008. Posted Aug. 21, 2008

Sometimes it’s helpful to understand what does that mean? Is she telling you that she found a lump, it’s in a very early stage and she’s got a very good prognosis and she’s very hopeful and optimistic, or is it at a more progressed stage and she’s much more anxious about the treatment and disfiguring surgery and, uh … (Q: death?). Yes, right.

When you hear this from a friend it’s helpful to know (her physical health status), and then move onto the emotional side of the conversation. This is where you help them talk through what meaning this has for them in their life. That sounds very abstract. It’s like after hearing about the medical parts of it, … then say things like, “Gee, this sounds overwhelming for you, tell me how you’re coping with this. How are you able to process this information.” Explore how has the emotional side been for them and then who’s there to help them with that.

The thing that I think that’s hard for people to understand is that by opening the door and allowing someone to talk about it you’re conveying to them that you care enough to listen and that you can handle listening to their emotions, even if those emotions are difficult for you to hear.

In other words, many folks feel unprepared or ill-equipped to know what to say if a friend says, “you know, the oncologists are hopeful, but there’s times when I’m really afraid I’m going to die from this.”

Now, the usual reaction is, “oh, come on, you’re not going to die.” Which, of course, sounds good, but it may not be true.

So it’s very helpful if the friend says, “well of course you’re worried about that.”

But then say, what does your treatment team say? What’s the likelihood that that will happen? In other words, accept that that is your friends’ fear, but then try to get some information about how warranted that fear really is. “Have you talked with your oncologist about that fear?” Really trying to help them. If they’re not talking with their medical team encourage them to get information from that team.

To be willing to listen, and even to say, to admit that you’re not sure you have comforting words and you’re willing to go through this with them. And listen to them struggle with this even though you may not always say the right thing. But extend to the person the desire to be part of this with them.

(Raphael-Grimm explained that she used to run a cancer survivor support group.)

They used to say, one of the most difficult things was that they felt like they were in this alone, because their friends thought the best way to deal with those fears was to deny them – come on, you’re not going to die. And the patient is afraid. And then (the people with cancer) realize that those folks can’t hear them talk about it, and so they have to try to grapple with that on their own.

Q: But if a friend starts down that path, he needs to be able to continue. To see it through.

A: If you open up a willingness to listen, you have to maintain that willingness throughout the treatment.

It’s usually best if the confidant is close enough that they are able to offer that support, even if they are not geographically close. That’s not it. The more the patient feels as if they have a strong social support network, the more they will feel the comfort of that support.

The rule of thumb is that no matter what disaster befalls us in life we all do better with social support. We also know that some of our friends and loved ones are limited in the amount of support they can provide, either because they’re not psychologically oriented or because they have their own life disasters that they’re trying to manage at the same time, but knowing that people care and want to help to the extent that they can is very comforting to someone.

Q: How does a friend put his issues aside in order to be there?

When you start school to be a psychologist one of the first rules is that you learn to control your own reactivity. In other words, you learn to sit on your own issues and just see them … it’s almost kind of a mindfulness exercise. You realize that your own anxiety is going up as you talk to this person, and you realize that looking at the mortality of someone else brings up your own mortality issues. And (you have) to see it, to recognize it and to give the support anyway.

That doesn’t mean that loved ones don’t need relief from that too. I mean, we all need balance in our lives. But this, this is difficult for that reason. That, you know when you talk to folks about their potential death, which, I do a lot of, there are days when you think, yikes, are we just all here for a short time and just all going to die, and life can be so cruel, and it can be, and that’s where doing your own mental health promotion is really helpful so that you have the resilience that you need in order to give the support to your loved one.

Q: On the other side, there’s some benefit to the support person.

A: As difficult as it is for the support person, to sit with someone and watch someone suffer and feel how distressing that can feel at times, while very difficult, helps all of us become more compassionate, more understanding, more evolved in our … and this is my own philosophical bent on this, but it helps us all kind of move along in our personal evolution towards ultimate wisdom.

The goal of adult development is to reach a state of wisdom and to understand ourselves and others and in a deep and passionate way. I know this is abstract and I don’t know how to put this in any more concrete terms. I think this is what we achieve in it. …

If you ask me, and what I do, I spend so much time with people who are so sick and are suffering, both physically and emotionally, How do I do it? Because you know that at the end of the day you know you’ve helped someone going through unbearable pain bear that pain more easily, and I don’t know that there’s a better gift to give someone.

It’s easy to be friends with people in good times. It’s easy to enjoy someone’s laughter and love and enthusiasm. The hard part is being that friend when our loved one is undergoing severe emotional distress, and yet it’s in the being there that we provide enormous comfort.

“I just need somewhere to go to say out loud all the things that are going on in my head, to have someone know what I’m going through and to care what I’m going through.”

Q. Whether they can do anything or not?

It’s not the doing. This is the mistake that people make. They feel that it’s the doing that provides comfort. And sometimes that’s true. Someone’s too sick to make their own meals or needs a ride to an appointment. There are times when doing really is really valuable. As long as people don’t get lost in that and forget that so much of the comfort we provide is just in being there.

Sometimes extending that compassion is just a matter of listening them talk through it, and allowing them to unload their burden.

(Next I asked Raphael-Grimm more about her work.)

In my clinical practice role I work with the psychiatry consult team. I see patients throughout the hospital who are having severe emotional reactions to their medical illness. People who are making end of life decisions.

I’m there to provide psychological support to someone who is in distress.

Often, someone is so depleted in their fight against their physical illness that they give up, but in a time when in their medical prognosis, they’re really doing OK. So part of what I do is I go in with them and help them regain their emotional stamina and to finish out the treatment and recover.

Q: How do you recharge?

A: (She laughs.) Somebody recently asked me that. You’re hitting me at a particularly difficult time because I’ve had a lot of very challenging patients recently.

I take the month of July off and I go play. I have a very supportive spouse. My children are positively lovely. They’re always fun. They make me laugh. I have good friends. I preserve my time off.

Usually on Friday nights I go out with friends … I work out, I do yoga, and I have people I can talk to. So if it get really overwhelming I have a psychologist friend who I can talk to about these things and he kind of shares the burden with me.

Q: Do you see a lot of physicians or staff, nurses?

A: Yes. More and more I’m seeing staff form the hospital.

Q: Is there an upward trend?

A: Well, sometimes I see staff, physicians or nurses who have an illness. …

Many of the folks who work in some of these areas do have, are wonderfully caring and compassionate people. They do OK in their jobs until something in their lives starts to fall apart. It’s hard to do your job well when you’re getting a divorce, or your kid’s died or something awful has happened to you at the same time. That’s why they come to me. They were coping fine, even though it was difficult being a resource to these patients, but it’s really hard to be that resource when … outside stressors really come crashing down on you.

Q: Are physicians more open to seeking psychological support now? Is it generational?

A: I have a hard time answering that. I would say yes and no. A lot of physicians are reluctant to … I think that there is still an expectation that physicians are able to handle it all, and that by seeking mental health support it demonstrates a weakness. I think that while sometimes they do seek that support … somebody said to me, “Yeah, I’ll go for therapy, but I’m going to Duke, because I don’t want anybody to know in the system that I’m getting that help.” Do they seek help? Yes. Do they seek it in the same institution that they work? Unlikely. Part of that is that they feel so pressured to maintain an outward appearance of being able to do it all, to balance everything, and I think it’s very hard on them. However, I am the facilitator for Schwartz Rounds.

The oncology department sponsors Schwartz Rounds, which is a monthly discussion for nurses, interns, residents, fellows, attendings, etc. They mostly come from oncology but they can come from anywhere in the hospital.

We talk about how to treat the psychosocial issues of the patients and within those rounds we have open discussions about how stressful some of those patient situations can be for the staff, and we talk about … chaplains are actively involved in this too – about how important it is for the team members to be talking to each other, to be kind of checking in with each other on some of these cases because they about how they’re coping with some of these cases because they’re so sad, talking about how we can better support each other.

Some of the interns and residents say that if they express to their attendings their tendency to really be overwhelmed with feeling badly for a patient that sometimes it’s hard for the attendings to help them, they’ll say, “oh, you’ll get over it in time.”

Being able to share it with the team and talk it over and get support from each other is really helpful, instead of pretending that it’s not impacting them in a significant way.

We talk about if a case goes badly or if a patient and family are irate because they feel like they didn’t get their needs me. We talk about it, and take that case apart and look at what happened, look at what went wrong. We look at the toll caring for patients takes on us and how we can better support each other. We look at all kinds of controversial issues. Are we as good at caring for people from unusual ethnic groups? Are we as compassionate toward prisoners as we should be?

Some of the comments are, things like this is the only place we can talk about these kinds of issues.

As you can tell I can talk about it forever.

I remember being in school and being on an oncology floor and just sitting at a desk outside a patient’s room, and the oncologist went in and said to the patient, “Mrs. So-and-so, you have terminal .. some kind of cancer, and at this point there’s very little we can do for you. I’m afraid that you’ve got about” I think he told her she had three months to live, “and I’m sure you have some concerns that you want to talk about so I’ll send the nurse in.”

And he walked out of the room. And I remember being horrified, and thinking, somebody’s got to change that.