Clinical Briefs
October 30, 1999
Clinical Briefs
Will to Live in the Terminally Ill
It is not uncommon for patients suffering terminal illness to have a desire for death. Whether such thoughts are transient, maintained, or progressively more entrenched as time and the disease progress remains unknown. This study prospectively examined 585 patients with terminal cancer; at baseline, a mini mental status examination was performed to ensure lack of cognitive impairment. At baseline, the Edmonton system assessment system (ESAS), a self-report visual analogue scale instrument designed specifically for patients in palliative care, was administered. Added to this was a will-to-live scale. Scalar data were obtained twice daily until the patient was no longer able to provide the information or died.
These terminally ill cancer patients demonstrated a highly unstable pattern of will to live, and these changes occurred often over short time intervals. Sense of well-being correlated with will-to-live scores, as did anxiety and dyspnea. Short-term statistical models (12-24 hour time period) demonstrated different factors affecting will-to-live than long term (1-4 weeks). Specifically, as death approached closer, physiologic variables like dyspnea were most prominent, whereas at initial interviews, psychological issues like depression and anxiety figured dominantly.
Chochinov and colleagues comment that these findings are pertinent to issues surrounding euthanasia, in that requests to die are often transient. Hence, a sustained wish to die must be part of any considerations of death-hastening requests.
Chochinov HM, et al. Lancet 1999; 354:816-819.
Nonpathogenic Escherichia coli vs. Mesalazine for the Treatment of Ulcerative Colitis: A Randomized Trial
Although the exact mechanisms inducing ulcerative colitis remain unclear, both genetic and infectious components are likely predisposing factors for developing disease. To date, antibacterial therapy has been generally disappointing, producing only short-term benefits. Based upon the premise that alteration in gut flora might be contributory to the favorable short-term changes seen after oral tobramycin, Rembacken and colleagues undertook a trial comparing oral gentamicin followed by GI seeding with nonpathogenic E. coli, to gentamicin + mesalazine for preventing ulcerative colitis relapses over a one-year period.
Half of the study group (n = 116) received E. coli twice daily, delivered in capsules that protect the bacteria from destruction by gastric acid. To be eligible for the trial, patients were required to have at baseline ulcerative colitis of sufficient activity to produce at least four daily liquid stools. Doses of intervention agents were reduced as symptoms improved.
Patients who received E. coli reached remission more quickly (37 days vs 42 days), and with greater frequency (75% vs 68%) than mesalazine subjects. Potential mechanisms of nonpathogenic E. coli’s beneficial effect include blockade of intestinal E. coli receptors to pathogenic E. coli, production of bacteriocins toxic to other pathogenic bacteria by the nonpathogenic strain, and alterations in colonic pH. Rembacken et al conclude that E. coli is as effective as mesalazine in eliciting and maintaining remission of ulcerative colitis.
Rembacken BJ, et al. Lancet 1999; 354:635-639.
Monosodium Glutamate Sensitivity in Asthma
The typical american diet contains up to 1 g per day of MSG, plus up to half as much or more coming from added MSG; foods like Parmesan cheese and soy sauce are particularly good sources for MSG, so dietary content may vary widely. MSG has been suspect as an asthma precipitant since reports in the early 1980s. In contrast to early convincing data on the asthma-MSG link, more recent trials have called into question whether MSG is a significant inducing agent for acute asthma.
Woessner and colleagues studied two groups of asthmatic patients: one group was self-designated as MSG sensitive and had experienced asthma attacks in Oriental restaurants, and the second group was composed of aspirinsensitive asthmatics (total, n = 100). Subjects were challenged in a blinded fashion with 2.5 mg MSG.
Under strict study conditions, Woessner et al were not able to demonstrate any relationship between ingestion of MSG and provocation of asthma. A substantial number of asthmatics who had experienced symptoms referable to Oriental restaurants were subsequently determined to be suffering gastroesophageal reflux disease. Woessner et al’s results call into question whether persons believing they suffer MSG-sensitive asthma are, in fact, deleteriously affected by this substance.
Woessner KM, et al. J Allergy Clin Immunol 1999;104:305-310.
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