Pattern of referral of noncancer patients to palliative care in the eastern province of saudi arabia

Aim:

The palliative care (PC) needs of patients with noncancer life-threatening illnesses are comparable to that of cancer patients. This report describes the contribution of noncancer patients to the population of PC patients in a tertiary care hospital in the Eastern Province of Saudi Arabia.

Materials and Methods:

This is a retrospective review of the “palliative care inpatient database” of 21 months.

Results:

From 474 patients, 20 (4.2%) had a noncancer diagnosis. The main reason for the referral of noncancer patients was pain control. The most prevalent diagnoses were sickle cell disease (SCD) in 6 (30%) patients and peripheral arterial disease (PAD) in 5 (25%).

Conclusions:

These findings suggest that the PC needs of noncancer patients are largely unmet in our region. Further efforts are necessary to advance noncancer PC in Saudi Arabia. The PC needs of patients with SCD and PAD need to be addressed in future research.     

Mechanism-based Classification and Physical Therapy Management of Persons with Cancer Pain: A Prospective Case Series

Context:

Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain.

Aims:

This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain.

Settings and Design:

A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital.

Material and Methods:

A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration.

Statistical Analysis Used:

Pre–post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL).

Results:

There were statistically significant (P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30.

Conclusion:

MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.     

Care of Terminally Ill Cancer Patients: An Intensivist's Dilemma

Background and Context:

Treatment of terminally ill cancer patients always poses great challenges especially when these critical patients are admitted in intensive care unit (ICU). The severity of their diseases throws a clinical and ethical dilemma to the treating intensivist.

Aims and Objectives:

To evaluate the benefits of intensive care treatment in terminally ill cancer patients and also to find out whether optimal utilization of critical care resources has got any positive financial, psychological and clinical outcome.

Materials and Methods:

A retrospective evaluation of 53 terminally ill cancer patients, who got admitted to ICU of our department, was carried out. Majority of these patients presented with terminal phase of illness involving multi-organ pathologies with diverse range of symptoms. These patients were provided ventilatory, symptomatic and supportive treatment on patient-to-patient basis. Strict and vigilant monitoring of all vital parameters was carried out. At the end of study, all the data was compiled systematically and was subjected to statistical analysis using non parametric tests.

Results:

The demographic profile of such patients was highly variable with regard to educational, social and financial status (P<0.05). The most common group of cancer was hematological malignancies (24.53%) followed by lung cancer (18.87%), uteri-ovarian (15.09), colorectal (13.2%) and others. Significant number (P<0.05) of patients (64.15%) required mechanical ventilation and ionotropic support (79.24%). Mortality increased with increasing number of organ system involvement and reaching up to 100% with involvement of 5 or more organ systems.

Conclusions:

ICU care is the best form of treatment for terminally ill but resources should be used optimally so that a young deserving patient should not be sacrificed for the scarcity of resources.     

Opioid-prescribing Practices in Chronic Cancer Pain in a Tertiary Care Pain Clinic

Introduction:

Under treatment of pain is a recognized global issue. Opioid analgesic medication is the mainstay of treatment in cancer patients as per the World Health Organization (WHO) pain relief ladder, yet 50% of cancer patients worldwide do not receive adequate pain relief or are undertreated.

Aim:

The aim of this study was to audit the ongoing opioid-prescribing practices in our tertiary cancer pain clinic during January–June 2010.

Materials & Methods:

The prescribed type of opioid, dose, dosing interval, and laxatives details were analyzed.

Results:

Five hundred pain files were reviewed and 435 were found complete for audit. Three hundred forty-eight (80%) patients were prescribed opioids. Two hundred fifty-nine (74.4%) received weak opioids while 118 (33.9%) received strong opioids. A total of 195 (45%) patients had moderate and 184 (42%) had severe pain. Ninety-three (26.7%) patients received morphine; however, only 31.5% (58 of 184) in severe pain received morphine as per the WHO pain ladder. Only 73 of 93 (78.4%) patients received an adequate dose of morphine with an adequate dosing interval and only 27 (29%) were prescribed laxatives with morphine.

Conclusion:

This study shows that the under treatment of pain and under dosing of opioids coupled with improper side effect management are major issues.     

Emotional reactivity,coping style and cancer trauma symptoms

Introduction

This article studies the relationship between emotional reactivity and coping style on the one hand and intensity of symptoms of trauma in adult patients with cancer on the other hand.

Material and methods

The study was conducted on 150 patients, 55 women and 95 men, hospitalized for diagnosed cancer. Temperament was assessed with the Formal Characteristics of Behaviour – Temperament Inventory (FCB-TI). Coping style was assessed with the Polish version of the Mental Adjustment to Cancer Scale (Mini-MAC). Intensity of intrusion/hyperarousal and avoidance/numbing was assessed with the Factorial Version Inventory (PTSD), a quantitative measure of trauma-related symptoms.

Results

The outcomes of this study suggest that individual coping style is what determines the intensity of trauma-related symptoms most strongly. Destructive coping style accounts for 49% of the variance of symptom intensity and emotional reactivity accounts for 6%. Combined, destructive coping style and emotional reactivity account for 55% of the variance of general post-traumatic stress symptoms.

Conclusions

Destructive coping style (more important determinant of trauma symptoms) and high emotional reactivity as one of temperament traits are conducive to intensification of cancer trauma symptoms in adult patients. Our findings suggest that constructive coping style and low emotional reactivity may act as a specific protector against cancer trauma symptoms in adults.     

End-of-life decisions guiding the palliative care of cancer patients visiting emergency department in South Western Finland: a retrospective cohort study

Background

Until recently, palliative care (PC) resources in Finland have been sparse. To meet the increasing need for PC an end-of-life (EOL) care project has been ongoing in South Western Finland since 2012, and in 2015, a weekday palliative outpatient clinic was established in Turku University Hospital (TUH). The aim of this study was to explore the effect of the project and the PC clinic on the management practices of EOL cancer patients attending the Emergency Department (ED) of TUH from 2013 to 2016.

Methods

The medical records of all cancer patients (ICD-10 codes C00–97) admitted to the ED of TUH between August 1–December 31, in 2013 and 2016, were analyzed: n?=?529, n?=?432 respectively (2013 and 2016). The analysis focused on those patients in EOL care; n?=?77, n?=?63, respectively. The late palliative patients were defined by PC decision, thus termination of life-prolonging cancer-specific treatments. The EOL patients were in the imminently dying phase of their illness. The site of referral after an ED visit was also verified together with the documentation on advance care plans (ACP), and the impact of palliative outpatient visits.

Results

In 2016, the number of late palliative and EOL patients admitted to the ED has shown a tendency to decrease. The quality of the documentation for treatment goals, do-not-resuscitate (DNR) orders, living wills and connections to primary care providers has improved since 2013. Prior visits to palliative outpatient clinic correlated well with the more comprehensive ACP information: i) DNR order (p?=?0.0001); ii) connection to primary care (p?=?0.003); iii) documented ICD-10 code Z51.5 (p?=?0.0001).

Conclusions

Even modest investments in resources for PC can induce an objective change in the allocation of health care resources, and improve the ACP for the cancer patients at their EOL. A visit to a palliative outpatient clinic may offer one approach for improving the quality and completion of ACP documentation.

     

Prevalence of Fatigue Among Cancer Patients Receiving Various Anticancer Therapies and its Impact on Quality of Life: A Cross-Sectional Study

Background:

Fatigue is disabling and continuous phenomenon in cancer patients during and after various anticancer treatments which can continue for many years after treatment and definitely it has profound effect on Quality of Life (QOL). However, determining its severity is still underestimated among the cancer patients and also very few studies in the literature exist reporting on Cancer-Related Fatigue (CRF) among Indian population.

Aims:

To find out the prevalence of rate of fatigue in cancer patient receiving various anti cancer therapies. To find out the relative impact of fatigue on QOL.

Materials and Methods:

This cross-sectional observational study included a total 121 cancer patients receiving radiotherapy, chemotherapy, and concurrent chemo-radiation with the age group of above 15 years who fulfilled the inclusion and exclusion criteria. All the patients were assessed for severity of fatigue using Brief Fatigue Inventory (BFI) and for QOL using FACT-G scale while they were receiving the anticancer therapies as an in-patient in the regional cancer centers in Madhya Pradesh, India.

Results:

The severe fatigue was more prevalent in chemotherapy [58/59 (98.30%)], and concurrent chemo-radiation (33/42 (78.57%)) as compared to radiotherapy (Moderate-9/20 (45%) and Severe-9/20 (45%)). Moderate correlations were exhibited between fatigue due to radiotherapy and QOL (r = -0.71, P < 0.01), whereas weak correlation was found between fatigue due to chemotherapy and concurrent chemo-radiation (r = -0.361, P < 0.01 and r = -0.453, P < 0.01, respectively).

Conclusion:

Severity of fatigue was found more after chemotherapy and concurrent chemo-radiation therapy while impact on QOL was more after the radiotherapy.     

Psychiatric morbidity in stroke patients attending a neurology clinic in Nigeria

Back ground

Stroke produces a wide range of mental and emotional disorders. Neuropsychiatric complications associated with stroke may have negative effects on the social functioning, overall quality of life and the recovery of motor functioning of stroke survivors.

Objective

To determine the prevalence and nature of psychiatric morbidity among stroke patients attending neurology outpatient clinic of the University of Ilorin Teaching Hospital (UITH), Ilorin-Nigeria.

Methods

All patients with stroke aged 18 years and above at an outpatient neurology clinic in Ilorin, Nigeria were assessed for mental and emotional disorders using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) over one year (March 2009 to February 2010).

Results

Overall prevalence of psychiatric morbidity was 36.0% (30/83) among 83 patients who constituted the study population. Specific diagnoses recorded were depression (19.2%), generalised anxiety disorder (9.6%), harmful alcohol use (2.4%); dementia, somatoform disorder, phobia and delusional disorder each had a prevalence of 1.2%. Clinical and sociodemographic variables were not significantly associated with psychiatric morbidity.

Conclusion

Psychiatric disorders are often associated with stroke. Identifying and treating stroke patients with these psychiatric co-morbidities could thus help to improve the overall quality of life of these patients.     

Angiotensin-Converting Enzyme Inhibitors and Angioedema

Purpose

To investigate the incidence and clinical characteristics of angioedema associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) in an outpatient allergy department.

Methods

A retrospective review of medical records of new patients seen in an allergy clinic. Demographic and clinical data of patients with ACEI-induced angioedema were analyzed.

Results

Nine (0.37%) out of 2,421 new patients attending the allergy clinic developed ACEI-associated angioedema. Enalapril was the drug most frequently incriminated. The onset of the angioedema was as early as after the first dose or as late as 2 years after beginning treatment. Six patients experienced life-threatening angioedema involving the tongue, oropharynx, or larynx, and two patients required transfer to the intensive care unit. One patient required a tracheostomy.

Conclusions

Angiotensin-converting enzyme inhibitor treatment is often responsible for angioedema, especially involving the upper airways. Due to the high proportion of the population exposed to ACEIs and to the severity of this adverse effect, it is important that physicians consider ACEIs as possible inducers when evaluating patients with acute or recurrent angioedema.     

Prevalence of Pain in Patients with HIV/AIDS: A Cross-sectional Survey in a South Indian State

Objectives:

Primary - To measure the prevalence of pain in HIV/AIDS with patients.Secondary - To assess the type, site, severity, management of pain and impact of pain on quality of life in these patients.

Design:

Multicentre cross-sectional survey (This paper is a pilot study).

Settings:

ART centre at St. John''s Medical College Hospital, Bangalore and Snehadan, A supportive and care centre for HIV/ AIDS patients at Bangalore.

Materials and Methods:

Data sheet, Brief pain inventory and Short – Form McGill pain questionnaire.

Subjects:

This is an ongoing study and the pilot study includes 140 HIV/AIDS patients in different stages of the disease.

Results:

About 66.7% (28/42) in-patients and 24.5% (24/98) out-patients complained of pain. Of the 52 patients who reported pain, 32% (14/52) reported neuropathic pain and 68% (38/52) reported noci-ceptive pain. Headache was most common followed by pain in the soles of feet and low back. Only 26.9% (17/52) received any form of analgesic. Pain severity significantly affects the quality of life.

Conclusions:

Pain is a common and debilitating symptom of HIV/AIDS. It is however, under-estimated and under treated.     

Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital

Context:

An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown.

Aims:

The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital.

Settings and Design:

A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India.

Materials and Methods:

A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response.

Statistical Analysis:

Statistical analysis was done using the Mann-Whitney and chi-square tests.

Results:

Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding “change in the patient''s condition” compared to the objective change in severity of illness. “Change in worry” was incongruous compared to the perception of improvement of the patient''s condition in 78% of relatives.

Conclusions:

Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.     

Artificial Hydration at the end of Life in an Oncology Ward in Singapore

Aim:

The objective of this study has been to examine the frequency of use of artificial hydration in terminally ill cancer patients during the last 48 h of life and the occurrence of symptoms specific to hydration status. Other objectives were to find out if artificial hydration has any impact on survival or had any influence on the patterns of use of opioids and sedatives while under palliative care.

Materials and Methods:

Retrospective review of case notes of palliative care patients who died in a 95 bedded oncology ward was done. Information on demographic profile, duration of palliative care, medication use and on symptoms related to hydration status was collected. Patients on artificial hydration were compared to those who were not on artificial hydration for the above parameters. Survival curves were plotted for both groups using Kaplan-Meier method.

Results:

There were 238 patients of which 55.5% were females. The median age was 62 years and the median duration of palliative care was five days. Artificial hydration was given to 59.2% of patients. There was no significant difference in the incidence of symptoms related to hydration status or in the patterns of medication use between patients who received artificial hydration and those who did not. Kaplan-Meier survival curves did not show any significant survival difference (P value=0.9) between the two groups.

Conclusion:

Artificial hydration during the last 48 h of life did not have any significant impact on symptoms related to hydration status, medication use or on survival in terminally ill cancer patients under palliative care.     

Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm

Background

Gastro-oesphageal is one of the most common cancers worldwide. Evidence suggested that increased awareness of symptoms and earlier diagnosis could help improve treatment options and improve survival.

Aim

To derive and validate an algorithm to estimate the absolute risk of having gastro-oesophageal cancer in patients in primary care with and without symptoms.

Design and setting

Cohort study of 375 UK QResearch® general practices for development, and 189 for validation.

Method

Included patients were aged 30-84 years, free at baseline of a diagnosis of gastro-oesophageal cancer, and without dysphagia, haematemesis, abdominal pain, appetite loss, orweight loss recorded in previous 12 months. The primary outcome was incident diagnosis of gastro-oesophageal cancer recorded in the next 2 years. Risk factors examined were age, body mass index, alcohol status, smoking status, deprivation, family history of gastrointestinal cancer, dysphagia, previous diagnosis of cancer apart from gastro-oesophageal cancer, haematemesis, abdominal pain, appetite loss, weight loss, tiredness, and anaemia. Cox proportional hazards models were used to develop risk equations. Measures of calibration and discrimination assessed performance in the validation cohort.

Results

There were 2527 incident cases of gastro-oesophageal cancer from 4.1 million person-years in the derivation cohort. Independent predictors were age, smoking, dysphagia, haematemesis, abdominal pain, appetite loss, weight loss, and anaemia. On validation, the algorithms explained 71% of the variation in females and 73% in males. The receiver operating curve statistics were 0.89 (females) and 0.92 (males). The D statistic was 3.2 (females) and 3.3 (males). The 10% of patients with the highest predicted risks included 77% of all gastro-oesophageal cancers diagnosed over the next 2 years.

Conclusion

The algorithm has good performance and could potentially be used to help identify those at highest risk of gastro-oesophageal cancer, to facilitate early referral and investigation.     

Impact of Specialist Home-Based Palliative Care Services in a Tertiary Oncology Set Up: A Prospective Non-Randomized Observational Study

Background:

Home-based specialist palliative care services are developed to meet the needs of the patients in advanced stage of cancer at home with physical symptoms and distress. Specialist home care services are intended to improve symptom control and quality of life, enable patients to stay at home, and avoid unnecessary hospital admission.

Materials and Methods:

Total 690 new cases registered under home-based palliative care service in the year 2012 were prospectively studied to assess the impact of specialist home-based services using Edmonton symptom assessment scale (ESAS) and other parameters.

Results:

Out of the 690 registered cases, 506 patients received home-based palliative care. 50.98% patients were cared for at home, 28.85% patients needed hospice referral and 20.15% patients needed brief period of hospitalization. All patients receiving specialist home care had good relief of physical symptoms (P < 0.005). 83.2% patients received out of hours care (OOH) through liaising with local general practitioners; 42.68% received home based bereavement care and 91.66% had good bereavement outcomes.

Conclusion:

Specialist home-based palliative care improved symptom control, health-related communication and psychosocial support. It promoted increased number of home-based death, appropriate and early hospice referral, and averted needless hospitalization. It improved bereavement outcomes, and caregiver satisfaction.     

Evaluation of 968 children with corrosive substance ingestion

Background and Aims:

The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature.

Materials and Methods:

The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used.

Results:

A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1–52 sessions (mean 15 ±12) of dilatation.

Conclusion:

We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.