e4
Letters
as an immediate-release injection administered SC two or three times a day, as well as an intramuscular depot injection given monthly. The drug is generally well tolerated, with injection site irritation as the most common adverse effect. Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation.7 The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding8 as a bridge to more definitive therapy. Octreotide also has been suggested to have utility in the management of bleeding from gastrointestinal angiodysplasia, again in part related to its vasoactive mechanism in addition to inhibition of angiogenesis and possibly improved platelet aggregation.9,10 This effect is reported in the absence of portal hypertension, and although both our patients had disease that may have increased portal pressures and had demonstrable varices, we did not specifically demonstrate portal hypertension in either. In our patients, endoscopy failed to reveal a specific site of bleeding, rendering techniques such as embolization or local cauterization ineffective, and, given the advanced nature of their illnesses, aggressive therapy such as a TIPS procedure was not considered. For both, the bleeding caused marked psychosocial distress, and both had required transfusion support before initiation of octreotide. Given the observed effectiveness of octreotide for these patients, its lack of significant side effects, and its broad application in palliative care, we suggest it be considered for patients for whom noninterventional care is appropriate in the setting of peristomal bleeding varices. Debbie Selby, MD Lawrence D. Jackson, BScPhm Sunnybrook Health Sciences Center Toronto, Ontario, Canada E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.12.001
References 1. Kwok A, Wang F, Maher R, et al. The role of minimally invasive percutaneous embolization technique in the management of bleeding stomal varices. J Gastrointest Surg 2013;17:1327e1330. 2. Spier B, Gayyad A, Lucey M, et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008;6:346e352. 3. Deipolyi A, Kalva S, Oklu R, et al. Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014;203:668e673.
Vol. 49 No. 3 March 2015
4. AVASTINÒ monograph. Revised June 27, 2014. Mississauga, ON: Hoffmann-La Roche Limited. Available at: www.rochecanada.com. Last accessed November 23, 2014. 5. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000;8:188e191. 6. Murphy E, Prommer E, Mihalyo M, Wilcock A. Octreotide. J Pain Symptom Manage 2010;40:142e148. 7. Chan M, Chan M, Mengshol J, Fish D, Chan E. Octreotide: a drug often used in the critical care setting but not well understood. Chest 2013;144:1937e1945. 8. Wells M, Chande N, Adams P, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012;35: 1267e1278. 9. Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010;55:2129e2134. 10. Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia-pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2013;39: 15e34.
Re: The Sidney ProjectÔ To the Editor: We were moved by the article ‘‘Reflections on the Sidney ProjectÔ: Can We talk? Can We Give Voice to the Taboo Topics That Are Usually Not Embraced in Residency Medical Education?’’ by Janet Lynn Roseman.1 Dr. Roseman was quite open about the death of her father, Sidney, and that this death occurred ‘‘at the hands of a wounded medical culture . that refused to acknowledge that his life was not worth saving.’’1(p. 478) What a wonderful compliment to her father and his legacy by establishing the Sidney Project. We also congratulate Dr. Roseman for expanding the project from just 16 residents to many moredand not just in psychiatry. We, too, value a safe place where residents can share their work experiences and specifically, the affective side of this work, as they learn an immense amount of knowledge and try to keep pace with high patient volume and severity of illness. In palliative care and in internal medicine, in general, there are multiple venues for providers at all stages in their careers to learn more about and, in some instances, share with other house officers in a safe environment, the toll of their work. We all participate in ‘‘G Briefing’’ at Dukedvoluntary forums facilitated by a senior palliative care clinician, ‘‘Dr. G,’’ and an experienced clinical social workerdwhere internal
Vol. 49 No. 3 March 2015
Letters
medicine residents discuss recent or distant deaths that were never processed fully. Data are currently being collected on this intervention, and like the Sidney Project, the benefits are immediate and obvious. We applaud Dr. Roseman and the JPSM for publishing this article. It is part of a much larger discussion that has been ongoing for some time in residency education. That is not to say that the culture is not ‘‘wounded,’’ but it is to say that self-care of the developing physician and improved mindfulness are paramount at most training institutions and a much needed focus.
e5
Adrienne Belasco, MD Victoria Leff, LCSW Anthony N. Galanos, MD Duke Medicine Durham, North Carolina, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.10.008
Reference 1. Roseman JL. Reflections on the Sidney ProjectÔ: can we talk? Can we give voice to the taboo topics that are usually not embraced in residency medical education? J Pain Symptom Manage 2014;48:478e482.
Letters
as an immediate-release injection administered SC two or three times a day, as well as an intramuscular depot injection given monthly. The drug is generally well tolerated, with injection site irritation as the most common adverse effect. Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation.7 The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding8 as a bridge to more definitive therapy. Octreotide also has been suggested to have utility in the management of bleeding from gastrointestinal angiodysplasia, again in part related to its vasoactive mechanism in addition to inhibition of angiogenesis and possibly improved platelet aggregation.9,10 This effect is reported in the absence of portal hypertension, and although both our patients had disease that may have increased portal pressures and had demonstrable varices, we did not specifically demonstrate portal hypertension in either. In our patients, endoscopy failed to reveal a specific site of bleeding, rendering techniques such as embolization or local cauterization ineffective, and, given the advanced nature of their illnesses, aggressive therapy such as a TIPS procedure was not considered. For both, the bleeding caused marked psychosocial distress, and both had required transfusion support before initiation of octreotide. Given the observed effectiveness of octreotide for these patients, its lack of significant side effects, and its broad application in palliative care, we suggest it be considered for patients for whom noninterventional care is appropriate in the setting of peristomal bleeding varices. Debbie Selby, MD Lawrence D. Jackson, BScPhm Sunnybrook Health Sciences Center Toronto, Ontario, Canada E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.12.001
References 1. Kwok A, Wang F, Maher R, et al. The role of minimally invasive percutaneous embolization technique in the management of bleeding stomal varices. J Gastrointest Surg 2013;17:1327e1330. 2. Spier B, Gayyad A, Lucey M, et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008;6:346e352. 3. Deipolyi A, Kalva S, Oklu R, et al. Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014;203:668e673.
Vol. 49 No. 3 March 2015
4. AVASTINÒ monograph. Revised June 27, 2014. Mississauga, ON: Hoffmann-La Roche Limited. Available at: www.rochecanada.com. Last accessed November 23, 2014. 5. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000;8:188e191. 6. Murphy E, Prommer E, Mihalyo M, Wilcock A. Octreotide. J Pain Symptom Manage 2010;40:142e148. 7. Chan M, Chan M, Mengshol J, Fish D, Chan E. Octreotide: a drug often used in the critical care setting but not well understood. Chest 2013;144:1937e1945. 8. Wells M, Chande N, Adams P, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012;35: 1267e1278. 9. Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010;55:2129e2134. 10. Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia-pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2013;39: 15e34.
Re: The Sidney ProjectÔ To the Editor: We were moved by the article ‘‘Reflections on the Sidney ProjectÔ: Can We talk? Can We Give Voice to the Taboo Topics That Are Usually Not Embraced in Residency Medical Education?’’ by Janet Lynn Roseman.1 Dr. Roseman was quite open about the death of her father, Sidney, and that this death occurred ‘‘at the hands of a wounded medical culture . that refused to acknowledge that his life was not worth saving.’’1(p. 478) What a wonderful compliment to her father and his legacy by establishing the Sidney Project. We also congratulate Dr. Roseman for expanding the project from just 16 residents to many moredand not just in psychiatry. We, too, value a safe place where residents can share their work experiences and specifically, the affective side of this work, as they learn an immense amount of knowledge and try to keep pace with high patient volume and severity of illness. In palliative care and in internal medicine, in general, there are multiple venues for providers at all stages in their careers to learn more about and, in some instances, share with other house officers in a safe environment, the toll of their work. We all participate in ‘‘G Briefing’’ at Dukedvoluntary forums facilitated by a senior palliative care clinician, ‘‘Dr. G,’’ and an experienced clinical social workerdwhere internal
Vol. 49 No. 3 March 2015
Letters
medicine residents discuss recent or distant deaths that were never processed fully. Data are currently being collected on this intervention, and like the Sidney Project, the benefits are immediate and obvious. We applaud Dr. Roseman and the JPSM for publishing this article. It is part of a much larger discussion that has been ongoing for some time in residency education. That is not to say that the culture is not ‘‘wounded,’’ but it is to say that self-care of the developing physician and improved mindfulness are paramount at most training institutions and a much needed focus.
e5
Adrienne Belasco, MD Victoria Leff, LCSW Anthony N. Galanos, MD Duke Medicine Durham, North Carolina, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.10.008
Reference 1. Roseman JL. Reflections on the Sidney ProjectÔ: can we talk? Can we give voice to the taboo topics that are usually not embraced in residency medical education? J Pain Symptom Manage 2014;48:478e482.
