What Kyle Learned Recently

"Intranasal Ketamine for Episodic Neuropathic Pain in a Cancer Patient: A Case Report" in Journal of Palliative Medicine.

One of the innovations our pain management committee developed over a decade ago is the concept of a "rescue" dose of opioid available to hospitalized patients who continue to have pain following a routine dose of as needed opioid. These are available up to three times in a day roughly an hour after the as needed dose and help boost the opioid Cmax. I refer to these as our canary in the coal mine. If someone is receiving all of their rescue doses then either (1) their as needed dose is too low, (2) their as needed dosing frequency is too infrequent, or (3) they are the type of patient who will take every medication available to them.

Generally, the rescue dose is covering up for system barriers in the hospital which keep people from being able to take their as needed opioids with as much flexibility as they can at home. It takes time for the patient to call for the med and the nurse to retrieve it.

But every once in a while someone has disruptive, intermittent pain which needs something different than an oral as needed opioid and in those cases we can get stuck with few (really no) options.

This article provides an elegant potential solution ("compounded racemic ketamine was dispensed as a 100 mg/mL solution that the patient was able to self-administer from a syringe with a mucosal atomization device"), especially as their other medications were coming to effect. Cost, however, would be a primary barrier for many of my patients. More study of this potential solution will be important and could open up better access.

"Methylphenidate for Depression in Advanced Cancer: Exploratory
Meta-Analysis of Randomized Trials" a preprint in JPSM.

Speaking of symptoms that can be challenging to palliate on a tight timeline, we have depression in folks with late-stage cancer. This meta-analysis is challenged by the usual problem when it comes to high-quality research in folks with advanced serious illness, which is a low number of included participants, although 189 is pretty darn respectable for the types of articles we usually publish.

In this case, with a respectable NNT, methylphenidate as either monotherapy or adjuvant therapy show an impressive improvement in depression symptom burden and increased rate of remission on a timeline of only two weeks. Historically, I have taught that the hospitalized patients I see are too sick (and have too many ways to get delirious) for stimulants like this to be appropriate. But the fact that this relatively large group of participants didn't have any elevated risk of agitation or confusion makes me wonder whether I'm being too chicken shit.

I'll be keeping an eye on this as its peer reviewed for the potential of making changes in my practice.

"Beyond the Label: How Naming and Framing Impact Pediatric Palliative Care Acceptance" in JPSM.

We specialists in palliative care HATE euphemisms (see, "pass away") for lacking clarity and skirting issues. EXCEPT when those euphemisms are for naming what we do or the teams on which we work. Are we "Supportive Care" (sorry folks, this is an established phrase already in oncology, we can't claim it)? Are we the "Quality of Life Service" (and what would that even mean and doesn't that imply no other team can provide QoL)? In the Pediatric Palliative Care (PPC) world we've also got PACT (Pediatric Advance Care Team) teams which, beyond having a "PIN number" nomenclature problem, is perhaps the vaguest name of all.

I once heard a linguist on an otherwise long-forgotten podcast episode refer to renaming things to get away from a connotation as being like a flock of birds all lifting off a power line wire at once...and then settling back down on the wire over time. The misunderstandings will return, no matter how many times we scare away the birds. We need to lean into and own the name "Palliative Care" proudly and repeat it alongside the words people need to hear about who we are and what we do.

So here we have a preprint which adds further data that it is not what we name ourselves, it's what we offer to people. And I could not possibly love this sentence more in capturing that, "[...] care providers may benefit from interpreting family distress not as a barrier, but as an explicit indication for introducing PPC, framing the consultation as a direct means of providing support, managing overwhelm, and ensuring alignment with the child’s best interest."

"Respect for the Patient-Oncologist Relationship May Limit Serious Illness Communication by Acute and Postacute Care Clinicians After Discharge to a Skilled Nursing Facility" in JCO Oncology Practice and the accompanying editorial.

This is a wonderful article highlighting, if I'm feeling less generous, how good we are at pointing fingers and blaming each other for system problems. This part feels so true to my day-to-day that it's hard for me to even see it as elucidating anything new for the literature:

The oncologists that I work with take exquisite care of their patients and all do the very best they can with the ground constantly shifting beneath their feet. It's my job to align with the medical options that are on the table and close any gaps between a patient and their other docs. It is not my job to get righteously angry about system dysfunction. I can get mad at my oncologist colleagues for not visiting their patients in the hospital, or I can open my eyes and see that there is no sustainable system to allow those oncologists to walk over from their packed clinics. Treating my oncologist colleagues with respect and giving them the benefit of the doubt allows me to form with many of them a relationship of professional trust which gives me more room to maneuver in the care of their patients without threatening their continuity relationship.

AND I always have to remember as an inpatient doc that I see the sickest patients in our health system. I don't get to see the patients with advanced cancer who successfully rehab and return to their oncologist for more cancer-directed therapy. My patient population is weird.

If I had been quoted as the palliative doc in this article, I would've framed this not as a failure but as an inevitability. Yes, sometimes people need to try and fail something to see their path more clearly. The bean counters may hate that "readmission," but if it helps organically and non-traumatically move the decision-making forward then we are mitigating risks for long-term generational harm by forcing people into a decision they're not ready to make.

I will give the editorial authors the final word on this topic,

"What Does It Mean To Be Thirsty?" from Quanta Magazine.

This falls under my favorite heading of topics: "things we understand way less than we think." See also, shortness of breath and itching.

Thirst isn’t a simple signal—it’s a predictive, brain-mediated strategy balancing survival chemistry with environmental constraints. We all thirst, but never in the same way. Every cell depends on it, yet thirst isn’t a cellular cry—it’s a brain-driven motivational state. Deep structures like the hypothalamus and brainstem monitor blood chemistry through specialized sensory organs (OVLT and SFO), which sample salt concentration as a proxy for hydration. A mere 1–3% drop in blood water triggers the discomfort we call thirst.

But here’s the twist: the brain can’t wait 30–60 minutes for water to hit the bloodstream. It predicts. Signals from the mouth, throat, and gut quickly tell the brain, “Enough,” shutting off thirst before balance is restored. In short, thirst is an educated guess, not a precise measurement.

Salt regulation adds another layer. Sodium is essential for nerve impulses and protein function, yet we lack a strong “salt pang.” Instead, taste and dopamine-driven reward pathways govern salt intake—think potato chips when your body needs sodium.

Species improvise differently. Camels burn fat for water; sea otters drink seawater and excrete extra salt; hibernating squirrels suppress thirst entirely, even as vasopressin ramps up to conserve water. The circuitry is universal, but behavior is wildly adaptive.

Knowing all of this, and all we don't know, how can I confidently say to families that their loved one doesn't feel thirst at the end of life? Not sure I can answer that question.