PLEASE VIEW THE FULL-TEXT PDF.

PLEASE VIEW THE FULL-TEXT PDF.

PLEASE VIEW THE FULL-TEXT PDF.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Is your hospital going to the dogs? Perhaps, that is, if your hospital administrators believe in AAT.

That’s not a new randomized placebo-controlled trial for a nifty new medication? Far less complex, it is the simple acronym for animal-assisted therapy, a novel therapeutic modality that is spreading across the country.

Dan/freedigitalphotos.net

I was surprised the first time I saw a canine proudly strutting down the hall of a hospital like he belonged there, but it makes perfect sense. Numerous studies have shown the positive psychological, physical, and even survival benefits of pet ownership. For many, their pet is a beloved member of the family.

But does AAT really work? Apparently so.

Northwest Community Hospital in Arlington Heights, Ill., utilizes AAT regularly to improve both the emotional and physical well-being of its patients. The renowned UCLA Medical Center has gone four-legged. The UCLA People-Animal Connection (PAC) is one of America’s most comprehensive animal-assisted therapy and activity programs. Even the Joint Commission uses PAC’s protocols to promote AAT, both here and abroad.

According to research published in the American Journal of Critical Care (2008;17:373-6), the benefits of AAT are primarily the result of "contact comfort," a tactile process during which unconditional attachment bonds form between humans and animals, leading to relaxation by reducing cardiovascular reactivity to stress. AAT was found to improve hemodynamics in patients with advanced heart failure by reducing right atrial pressure, both systolic and diastolic pulmonary artery pressure, pulmonary capillary wedge pressure, and neurohormone levels.

So the next time you see a dog and his owner stroll down the halls of your hospital, step aside. They have an important job to do as well.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a mobile app for iOS.

Clinical question

Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?

Bottom line

Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)

Reference

Armstrong PW, Gershlick AH, Goldstein P, et al, for the STREAM Investigative Team. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368(15):1379-1387.

Study design

Randomized controlled trial (nonblinded)

Funding source

Industry

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?

Bottom line

Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)

Reference

Armstrong PW, Gershlick AH, Goldstein P, et al, for the STREAM Investigative Team. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368(15):1379-1387.

Study design

Randomized controlled trial (nonblinded)

Funding source

Industry

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Is early fibrinolysis followed by angiography an effective strategy for patients with STEMI presenting to hospitals without the capability to perform percutaneous coronary intervention?

Bottom line

Current guidelines recommend primary percutaneous coronary intervention (PCI) with a door-to-balloon time of 90 minutes for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, this can be difficult to achieve, especially in remote areas without prompt access to PCI. This study finds that early fibrinolysis plus adjunctive antiplatelet and anticoagulant therapy followed by coronary angiography within 24 hours is effective in preventing adverse outcomes in patients presenting with recent onset symptoms of STEMI in whom PCI within 1 hour is not feasible. However, fibrinolysis therapy leads to a higher rate of ischemic strokes and intracranial bleeding, suggesting that timely PCI is still the optimal therapy for these patients. (LOE = 1b)

Reference

Armstrong PW, Gershlick AH, Goldstein P, et al, for the STREAM Investigative Team. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368(15):1379-1387.

Study design

Randomized controlled trial (nonblinded)

Funding source

Industry

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 1892 patients who presented within 3 hours after onset of symptoms of STEMI but could not undergo PCI within 1 hour to receive 1 of 2 interventions: immediate transfer to a PCI-capable facility, or initial fibrinolysis treatment with tenecteplase followed by angiography within 24 hours. The fibrinolysis group also received enoxaparin and clopidogrel as adjunctive therapy. The primary endpoint was the composite of all-cause mortality, shock, congestive heart failure, or reinfarction at 30 days. Baseline characteristics were similar in the 2 groups, except for a higher frequency of previous congestive heart failure in the PCI group. Partway through the trial, the dose of tenecteplase was halved in patients 75 years or older because of a higher frequency of intracranial bleeds in this group. The median time from symptom onset to start of reperfusion therapy (either initiation of fibrinolysis or arterial sheath insertion for PCI) was shorter in the fibrinolysis group (100 minutes vs 178 minutes; P < .0001). However, one third of the patients in the fibrinolysis group required rescue PCI because of failed reperfusion. Overall, there were no significant differences detected between the 2 groups in either the primary endpoint or in the individual components of the endpoint. The fibrinolysis group had a higher rate of total hemorrhagic and ischemic strokes (1.6% vs 0.5%; P = .03).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?

Bottom line

There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)

Reference

Needham DM, Dinglas VD, Bienvenu OJ, et al, for the NIH NHLBI ARDS Network. One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial. BMJ 2013;346:f1532.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?

Bottom line

There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)

Reference

Needham DM, Dinglas VD, Bienvenu OJ, et al, for the NIH NHLBI ARDS Network. One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial. BMJ 2013;346:f1532.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does initial trophic feeding, as compared with full feeding, affect long-term outcomes in critically ill patients with acute lung injury?

Bottom line

There were no significant long-term differences in physical function, survival, psychological symptoms, or cognitive function in patients with acute lung injury who received initial trophic feeding as compared with full enteral feeding. (LOE = 1b)

Reference

Needham DM, Dinglas VD, Bienvenu OJ, et al, for the NIH NHLBI ARDS Network. One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial. BMJ 2013;346:f1532.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Low-energy permissive underfeeding, or "trophic feeding," is one proposed nutritional strategy for mechanically ventilated patients. The previously published EDEN trial showed no significant differences in short-term mortality or ventilation-free days in patients with acute lung injury who received initial trophic feeding versus full enteral feeding (Rice, et al. JAMA 2012;307(8):795-803). In this follow-up of the EDEN trial, investigators examined the long-term effects of this intervention. The patients included in the EDEN trial had acute lung injury primarily due to pneumonia or sepsis and had a mean age of 52 years. The patients were randomized to either full feeding (meeting 80% of the caloric goal) or trophic feeding (meeting 25% of the caloric goal) for up to 6 days. Of the 951 patients in the initial EDEN trial, 563 consented to this follow-up study. Research staff interviewed the surviving participants at 6 months (n = 514) and at 12 months (n = 487). Taken together, these patients had decreased physical and mental abilities as compared with population norms, impaired quality of life and return to work, and increased psychological symptoms. When comparing the full feeding cohort with the patients that received trophic feeding, there was no significant difference in the primary outcome of physical function at 6 or 12 months as assessed by the Short-form Health Outcomes Survey (SF-36). The SF-36 mental health measures favored the trophic feeding group at 12 months, but the differences in scores were small. Overall, there were no differences in specific psychological symptoms -- such as anxiety or depression, 12-month survival, cognitive function, or employment status -- between the 2 groups.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.