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an odds ratio of 5.2 following pramipexole therapy in patients with a Hoehn and Yahr stage less than three.6 Methylphenidate also is being increasingly used for decreasing PD-related fatigue. It mediates its effects through its blocking effect on norepinephrine transporters in the corpus striatum. It also acts on the prefrontal cortex.7 In addition, methylphenidate blocks presynaptic dopamine transporters, which further abrogates PD-related fatigue. The usual effective dose is a treatment regimen including 10 mg administered three times a day.8 Modafinil is also emerging as an agent with significant efficacy in mitigating PD-associated fatigue. A significant improvement in scores on the Epworth Sleepiness Scale is seen following modafinil therapy.9 This has been confirmed by Tyne et al. in a recent study in which patients were administered a maximum dosage of 400 mg daily, which was increased over the duration of a month.10 Part of the fatigue in patients with PD can be attributed to dopamine deficiency. As a result, levodopa administration does improve fatigue in PD patients to some extent by virtue of its direct dopaminergic effects.11 Thus far, the above treatment options have shown considerable promise. There is a need to increase awareness about these treatment options among physicians treating patients with PD-associated fatigue. Shailendra Kapoor, MD Schaumburg, IL, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2013.11.005

References 1. Nilsson MH, Bladh S, Hagell P. Fatigue in Parkinson’s disease: measurement properties of a generic and a condition-specific rating scale. J Pain Symptom Manage 2013;46:737e746. 2. Wen H, Zhang Z, Wang H, et al. Epidemiology and clinical phenomenology for Parkinson’s disease with pain and fatigue. Parkinsonism Relat Disord 2012;18:S222eS225. 3. Miwa H, Miwa T. Fatigue in patients with Parkinson’s disease: impact on quality of life. Intern Med 2011;50:1553e1558. 4. Saez-Francas N, Hernandez-Vara J, Corominas Roso M, Alegre Martı´n J, Casas Brugue M. The association of apathy with central fatigue perception in patients with Parkinson’s disease. Behav Neurosci 2013;127:237e244.



5. Ray Chaudhuri K, Martinez-Martin P, Antonini A, et al. Rotigotine and specific non-motor symptoms of Parkinson’s disease: post hoc analysis of RECOVER. Parkinsonism Relat Disord 2013;19:660e665. 6. Morita A, Okuma Y, Kamei S, et al. Pramipexole reduces the prevalence of fatigue in patients with Parkinson’s disease. Intern Med 2011;50: 2163e2168. 7. Mendonc¸a DA, Menezes K, Jog MS. Methylphenidate improves fatigue scores in Parkinson disease: a randomized controlled trial. Mov Disord 2007;22: 2070e2076. 8. Devos D, Dujardin K, Poirot I, et al. Comparison of desipramine and citalopram treatments for depression in Parkinson’s disease: a double-blind, randomized, placebo-controlled study. Mov Disord 2008;23:850e857. 9. Lou J, Dimitrova DM, Park BS, et al. Using modafinil to treat fatigue in Parkinson disease: a double-blind, placebo-controlled pilot study. Clin Neuropharmacol 2009;32:305e310. 10. Tyne HL, Taylor J, Baker GA, Steiger MJ. Modafinil for Parkinson’s disease fatigue. J Neurol 2010; 257:452e456. 11. Lou J, Kearns G, Benice T, et al. Levodopa improves physical fatigue in Parkinson’s disease: a double-blind, placebo-controlled, crossover study. Mov Disord 2003;18:1108e1114.

Asia Pacific Palliative Care Development Through Education To the Editor: Within the Asia Pacific region, there is great diversity of culture and practice of palliative care, including many resource-challenged areas.1 Approximately one-third of countries have no palliative services or services in early development.2 Flinders University, working with the Asia Pacific Hospice Palliative Care Network, developed a Graduate Certificate in Palliative Care course, with a specific emphasis on resource-challenged areas. This course was available to students from the Asia Pacific region from 2006 to 2012 locally in Singapore, supported by a distance-learning framework. The local partner was the National Cancer Center Singapore, supported by funding from the Lien Foundation. A total of 108 students took the course, coming from Bangladesh (3), China (4), Hong Kong (1), India (18), Indonesia (4), Iran (1), Malaysia (14), Myanmar (3), Nepal (2), Philippines (9),


Saudi Arabia (1), Singapore (37), South Korea (1), Thailand (7), United Arab Emirates (1), and Vietnam (2). Students’ backgrounds included nursing, medicine, social work, pharmacy, and counseling. Their practice settings included radiation oncology, pain, palliative care, family and community practice, pediatrics, HIV medicine, surgery, obstetrics and gynecology, psychiatry, and intensive care. The approach to teaching in this course was multidisciplinary. A combined local and international faculty used an interactive and open teaching style. Students were encouraged to question practice and apply learning to their own cultural settings. There was an emphasis on identification and appraisal of the palliative care literature. Lecturers freely shared and discussed teaching resources. Clinical placements across the region with joint faculty supervision also were a requirement. This unique combination of teaching strategies for developing wisdom in practice3 not only increased the students’ clinical knowledge and skills but also their own teaching skills. As most of the students are pioneers and leaders in palliative care in their own countries, this is crucialcapacity building by creating life-long learners. The impact on the Asia Pacific region has already been remarkable. Many alumni went on to develop new services and become new regional leaders. Policies are being changed at the government level. As Dr. Rosalie Shaw, who has worked extensively across the region, has noted: . those who have completed the course have returned with renewed commitment to develop culturally and economically appropriate palliative care services in the settings in which they are working. They have gone back to the slums of New Delhi, the prisons of Jakarta and Surabaya, the overcrowded streets of Manila and the rice fields of Northern Thailand with greater confidence and an awareness of a community of like-minded colleagues linked by technology and ready to give support and encouragement. The Graduate Certificate Program has helped build this community that will have a major impact on development of palliative care in the region. Some students have gone on to further postgraduate studies in palliative care and into research, some of which has already been


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published. Most have remained in clinical work in palliative care. All are connected online via a peer network, which provides crucial ongoing peer support, where there is often little or none locallydyet. The development of this regional community of practice as a collateral outcome is invaluable. At an academic level, the program has been recognized nationally through the Office for Learning and Teaching, with a 2010 Australian Learning and Teaching Council citation for outstanding contributions to student learning and a 2012 Australian Award for University Teaching Program. Locally expanding educational offerings in palliative care indicate further development in palliative care expertise in the region. As this was a major goal of offering the Flinders’ postgraduate course in Singapore, this growth in locally available education with possibilities for further development in the region is another measurable benefit. Meg Hegarty, BN, MPHC Katrina Breaden, BAppSc, MN, PhD, Grad Cert Ed Meera Agar, MBBS, FRACP, FAChPM, MPC, PhD Kim Devery, BSocSc (Honors) Discipline of Palliative and Supportive Services Flinders University Adelaide, South Australia Australia E-mail: [email protected] Cynthia Goh, MBBS, PhD, FRCP, FRCP(Edin), FAMS, FAChPM Rosalie Shaw, MBBS, FRACMA, FAChPM, BA, BEd Asia Pacific Hospice Palliative Care Network c/o Department of Palliative Medicine National Cancer Centre Singapore, Singapore, Singapore Kate Swetenham, BN, Grad Dip Psycho Oncology, M Pall Care David C. Currow, BMed, MPH, FRACP Discipline of Palliative and Supportive Services Flinders University Adelaide, South Australia Australia http://dx.doi.org/10.1016/j.jpainsymman.2013.11.006

Disclosures and Acknowledgments Scholarships for this program of study were funded by the Lien Foundation, Singapore. The views expressed are those of the authors

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and not necessarily those of the Lien Foundation. The authors declare no conflicts of interest.

2. Goh CR. The Asia Pacific Hospice Palliative Care Network: supporting individuals and developing organizations. J Pain Symptom Manage 2007;33: 563e567.


3. Hegarty M, Currow D. Postgraduate education in palliative medicine. Ch 20.2. In: Hanks G, Cherny N, Christakis N, et al, eds. Oxford textbook of palliative medicine, 4th ed. Oxford: Oxford University Press, 2010:1576e1585.

1. Goh C, Shaw R. Asia Pacific. In: Wee B, Hughes N, eds. Education in palliative care: Building a culture of learning. Oxford: Oxford University Press, 2007:49e58.

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