Jarrett W. Richardson

Impacting Quality of Life for Patients With Advanced Cancer With a Structured Multidisciplinary Intervention: A Randomized Controlled Trial

PURPOSE The primary goal of this study was to evaluate the feasibility and effectiveness of a structured, multidisciplinary intervention targeted to maintain the overall quality of life (QOL), which is more comprehensive than psychosocial distress, of patients undergoing radiation therapy for advanced-stage cancer. PATIENTS AND METHODS Radiation therapy patients with advanced cancer and an estimated 5-year survival rate of 0% to 50% were randomly assigned to either an eight-session structured multidisciplinary intervention arm or a standard care arm. The eight 90-minute sessions addressed the five domains of QOL including cognitive, physical, emotional, spiritual, and social functioning. The primary end point of maintaining overall QOL was assessed by a single-item linear analog scale (Linear Analog Scale of Assessment or modified Spitzer Uniscale). QOL was assessed at baseline, week 4 (end of multidisciplinary intervention), week 8, and week 27. RESULTS Of the 103 participants, overall QOL at week 4 was maintained by the patients in the intervention (n = 49), whereas QOL at week 4 significantly decreased for patients in the control group (n = 54). This change reflected a 3-point increase from baseline in the intervention group and a 9-point decrease from baseline in the control group (P = .009). Intervention participants maintained their QOL, and controls gradually returned to baseline by the end of the 6-month follow-up period. CONCLUSION Although intervention participants maintained and actually improved their QOL during radiation therapy, control participants experienced a significant decrease in their QOL. Thus, a structured multidisciplinary intervention can help maintain or even improve QOL in patients with advanced cancer who are undergoing cancer treatment.

Multiple blood donations associated with iron deficiency in patients with Restless Legs Syndrome

OBJECTIVE To describe a series of patients with restless legs syndrome (RLS) and iron deficiency with and without anemia related to repeated blood donations. PATIENTS AND METHODS Study patients were identified by asking consecutive patients with RLS seen at the Mayo Clinic in Rochester, Minn, from February 1 to December 31, 2001, whether they donated blood. All patients who fulfilled the International Restless Legs Syndrome Study Group criteria for RLS, had donated blood a minimum of 3 times a year the preceding 3 years, and had iron deficiency (serum ferritin concentration <20 microg/L) were included in the study. RESULTS Eight patients met the study criteria. The mean +/- SD serum ferritin concentration was 8.1 +/- 3.5 microg/L, and 4 patients had anemia. In 6 of the 8 patients, RLS began at about the same time of or after blood donation. Patients had donated blood for 4.2 +/- 13 times a year (range, 3-6 times a year) for 15.2 +/- 83 years (range, 5-25 years). Hemoglobin concentrations were 12.8 +/- 1.8 g/dL (range, 10.6-15.5 g/dL). In 2 patients, RLS essentially resolved with correction of iron stores alone, and medications for RLS were successfully discontinued in 2 other patients. CONCLUSIONS Repeated blood donation is associated with induction or perpetuation of RLS due to iron deficiency with or without coexisting anemia. Potential blood donors should be questioned about RLS, and donation should not be allowed until the serum ferritin concentration has been measured and iron stores replenished if necessary.

Applying Quality-of-Life Data Formally and Systematically Into Clinical Practice

The systematic integration of quality-of-life (QOL) assessment into the clinical setting, although deemed important, infrequently occurs. Barriers include the need for a practical approach perceived as useful and efficient by patients and clinicians and the inability of clinicians to readily identify the value of integrating QOL assessments into the clinical setting. We discuss the use of QOL data in patient care and review approaches used to integrate QOL assessment into the clinical setting. Additionally, we highlight select QOL measures that have been successfully applied in the clinical setting. These measures have been shown to identify key QOL issues, improve patient-clinician communications, and improve and enhance patient care. However, the work done to date requires continued development. Continued research is needed that provides information about benefits and addresses limitations of current approaches.

Quality of life of caregivers of patients with advanced-stage cancer.

There has been much research documenting the impact of having a loved one diagnosed with advanced cancer, but little is known about how to reduce care-giver burden. In this randomized controlled trial, the authors examined the potential relationship of an advanced cancer patient’s participation in an 8-session, structured, multidisciplinary intervention on the care-giver’s burden and quality of life (QOL). Although the patients randomly assigned to the intervention (n = 54) demonstrated improved QOL compared to the control condition (n = 49) participants (P < .05), there was no evidence that improving the patient’s QOL made an impact on the caregiver’s level of burden or the care-giver’s QOL. Further investigation is warranted in this area, including interventions specifically designed and targeted to both reduce caregiver burden and to improve caregiver QOL.

Major depression in medically ill patients

Major depression is one of the most common psychiatric problems complicating the treatment and prognosis of patients with active medical illness. Recognizing and treating major depressive conditions in this population can often be challenging, even for the most seasoned clinicians. This article reviews the medical and neurologic conditions that have been associated with the high prevalence rates of major depression. Highlights of the evaluation process that help confirm this suspected diagnosis are addressed, and management issues are discussed. Brief reviews of supportive psychotherapeutic tools that the clinician may find helpful are included, as well as current advances in pharmacologic interventions.

Randomized controlled trial of maintaining quality of life during radiotherapy for advanced cancer

Psychosocial interventions often address only 1 domain of quality of life (QOL), are offered to patients with early‐stage cancer, do not include the caregiver, and are delivered after cancer treatment has been completed.

Statins use and risk of depression: A systematic review and meta-analysis

IMPORTANCE Statin use has been associated with depression; however studies of the association between statin use and depression have yielded mixed results. OBJECTIVE To determine whether statin use is associated with depression and to evaluate the evidence supporting this association. DATA SOURCES Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched through December 28, 2012. STUDY SELECTION We included studies that evaluated exposure to statins, reported the development of depression, and relative risks or odds ratios (ORs) or provided data for their estimation. Two reviewers screened 981 abstracts independently using a standardized form, reviewed full text of 59 selected articles, and included 7 studies in this metaanalysis. DATA EXTRACTION AND SYNTHESIS Study design, statin exposure, development of depression, and study quality were extracted by 2 independent reviewers. A pooled OR with 95% confidence interval (CI) was estimated using the random-effects model and heterogeneity was assessed using Cochrans Q test and the I(2) statistic. RESULTS Seven observational studies (4 cohort, 2 nested case-control, and 1 cross-sectional) from 5 countries enrolling 9187 patients were included. Statin users were 32% less likely to develop depression than nonusers (adjusted OR, 0.68; 95% CI, 0.52-0.89). Modest heterogeneity was observed between the studies (I(2)=55%, P=0.01), which could be accounted for by one study, exclusion of which removed the heterogeneity (P=0.40, I(2)=2%) and further strengthened the antidepressant effect of statin (adjusted OR, 0.63; 95% CI, 0.43-0.93). Heterogeneity could not be explained by study design or study population. The quality of supporting evidence was fair. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis suggests that statin use is associated with lower risk for depression. However, higher-quality studies are needed to confirm the magnitude of this association.

Role of a Medical Social Worker in Improving Quality of Life for Patients with Advanced Cancer with a Structured Multidisciplinary Intervention

Abstract Background: Patients with advanced cancer face multiple challenges to their quality of life (QOL). The goal of this study was to investigate the impact of participation in a multidisciplinary intervention, including a social service component, on improving the QOL of patients with advanced cancer undergoing radiation therapy. Design: A total of 115 participants with newly diagnosed advanced stage cancer, who were receiving radiation therapy, were randomly assigned to either participate in an 8-session structured multidisciplinary intervention or to receive standard care. Each 90-minute session was led by either a psychologist or psychiatrist and co-led with a nurse, physical therapist, chaplain, and/or social worker. The sessions were designed to address the domains that impact QOL: emotional, spiritual, physical, and social domains (support, community resources, financial and legal issues, and advance directives). QOL was assessed, at baseline, 4 (end of treatment), 8 and 27 weeks. The primary endpoint was overall QOL assessed on a 0–100 scale at Week 4. Results: A total of 115 patients were enrolled from October 2, 2000 to October 28, 2002. Overall QOL at Week 4 averaged 10 points higher in the intervention group than in the control group (80 vs. 70 points, p =0.047) which was an increase of 3% from baseline in the intervention group versus a decrease of 9% in the control group (p =0.009). Of the subscores reflecting patients opinion regarding their QOL, there was improvement in all social domains which contributed to the overall improvement in QOL. Significant changes from baseline to Week 4 scores were seen in the areas of financial concerns (p =0.025) and legal issues (p =0.048). Conclusions: A social work component within a structured multi-disciplinary intervention results in significant advantages in the social domain of QOL, and contributes to clinically meaningful improvements in the overall QOL for patients with advanced cancer undergoing active medical treatment. Numerous studies have documented the financial burdens and social changes that may occur with the diagnosis of cancer. However, previous research has not examined the role of a social worker in providing financial, social, and legal education, in a structured multidisciplinary intervention, and its direct impact on QOL. Outlined in this paper is the role of the medical social worker in a clinical trial, how education was provided and strategies for future interventions.

Improving the quality of life of geriatric cancer patients with a structured multidisciplinary intervention: A randomized controlled trial

OBJECTIVE To examine the potential impact of elderly age on response to participation in a structured, multidisciplinary quality-of-life (QOL) intervention for patients with advanced cancer undergoing radiation therapy. METHODS Study design was a randomized stratified, two group, controlled clinical trial in the setting of a tertiary care comprehensive cancer center. Subjects with newly diagnosed cancer and an estimated 5-year survival rate of 0%-50% who required radiation therapy were recruited and randomly assigned to either an intervention group or a standard care group. The intervention consisted of eight 90-min sessions designed to address the five QOL domains of cognitive, physical, emotional, spiritual, and social functioning. QOL was measured using Spitzer uniscale and linear analogue self-assessment (LASA) at baseline and weeks 4, 8, and 27. RESULTS Of the 103 study participants, 33 were geriatric (65 years or older), of which 16 (mean age 72.4 years) received the intervention and 17 (mean age 71.4 years) were assigned to the standard medical care. The geriatric participants who completed the intervention had higher QOL scores at baseline, at week 4 and at week 8, compared to the control participants. SIGNIFICANCE OF RESULTS Our results demonstrate that geriatric patients with advanced cancer undergoing radiation therapy will benefit from participation in a structured multidisciplinary QOL intervention. Therefore, geriatric individuals should not be excluded from participating in a cancer QOL intervention, and, in fact, elderly age may be an indicator of strong response to a QOL intervention. Future research should further explore this finding.

Electroconvulsive therapy in the medically ill

ECT is often a necessary treatment for severe psychiatric disorders in patients with medical or neurologic comorbidity. Although the available data consist largely of cases and case series, ECT is effective in treating psychopathology despite the comorbidity. With appropriate precautions and monitoring during and after ECT, complications can be minimized.